from page 68 of ISNVD 2012 abstracts http://www.isnvd.org/files/ISNVD%20Abstract%20Book.pdf
Intravascular Ultrasound for detection of Azygous and Internal Jugular vein (IJV) abnormalities as part of the
PREMiSe (Prospective Randomized Endovascular therapy in Multiple Sclerosis) study
Y Karmon1,2, R Zivadinov3, B Weinstock-Guttman2, C Kennedy3, K Dolic3, K Marr3, V Valnarov3, A Siddiqui1
1Department of Neurosurgery, 2The Jacobs Neurological Institute, and the 3Buffalo Neuroimaging Analysis Center, State
University of New York, Buffalo, NY
BACKGROUND: Chronic cerebrospinal venous insufficiency (CCSVI) is a condition recently reported in patients with multiple
sclerosis (MS) . A set of 5 extra- and trans-cranial venous Doppler Sonography (DS) criteria was proposed [1, 2] and reported
to be in accordance with catheter venography (CV) for the depiction of both Azygous and IJV stenosis [1, 3]. Despite being
the “gold standard” for assessing vascular problems, angiography only provides a luminography with little data on the vessel's
wall, or intraluminal structures. Our aim was to investigate for presence and type of mechanical impediments to the cranial/
spinal cord venous drainage and suspected deranged flow using CV based intravascular ultrasound (IVUS).
METHODS: PREMiSe is an endovascular angioplasty study enrolling patients with relapsing MS according to the revised
McDonald criteria[4,5], and who had Expanded Disability Status Scale  between 0-5.5 and fulfilled ≥2 CCSVI Doppler
sonography criteria at screening. The study was planned in two phases. The first phase was an open label and included 10
patients, whereas the second phase is placebo-controlled, blinded and randomized and will include total of 20 patients. The
current study is based on 10 patients participating in phase I and 16 in phase II. CV comprised visualization of AZY vein, right
IJV (RIJV) and left IJV (LIJV) in that order . IVUS was performed using IVUS Eagle Eye Gold catheter (Volcano, CA), across
suspected stenotic segments (≥50% restriction) of the IJV's and azygous vein (AZY), in the phase I, and in all vessels in the phase
II. Abnormal predefined IVUS parameters included the presence of stenosis, presence or absence of respiratory pulsatility
and the presence of various intraluminal defects (septa, multiple channeled vein, intraluminal hyperechoic filling defect,
double/parallel lumen), and abnormally thickened wall.
RESULTS: The study included twenty six patients (mean age 45.7, SD=9.7; male=9, females=17; average disease duration
10.1 years) with clinical and MRI proven MS (20 Relapsing remitting MS, 6 secondary progressive MS) that have fulfilled ≥2
CCSVI Doppler sonography criteria at screening. Out of 18 Azygous veins that were investigated with IVUS, 16 (88%) demonstrated
various intraluminal defects. Pulsatility was reduced in 7 (38.8%), and stenosis was demonstrated in 10 (55.5%). IVUS
of LIJV detected intraluminal defects in 7 out of 22 patients, reduced pulsatility in 14, and stenosis in 8. All patients who had
a stenosis by IVUS also demonstrated intraluminal defects. IVUS of the RIJV showed intraluminal anomalies in 4 patients
(20%), reduced pulsatility in 10 (50%), and stenosis in 5 (25%) patients out of 20 patients investigated.
CONCLUSIONS: Detailed IVUS imaging demonstrated a very high rate of intraluminal anomalies in the azygous vein during
the PREMiSe study. Similar anomalies were also found in the LIJV and RIJV in lower rates respectively. Stenosis demonstrated
by IVUS was demonstrated in a decreasing order in the azygous vein, left IJV and RIJV as well. IVUS provides
diagnostic advantages over "gold standard" CV in detecting intraluminal extra-cranial venous abnormalities indicative of
How does reduced pulsatility factor into CCSVI? It is unusual to have 16 out of 18 azygouses be abnormal, but this is looking at more than just stenosis and intraluminal abnormalities, and also including reduced pulsatility.
The conclusion is a familiar one: IVUS provides diagnostic advantages over catheter venography alone, because the intraluminal abnormalities of CCSVI can best be seen on IVUS.