That ultrasound is quite specific. The Doppler is quite relevant and the images need to be taken in just the right way, otherwise the diagnosis is unclear.
Erica, the PhD who works with Paolo, is phenomenal. She is very experienced at finding the veins and making pictures that are clear, unquestioned and sensible.
She starts with the right side of the neck in the lying down position. She does the doppler of the jugular vein in three areas J1 near the clavicle, J2 near the thyroid, and J 3 above the carotid bifurcation. She looks to see the direction of flow in each area. she images transversely. This shows the carotid and the jugular simultaneously. The color is supposed to be red and blue.....one going toward (IJ vein) and one going away (carotid) from the heart. Showing the two vessels together makes it very clear that they go in opposite directions if normal. Patients have sent me many images where the vein is seen in profile, but alone. can’t figure out flow direction like that.
Ok. after looking at the IJV at the three areas, she looks for the vertebral vein and artery. Again, the two vessels are imaged together and the colors should be opposite.
Great, then she has the patient take a big breath which allows the veins to distend. She measures the cross sectional area of the jugular in its largest dimension.
Then she does a transcranial doppler looking for the deep cerebral veins. (this is the part I find the most difficult) She is looking for reversal of flow. That is always abnormal.
Finally she puts the B-mode on and looks at the anatomy, looking for webs, stenoses, valves, etc
THEN She does everything again, in the upright position.
THEN, she does everything on the left side in just that order.
This study is quite challenging to learn. My colleague Dan Zinn finally got it, just by watching a few cases. It is not necessarily the most difficult but it certainly is quite specific and doing it wrong is going to lead to failures
As I was saying, I have reviewed a lot of studies done around the world. For the most part, they suck. When you get half the views, or the wrong maneuvers, one is left with the distinct impression that you have no idea what it all means.
So it is clear that we need to create a standard. That standard needs to be specific, reproducible and simple. By the time I learn this one, Paolo may have perfected a US test that is easier to do with similar reliability.
1. Transverse doppler of the IJV in J1, J2 and J3 during inspiration in the supine and sitting positions. Measure color and waveform at each site in both positions. Look for reflux and looking for no flow.
2. Longitudinal doppler imaging of the vertebral veins during inspiration in supine and sitting positions looking for reflux by color and waveform
3. B-mode ultrasound to look for abnormal valves, septae, webs
4. Transcranial color doppler and waveforms to look at the deep cerebral veins for reflux
5. Measure cross sectional area of jugular vein in the spot where it is largest in supine and measure same cross sectional area in the same location while sitting up. Subtract sitting csa from supine CSA.
DOPPLER DIAGNOSTIC OF CCSVI IF TWO OF FOLLOWING PRESENT
1. REFLUX IN IJV OR VERTEBRALS
2. NO FLOW IN JUGULAR
3. REFLUX IN DEEP CEREBRAL VEINS
4. CSA SUPINE MINUS CSA SITTING IS NEGATIVE NUMBER
5. BMODE SHOWS STENOSIS, WEBS, ABNORMAL VALVES ETC
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