Extracranial Venous Drainage Patterns in pwMS and HC

A forum to discuss Chronic Cerebrospinal Venous Insufficiency and its relationship to Multiple Sclerosis.

Extracranial Venous Drainage Patterns in pwMS and HC

Postby Cece » Sat Apr 21, 2012 5:17 pm

www.ajnr.org/content/early/2012/04/19/a ... 7.abstract
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.


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.

From Dr. Dake. A blinded comparison of MRVs of MS patients and healthy controlss shows that patients with MS have greater IJV flattening, as well as a trend toward more collaterals, than healthy controls. That trend toward more collaterals could show significance if it were a larger study. MRV is not the best way to show CCSVI, which is a condition of intraluminal abnormalities within the vein, and MRV is better at showing the structure of the vein and collaterals but not what's inside the vein.

This is positive research in CCSVI's favor. Published in a journal of neuroradiology, where the neurologists won't read it...
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Re: Extracranial Venous Drainage Patterns in pwMS and HC

Postby cheerleader » Sat Apr 21, 2012 6:48 pm

I have the full paper. The thing that's really important to understand it that this research method is not operator dependent.
The assertion has been that assessing doppler US is very subjective. Yes, doppler US can see intraluminal defects, it can detect reflux, etc. which MRV cannot. But there have been enough negative studies to bring doppler US into question. This study is not subjective. This study was blinded. There were healthy control volunteers, and people with MS, who all had the same testing. The techs grading this just looked at the images. They never saw an actual person.
The images are 3D--the techs can see flattening, severe stenosis, and absense of a vein. This flattening was graded according to the severity, and there was a correlation found in severity of flattening or absence of IJV in pwMS. There was also a correlation of severity of collaterals in pwMS.

The severity of collaterals was graded differently than past studies:

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.

Husband dx RRMS 3/07
dx dual jugular vein stenosis (CCSVI) 4/09
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Re: Extracranial Venous Drainage Patterns in pwMS and HC

Postby Cece » Sat Apr 21, 2012 9:31 pm

Good points, and thanks for the additional information. Operator independent, blinded! The MRV does not have to show all of the CCSVI, as long as it shows enough to distinguish between the pwMS and the healthy controls.
The CCSVI blockages are either there or not there. It reminds me of the autopsy study from Dr. Fox, and how good it felt to have some actual physical evidence of our jugular blockages, and not the endless controversy.

Here also is the other research from Dr. Dake:
Endovascular correction of cerebrovenous anomalies in Multiple Sclerosis: A retrospective review of an uncontrolled case series


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.

Reasonable as it gets. It is possible that some symptoms of MS may be secondary to disturbed venous flow. Endovascular intervention for obstruction to venous drainage of the head and neck is an established treatment for disorders such as superior vena cava syndrome. Rather than the controversial 'liberation procedure' or even the coined term CCSVI, it is good to call it what it is. Outflow obstructions and plain ol' angioplasty.
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Re: Extracranial Venous Drainage Patterns in pwMS and HC

Postby 1eye » Sun Apr 22, 2012 4:36 pm

I only read the abstract. It seems, some collaterals result from flattening (hypoxia?), collaterals don't lead to more disablility (they improve things, not worsen them), but some flattening does (hypoxia again?). I would further speculate: new collateral vein growth is behind remissions. So my guess is that when you stop having remissions, but continue to have disability progression, the compromise of jugular flow is complete, and further collateral growth will not give you any further remissions. It might be that you continue to have disability progression because your azygus vein, and vertebral drainage of the brain, still have problems. Both systems may reach a point where the problem feeds on itself: insufficient drainage makes the drains themselves more unhealthy, as well as the thing being drained, so more unhealthiness of both ensues. The thing that makes all the differences in the course from person to person, might be that everybody's vein configuration/healiing is so unique.
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