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Extracranial Venous Drainage Patterns in Patients with Multiple Sclerosis and Healthy Controls

R.A. McTaggart, N.J. Fischbein, C.J. Elkins, A. Hsiao, M.J. Cutalo, J. Rosenberg, M.D. Dake and G. Zaharchuk

+ Author Affiliations

From the Departments of Radiology (R.A.M., N.J.F., C.J.E., A.H., M.J.C., J.R., G.Z.) and Cardiothoracic Surgery (M.D.D.), Stanford University, Stanford University Medical Center, Stanford, California.

Abstract

BACKGROUND AND PURPOSE: CCSVI hypothesizes an association between impaired extracranial venous drainage and MS. Published sonographic criteria for CCSVI are controversial, and no MR imaging data exist to support the CCSVI hypothesis. Our purpose was to evaluate possible differences in the extracranial venous drainage of MS and healthy controls using both TOF and contrast-enhanced TRICKS MRV.

MATERIALS AND METHODS: Healthy subjects (n = 20) and patients with MS (n = 19) underwent axial 2D-TOF neck MRV (to assess flattening) and TRICKS MRV (to assess collaterals) at 3T. Two neuroradiologists blinded to cohort status scored IJV flattening and the severity of non-IJV collaterals by using a 4-point qualitative scale (normal = 0, mild = 1, moderate = 2, severe = 3). κ was used to assess reader agreement. Comparisons between groups were performed by using the Wilcoxon rank sum test. The Spearman rank correlation was used to assess the relationship between IJV flattening and collateral scores and, in patients with MS, EDSS scores.

RESULTS: The 2 groups were matched for age and sex (MS, 45 ± 8 years, 79% female; healthy controls, 47 ± 10 years, 65% female). Reader agreement for IJV flattening and collateral severity was good (κ = 0.74) and moderate (κ = 0.58), respectively. While IJV flattening was seen in both patients with MS and healthy controls, scores for the patients with MS were significantly higher (P = .002). Despite a trend, there was no significant difference in collateral scores between groups (P = .063). There was a significant positive correlation between flattening and collateral scores (ρ = 0.32, P = .005) and EDSS and flattening scores (ρ = 0.45, P = .004) but not between EDSS and collateral scores (ρ = 0.01, P = .97).

CONCLUSIONS: These results indicate that patients with MS have greater IJV flattening and a trend toward more non-IJV collaterals than healthy subjects. The role that this finding plays in the pathogenesis or progression of MS, if any, requires further study.

With regard to the presence and severity of collaterals (defined as vein prominence by Zivadinov et al12), our methods
again differ, but not arbitrarily. We believe that the major extracranial cerebral venous outflow pathway other than the
internal jugular veins is mediated by the anterior condylar confluence and the vertebral venous plexus;13 this is the primary
extracranial venous drainage system in the upright system. Our collateral scoring system emphasizes this pathway
because we assessed primarily the prominence of veins in the posterior paraspinal soft tissues with particular attention to
the presence of the vertebral venous plexus and deep cervical vein insertion (grade 2) on the low IJV and the presence of this
finding in combination with prominent upper thoracic collaterals (grade 3). Unlike Zivadinov et al, we ignored the facial,
external jugular, and anterior jugular veins. While Zivadinov et al concluded that there were no significant differences in vein prominence between patients with MS and healthy subjects, they did report that 21% (12/57) of patients with MS versus 0% (0/21) of healthy subjects had prominent deep cervical veins (P
.03). Unfortunately, the extracranial venous drainage pathways are immense and complicated, and no perfect scoring may exist for collaterals in the supine position. However, if obstructing lesions of the internal jugular veins are indeed present in patients with MS, it seems logical that these would lead to unexpected prominence of the vertebral venous system in the supine position.

Endovascular correction of cerebrovenous anomalies in Multiple Sclerosis: A retrospective review of an uncontrolled case series

Abstract

Endovascular intervention for obstruction to venous drainage of the head and neck is an established treatment for disorders such as superior vena cava syndrome. Some patients with multiple sclerosis have been observed to have anomalies of the veins draining the head and neck. It is possible that some symptoms associated with multiple sclerosis may be secondary to disturbed venous flow. In an uncontrolled clinical series of 40 patients who had been previously diagnosed with multiple sclerosis, anomalies of the venous drainage of the head and neck were observed, including venous stenoses of the internal jugular veins. In 38 of 40 patients, venous stents were placed with restoration of luminal dimensions and abrogation of the venous pressure gradient. The angiographic and hemodynamic improvement was associated with improvement in symptomatology, most particularly in cognitive and constitutional symptoms that may be related to cerebrovenous flow. Serious complications included death in one subject and stent embolization requiring open heart surgery in another. In conclusion, in this series, endovascular intervention to correct venous stenosis associated with multiple sclerosis was associated with improvement in symptoms possibly related to disturbed venous hemodynamics. However, given the serious adverse events in this small series, a randomized clinical trial is required to confirm these findings, and to determine if the procedure has any effect on the progression of multiple sclerosis, or untoward long-term adverse effects.