1. Epidemiology of CCSVI in MS using ECD-TCCS and venography
d’Alessandro A.*, Mandolesi S.**, Orsini A.***
*Chief Dep. of Angiology – San Severo Hospital (FG) – Italy
**Dep. of Cardiovascular Science, Respiratory, Geriatric and Nefrology – Sapienza University of Roma – Italy
***Dep. of Vascular Surgery – Gioia Hospital – Sora (FR) -Italy
Participants
Between January 2011 and January 2013, 200 patients were studied consecutively with US (136 famales, 68%, and 64 male, 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. Clinicaly, 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).
Background
Chronic Cerebrospinal Insufficiency (CCSVI) are a recently described vascular clinical finding, characterized by multiple stenoses of the major extracranial venous drainage pathways, particularly in the internal jugular veins (IJV) and in the azygos vein (AZY), which cause intracranial hypertension.
The activation of collateral circulation, clearly identified by selective venography, attemps 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.
Results/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 40 patients studied with selective preoperative venography and positive to CCSVI, all had venous anomalies of the internal jugular veins and 20 patients (50%) had venous anomalies of the azygos vein.
After our research we can outline the following conclusion:
1) The ECD-TCCS examination is an indispensable tool for the diagnosis of CCSVI for patients with MS. 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 venography (100% of patients) in terms of diagnosis of CCSVI, wile presenting significant marins 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 vessels concerned. On the other hand, a 100% sensitivity of ECD-TCCS examination with respect to selective venofraphy in the diagnosis of CCSVI indicates how the ultrasound examination is extremely reliable when diagnosis CCSVI.
3) In addition, a proportion of about 92% of positively diagnosed CCSVI patients with MS shows that CCSVI is the most important risk factor or contributor of MS.
Method
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 parameters:
1. Reflux of internal jugular veins and/or vertebral veins while in supine and sitting position Because cushions are, by definition, medically necessary, insuring that a 2. Reflux of DCVS (internal cerebral vein, basal vein of Rosenthal, and the great cerebral vein of vein of Galeno Presence of stenosis in the internal jugular vein after high-resolution B-mode examination; Flow in the internal jugular veins and/or vertebral veins undetectable with Doppler examination; Inverse postural control of the main cerebral venous outflow pathways Venography diagnosis: 40 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 on IJV and AZY preoperative systems.
References
P. Zamboni, E. Menegatti, S. Occhionorelli, F. Salvi. “The Controversy on chronic cerebrospinal venous insufficiency”. Veins and Lymphatics 2013; volume 2: e14:
A. d’Alessandro, R. Guglielmi, O. Di Cillo, A. d’Alessandro. “ Epidemiology of CCSVI in MS using ECD-TCCS and venography”. Italian Journal Practice Cardiology. 2013; anno 2, numero 2:70-82
ECD-TCCS
N 200
positive
184
negative 16
Venography
N 40 40
Total
100%
# of US
ECD-TCCS
200
MSRR
128
MSSP 62
MSPP 10
Acknowledgements
The authors declare non potential conflict of interests.
The authors acknowledge the contributions of Alessandro d’Alessandro at the Faculty of Medicine Catholic University “ Our Lady of Good Counsel “ of Tirana - Albanian.