Multigate Quality Doppler Profiles and Morphological/Hemodynamic Alterations in Multiple Sclerosis Patients

Abstract

Venous echo-color-Doppler (ECD) showed that chronic cerebrospinal venous insufficiency (CCSVI) syndrome is related to multiple sclerosis (MS). Study aims were to assess interobserver variability in ultrasound evaluation of MS patients and to relate echo-markers to MS clinical symptoms and the disability degree. 277 MS patients (117 men, mean age 43.05+10.04 years) admitted to the Neurology Department of Bari University General Hospital, underwent clinical, Expanded Disability Status Scale (EDSS) evaluation, and a cerebro-venous system ECD evaluation. Two operators reevaluated 32 patients to calculate interobserver variability. McNemar test confirmed the procedure reproducibility between two operators (p=ns). Septa/membranes correlated with deep cerebral veins reflux [right: 16% absence vs. 58% presence, p < 0.0001; left: 26% vs. 50%, p < 0.0001]; their absence in Primary Progressive (PP) MS form [right: 11% vs. 2%, p < 0.001; left: 12% vs. 2%, p < 0.001]. Internal jugular veins (IJVs) reflux absence was in Relapsing-remitting (RR) form [right: 60% vs. 74%, p=0.036; left: 56% vs. 85%, p < 0.0001] like hemodynamically significant stenosis [right: 57% vs. 69%, p=0.033; left: 49% vs. 73%, p < 0.001] not present in PP [right: 11% vs. 2%, p < 0.001; left: 10% vs. 3%, p=0.009]. A supine IJVs blocked flow was related to the EDSS class [right: 4.8±1.5 vs. 5.4±1.4, p=0.006; left: 4.7±1.6 vs. 5.5±1.2, p < 0.0001]; its absence was linked to RR [right: 60% vs. 76%, p=0.016; left: 58% vs. 79%, p < 0.001]. ECD has an important value in MS patients with IJV anomalies detection and a good interobserver procedure reproducibility. MS is associated with CCSVI, although further studies are needed.

The role of noninvasive and invasive diagnostic imaging techniques for detection of extra-cranial venous system anomalies and developmental variants

“…Even those DS studies which detected a significant difference for CCSVI diagnosis between MS patients and the controls, reported a substantially lower prevalence than was originally reported [30,31,83,88,90,92-94,98,99]. …”

“…There have been numerous additional DS studies that showed significant differences in CCSVI prevalence between MS patients and the controls [30,31,78,83,88,90,92-95,99]. However, an even higher number of DS studies have failed to show prevalence differences in CCSVI between MS patients and controls [34,80-82,84-87,89,91,96,97,100],[101].…”

Italian multicentre observational study of the prevalence of CCSVI in multiple sclerosis (CoSMo study): rationale, design, and methodology

“…Reliable evidence on which to base decisions requires sonographic consensus and assessment of the reproducibility of individual criteria between trained sonographers” [17]. This controversial problem, therefore, clearly needs to be addressed by adopting the highest possible scientific standards and thereby bypassing all limitations inherent in previous studies, such as the limited number of patients [4, 5, 7, 9, 11–13, 15, 16, 18], lack of blinding [5, 7, 8, 10, 11, 13–16], lack of appropriate controls [7–13, 15, 18], lack of multicentric design [4, 5, 7–16, 18], and lack of inter-observer variability assessment [4, 5, 7, 9–16, 18]. The aim of the CoSMo study, named after the Italian “CCSVI: studio Osservazionale Sclerosi Multipla e OND”, that is “Observational Study of the prevalence of CCSVI in Multiple sclerosis and in other neurodegenerative diseases (OND)”, is to conclude the heated debate that has arisen in recent years and provide an appropriate answer as to whether or not CCSVI is associated to MS.…”

Small internal jugular veins with restricted outflow are associated with severe multiple sclerosis: a sonographer-blinded, case–control ultrasound study

“…Thus, we must be cautious in drawing conclusions because there is a possibility that we were unable to detect all venous pathologies, both in the patients and the controls. Although it has recently been suggested that Doppler has limited diagnostic value for diagnosing venous morphological changes [25], others claim that the inter-rater reproducibility supports its use for diagnostic purposes in multicenter studies [8,26]. Ultrasound technology, which is widely used in this field, is promoted by the revised protocol for CCSVI screening [27] and is particularly advantageous due to its noninvasive nature.…”

“…The conflicting results about association between CCSVI (and its clinical correlates) and MS have been presented [2-6] and the question emerged if it is a primary or secondary condition to MS. It is believed that noninvasive venous echo-color ultrasound and transcranial (ECD/TCD) Doppler is useful for revealing the presence of outflow disturbances and morphological abnormalities in IJVs and VVs [7,8]. Using differing methodologies, all of these studies showed that IJV stenosis, defined either as a cross-sectional area (CSA) ≤ 0.3 cm2 or as a local CSA reduction of ≥50% [2,4,9], is one of the most frequently observed CCSVI criteria in patients with MS. IJV asymmetries were first observed in healthy subjects.…”