Paper: “Extracranial Doppler sonographic criteria of chronic cerebrospinal venouse insufficiency in the patients with multiple sclerosis” by M. Simka, J. Kostecki, M. Zaniewski, E. Majewski, and M. Hartel in International Angiology, 29(2), pp. 109-114.
In this study, Simka et al, used 70 patients with MS–49 had Relapsing-Remitting MS, 5 had Primary Progressive MS and 16 had Secondary Progressive MS aged 15-58 (median age 38.5 years). Reference was made to the improvements noted per Zamboni et al in 2 separate papers after endovascular correction of venous abnormalities including: chronic fatigue, heat intolerance and impaired cognitive functions. The researchers in this study sought determine the prevalence of venous abnormalities in MS patients using extracranial Doppler sonography per Zamboni’s 4 extracranial criteria (5th criteria is intracranial, not assessible by Doppler in this study). Internal jugular veins (IJV) and vertebral veins (VV) were assessed using the Doppler ultrasound and the results showed that 2 out of the 4 criteria were met in 63/70 patients and at least 1 criteria in 64/70 patients. In only 6 MS patients were they unable to find “obvious sonographic pathology” in the veins examined. The results of this study were similar to Zamboni’s study of 109 patients with a few differences. Simka et al found 91.4% of patients examined met Zamboni criteria while Zamboni et al found 100% of patients met Doppler criteria for CCSVI. This difference could be attributed to Simka et al’s inability to assess the 5th Zamboni criteria since they were using Doppler sonography lacking the special skills and software needed to assess deep intracranial veins.
In review, Zamboni’s criteria include:
1. Reflux in IJV and/or VV over 0.88s
2. At least 50% stenosis of provimal IJV/s
3. No detectable flow in the IJVs or VVs
4. No position dependent change in diameter of the IJV/s
5. Reflux in the deep cerebral veins over 0.5s
It is important to note that the researchers may not have been able to find venous abnormalities in some patients, especially abnormalities at the level of the skull (in IJVs) or some VV flow issues cannot be confirmed by Doppler sonography. Also, unlike the Italian study, some patients were noted to have only 1 venous abnormality. These findings indicate that CCSVI in MS patients is more complex that proposed. In addition, it appears to the researchers that the presence of even occlusions of 1 IJV can result in severe neurological problems. They have concluded the Dopper sonography should be the primary test for CCSVI followed by MRV serving as an additional test. The whole picture of pathology can be viewed with these 2 tests coupled with intra-operative venography.
The most common pathology found in the patients in this study was the presence of an inverted valve or another abnormal structure (such as a membranous or netlike septum) at the junction of the IJV and the brachiocephalic vein. The 3 main venous abnormalities found in these patients (some patients had a combination of the following) were:
1.Flow abnormalities in the VVs such as reflux (8/70) and so on, which suggests an obstruction in the azygous vein, however, stenosis in the azygous must be seen by venogram.
2.Pathologic structures (membranous or netlike septa, inverted valves in the junction of IJV and brachiocephalic vein) 41/70 patients
3.Stenoses of IJVs–present in 25/70 patients and 2 patients with pathologic valve also in opposite side IJV.
Therefore, in the presence of these findings, Simka et al conclude that MS is highly correlated with CCSVI. And, these abnormalities can exist in various combinations, especially noting the inverted valve or other pathologic structure at the junction of the IJV and brachiocephalic vein.
This article is important in that some criteria of CCSVI are not discernable by Doppler sonography, such as those hidden by the skeletal system (skull or rib cage). And, that the mere presence of 1 IJV occlusion can present with severe neurological symptoms. These findings beg the question: what is the most accurate way to determine the presence of CCSVI? It appears abnormalities of the veins can easily be masked from detection, however, cause a constellation of physical symptoms.
http://www.ccsvi.mx/correlation-ms-and-ccsvi