Epidemiology of CCSVI in MS using ECD-TCCS and venography

INTRODUCTION

Chronic Cerebrospinal Venous Insufficiency (CCSVI) are a recently described vascular clinical findings, characterized by multiple stenoses of the major extracranial venous drainage pathways, particularly in the internal jugular veins (IJV) and in the azigos vein (AZY), which cause intracranial hypertension.
The activation of collateral circulation, clearly identified by selective venography, attempts to compensate for the reduced venous return, however, the time of venous return is increased compared with control subjects.
The hemodynamic changes described in CCSVI, appear to be significantly correlated with multiple sclerosis (MS).
In this research we report our experience on the subject.

METHODS

Non-invasive screening: was performed by ECD-TCCS examination according to the protocol described by Zamboni, considering the presence/absence of five hemodynamic-ultrasonographic criteria required for the diagnosis of CCSVI: in order for a CCSVI diagnosis to occur, according to the protocol Zamboni, the patient should present at least 2 of the following 5 parame-
ters:

1. Reflux of internal jugular veins and/ or vertebral veins while in supine and sitting position;
2. Reflux of DCVS (internal cerebral vein, basal vein of Rosenthal, and the great cerebral vein of Galen)
3. Presence of stenosis in the internal jugular vein after high-resolution B-mode examination;
4. Flow in the internal jugular veins and/or vertebral veins undetectable with Doppler examination;
5. Inverse postural control of the main cerebral venous outflow pathways.
Phlebographic diagnosis: 38 patients with CCSVI ultrasound diagnosis, underwent selective venography executed in a blinded fashion by two different teams. The former of interventional radiologists and the latter of vascular surgeons of IJV and AZY preoperative systems.

POPULATION

Between January 2011 and August 2012, 200 patients were studied consecutively with US (136 females, 68%, and 64 males, 32%), aged between 20 and 73, all related to various neurological centers with clinically definite multiple sclerosis (CDMS), diagnosed according to the revised McDonald criteria.
Clinically, 128 patients (64%) had a clinical course with exacerbations-remitting (RR), 62 patients (31%) had a secondary progressive form (SP), and 10 patients (5%) a primary progressive form (PP).

RESULTS AND CONCLUSION

Of 200 patients with MS, 184 (92%) were diagnosed with CCSVI while 16 patients (8%) did not respond to at least 2 Zamboni criteria, resulting in a negative diagnosis of CCSVI.
Among 38 patients studied with selective preoperative venography and positive to CCSVI, all had venous anomalies of the internal jugular veins and 19 patients (50%) had venous anomalies of the azygos vein.
After our research we can outline the following conclusions:

1) the ECD-TCCS examination is an indispensable tool for the diagnosis of CCSVI for patients
with S.M. However, the ECD-TCCS examination needs a new type of cultural approach and requires an extended period for learning. Therefore it is of no surprise how the results of similar studies can present significant differences.

2) the ECD-TCCS examination is similar to selective phlebography (100% of patients) in terms of diagnosis of CCSVI, while presenting significant margins of error when detecting concerned vessels. ECD-TCCS examination should therefore be entrusted with the diagnosis of CCSVI without further specifying the nature of venous anomalies and the vessels concerned. On the other hand, a 100% sensitivity of the ECD-TCCS examination with respect to selective phlebography in the diagnosis of CCSVI indicates how the ultrasound examination is extremely reliable when diagnosing CCSVI.

3) In addition, a proportion of about 92% of positively diagnosed CCSVI patients with SM shows that CCSVI is the most important risk factor or contributor of SM.
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