Authors & Affiliation: Dr Ma’moon Al-omari, Department of Radiology, Jordan
University of science and Technology
Introduction: Chronic cerebrospinal venous insufficiency (CCSVI) is a syndrome seen
in multiple sclerosis (MS) patients characterized by abnormal venous haemodynamics
due to venous obstacles in main extracranial and extra spinal routes (1). This results in
poor venous drainage of the brain and spinal cord with opening of collaterals to
overcome cerebrospinal venous hypertension. CCSVI can be assessed by non invasive
Doppler ultrasound; (2) however this is highly operator dependent and needs special
training (3).The gold standard for assessment of venous pathology is catheter
angiography (4).
Objectives: To give detailed description of angiographic finding of CCSVI and
abnormal venous haemodynamics in MS patients. To correlate some of these findings
with the corresponding well established Doppler ultrasound criteria.
Materials & Methods: A retrospective analysis of the angiographic findings of 287
patients with clinically definite MS who underwent selective venography of the Internal
Jugular veins (IJV) and Azygus vein (AV).
Mean age o f the patients was 34 years (range 14-66 years). Mean duration of the
disease was 6.4 years. (Range 6 months - 17 years) Left common femoral vein approach
was used in the vast majority of cases. Injection rate in the IJV and AV were: 3
ml/second, Quantity: 10 ML.
Results: Angiographic evidence of abnormal venous haemodynamics was very
common in MS patients. Significant venous stenosis in at least one of the three veins
was seen in 93% of cases:
The most common angiographic finding was the stagnation of contrast and delayed
emptying at the level of the valve.
Signs of abnormal venous Haemodynamics in the IJV were (Rt IJV , Lt IJV) :

(1) Reflux at the level of the valve: 57 , 64% (2)Reflux propagated into the cranium
29,41% (3) Stagnation of the contrast with poor drainage: 71 , 77% (4)Stenotic valve
due to:-Annulus: 70 , 53% -Septum: 13 , 7% -Membrane like valve :5 , 4%,
Intraluminal Flap: 1, 2% , Twisting: 0 , 0.5%.
Sings of abnormal venous haemodynamics in the AV were:
(1) Obvious stenosis: 39%: Upper Stenosis 21%, lower stenosis 13%, -Multiple stenosis
5% (2) Intraspinal reflux: 35%
(3) Reflux into left renal vein: 30% (4)-Delayed emptying at the valve: 46% (5)
Significant collaterals: 28%
Discussion: CCSVI is usually diagnosed based on the known Doppler ultrasound
criteria. These criteria with the corresponding angiographic finding in patient with
CCSVI syndrome are summarized in table (1)
Table (1)
Doppler Ultrasound Criteria Corresponding Angiographic finding
1-Reflux in the IJV or AV Regurgitation of contrast in IJV or AV, Fig 1A,B
2-Reflux Propagated upward Reversed flow,contralateral IJV opacification,
Fig.2
3-Evidence of IJV.stenosis Frank stenosis, Annulus, Septum, Flap Fig.3
4-No flow in IJV Stagnation of Contrast in IJV Fig 4
5-Negative change in CSA in
IJV
Can not be assist
Fig 1A Fig1B Fig 2 Fig 3
Fig 4

Conclusions: Angiographic signs of abnormal venous haemodynamics are very
common in MS patient. These finding are so variable, most of these finding can be
correlated with the corresponding well established Doppler ultrasound criteria. However
some of these findings are unique and can be only appreciated by the gold standard
catheter venography.
References:
(1) Zamboni P,Galeotti R. Phlebology; 25:269-79, 2010. (2) Zamboni P et al J Neurol Neurosurg
Psychiatry.; 80:392-9, 2009. (3) Menegatti E et al. Int Angiol.; 29:121-6, 2010. (4) Zamboni P et al. J
Vasc Surg.; 50:1348-58, 2009

http://ccsvism.xoom.it/ISNVD/Abstract-Al-Omari.pdf