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Quantitative Colour Doppler Sonography Evaluation of Cerebral Venous Outflow: A Comparative Study between Patients with Multiple Sclerosis and Controls

Lucia Monti1*, Elisabetta Menci1, Monica Ulivelli2, Alfonso Cerase1, Sabina Bartalini2, Pietro Piu2, Nicola Marotti1, Sara Leonini1, Paolo Galluzzi1, Daniele G. Romano1, Alfredo E. Casasco3, Carlo Venturi1

1 Unit of Neuroimaging and Neurointervention, Department of Neurological and Sensorial Sciences, Azienda Ospedaliera Universitaria Senese, Santa Maria alle Scotte General Hospital, Siena, Italy, 2 Department of Neurosciences, University of Siena, Siena, Italy, 3 Unit of Endovascular and Percutaneous Therapy, Clinica Nuestra Señora del Rosario, Madrid, Spain

Background

Internal Jugular Veins (IJVs) are the principle outflow pathway for intracranial blood in clinostatism condition. In the seated position, IJVs collapse, while Vertebral Veins (VVs) increase the venous outflow and partially compensate the venous drainage. Spinal Epidural Veins are an additional drainage pathway in the seated position. Colour- Doppler-Sonography (CDS) examination is able to demonstrate IJVs and VVs outflow in different postural and respiratory conditions. The purpose of this study was to evaluate CDS quantification of the cerebral venous outflow (CVF) in healthy subjects and patients with multiple sclerosis (MS).

Methodology/Principal Findings

In a group of 27 healthy adults (13 females and 14 males; mean age 37.8±11.2 years), and 52 patients with MS (32 females and 20 males; mean age 42.6±12.1 years), CVF has been measured in clinostatism and in the seated position as the sum of the flow in IJVs and VVs. The difference between CVF in clinostatism and CVF in the seated position (ΔCVF) has been correlated with patients' status (healthy or MS), and a number of clinical variables in MS patients. Statistical analysis was performed by Fisher's exact test, non-parametric Mann-Whitney U test, ANOVA Kruskal-Wallis test, and correntropy coefficient.

The value of ΔCVF was negative in 59.6% of patients with MS and positive in 96.3% of healthy subjects. Negative ΔCVF values were significantly associated with MS (p<0.0001). There was no significant correlation with clinical variables.

Conclusions/Significance

Negative ΔCVF has a hemodynamic significance, since it reflects an increased venous return in the seated position. This seems to be a pathologic condition. In MS patients, a vascular dysregulation resulting from involvement of the autonomous nervous system may be supposed. ΔCVF value should be included in the quantitative CDS evaluation of the cerebral venous drainage, in order to identify cerebral venous return abnormalities.

Measure pwMS in reduced gravity machine (clinostatism)

In a group of 27 healthy adults (13 females and 14 males; mean age 37.8±11.2 years), and 52 patients with MS (32 females and 20 males; mean age 42.6±12.1 years), CVF has been measured in clinostatism and in the seated position as the sum of the flow in IJVs and VVs. The difference between CVF in clinostatism and CVF in the seated position (ΔCVF) has been correlated with patients' status (healthy or MS), and a number of clinical variables in MS patients. Statistical analysis was performed by Fisher's exact test, non-parametric Mann-Whitney U test, ANOVA Kruskal-Wallis test, and correntropy coefficient.

The value of ΔCVF was negative in 59.6% of patients with MS and positive in 96.3% of healthy subjects. Negative ΔCVF values were significantly associated with MS (p<0.0001). There was no significant correlation with clinical variables.

What are the honours that you have received that you look back on with pride?

I cherish the memories of my nomination as associated professor at the University of Paris, and the prize of the National Academy of Medicine of France for my work about “Endovascular treatment of intracranial aneurysms.”

What are your current research interests?

I am presently dedicated to the endovascular treatment of spinal vascular malformations, and to the combined treatment (surgery-laser-embolization) of superficial vascular malformations. I am also collaborating on the development of stent diversifiers of intracerebral flow.

What do you hope to achieve in your term as president of ESMINT?

I would like to bring together a group that is as large as possible comprising interventional neuroradiologists, neurosurgeons and neurologists from all nationalities. I would like to create an open space for real debate, without social, political or idiomatic obstacles. So we are working and hoping to achieve a high level of scientific discussion in a relaxed and friendly environment which allows young people to express themselves without any complexes, and for older people to speak with wisdom and humility.

What are three key questions in interventional neuroradiology which you would like to see answered?

Which future substance and technique will be able to achieve a 100% embolization in arteriovenous malformations? Is it possible to develop anti-angiogenic factors to reduce or heal vascular malformations? How long would it take for stroke units to be able to treat ischaemic stroke within the first four hours routinely?

What are the new techniques/technologies that you are watching closely?

The use of stent diversifiers of flow in the treatment of intracranial giant aneurysms, techniques for the treatment of acute ischaemia intra-arterially and embolization techniques of spinal vascular malformations.

Sounds like a method to show CCSVI procedure has worked. Measure pwMS in reduced gravity machine (clinostatism), if ΔCVF is negative then do CCSVI procedure.