Info prior to take the Doppler test

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

Info prior to take the Doppler test

Postby Algis » Tue Dec 01, 2009 2:14 am

Hello Fellas;

I saw the Neurologist Today and he scheduled me right away for a Doppler exam (sonography I guess) on Thursday (starting with and he will see how that come out).
Nonetheless; they have no prior experience in CCSVI therefore I inquire to anyone who already passed those tests.
This is exploratory only and no surgery procedure has even been talked over, it is far too early especially because no one here in Taiwan has the experience.

Is there anything particular I shall ask for to the radiologist? I downloaded the protocol and will bring it with me; is there any additional material that could help them to investigate?

The exam will be at the National Taiwan University Hospital. The Neurologist has heard of the work of Dr.Zamboni; he is very interested, open-minded and always have been of good advice to me.
I just wonder the Radiologist dont really understand what I am talking about; they probably have most of the requests for arteries or heart diseases.

Thank you for any help and Cheers!

Algis
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Re: Info prior to take the Doppler test

Postby CureOrBust » Tue Dec 01, 2009 4:01 am

Algis wrote:I downloaded the protocol and will bring it with me; is there any additional material that could help them to investigate?
There are two possible protocols. Dr Zamboni's and that which Dr Simka has made public. Which are you using?
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Postby Algis » Tue Dec 01, 2009 4:26 am

What I 'think' will be useful for them is:

1) THE MANY SONOGRAPHIC FACES OF THE CHRONIC CEREBROSPINAL
VENOUS INSUFFICIENCY: HOW TO PERFORM DOPPLER EXAMINATION IN A
MULTIPLE SCLEROSIS PATIENT. (no author but I think it is Dr.Simka)

2) Anomalous venous blood flow and iron deposition
in multiple sclerosis by Ajay Vikram Singh and Paolo Zamboni

Both were found in the thread "CCSVI RESEARCH here" http://www.thisisms.com/ftopict-7098.html

Thank you.

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Postby ozarkcanoer » Tue Dec 01, 2009 7:28 am

I posted this on a different thread yesterday, but I think it is worth repeating here :

I just want to remind everyone here about Dr Zamboni's advice concerning the doppler ultrasound to detect CCSVI. He said that the ultrasound technician should try the ultrasound procedure on 100 "normal" people before looking at anyone with MS. After looking at 100 normal people then the technician will know what is normal and what is not. I think very few ultrasound technicians have ever looked for CCSVI malformations. So be careful of false positives and false negatives. Go back and watch the CTV W5 video of Dr Zamboni again... don't take my word for it.

One more word of caution from Dr Haacke : he has a disclaimer on his website that not all venous malformations may be detected by his MRI protocol. He says that if the MRI is negative then doppler ultrasound may be required. This means the doppler ultrasound as specified by Dr Zamboni.
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Postby Algis » Tue Dec 01, 2009 7:35 am

Well understood and noted.

But that was not the question 8)
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Postby BBE » Tue Dec 01, 2009 7:47 am

It`s not easy to answer your question and at the moment it`s also impossible because no one knows except Zamboni etc. It is very likely that your radiologist won`t find anything on your neck. The documents you mentioned are IMHO useless.
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Postby Algis » Tue Dec 01, 2009 8:00 am

Hence my question; but perhaps I should re-phrase it:

What precisely shall I tell him/her to look for for a better chance of circumvent a possible anomaly


(actually linked or not to MS - I'd love to know if any part of my body is ~normal~ :roll: )
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Postby ozarkcanoer » Tue Dec 01, 2009 8:14 am

Algis, I don't think anyone here can guide you on what to tell the doppler sonographer. In the whole world there is at least one person in Italy and one person in Poland and one person in Buffalo who know how to perform the doppler sonography on the veins of the neck according to Dr Zamboni's protocol. That is three people (there may be more but I don't know about them). The two papers that you already have is all WE have.

A couple of people posted here went to Dr Dake at Stanford and had negative doppler ultrasounds but positive MRVs. This was because the ultrasound technician had never performed this test before and to a certain extent was skeptical.

This is all very new... What we want is for doppler ultrasound technicians to be trained properly. They may be able to train themselves. I don't know.

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Postby Algis » Tue Dec 01, 2009 8:21 am

Thank you Ozark. That is a clear answer.

Sorry if I look persistent and forgive me to be annoying.

Be well :)
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Postby ozarkcanoer » Tue Dec 01, 2009 8:30 am

:D :D

That's OK Algis, I can be persistent and annoying too !! LOLOL

We just want you to understand that getting a doppler ultrasound by a random person, no matter how good of a sonographer he/she is, may not give you the "right" (whatever that is) results.

I urge you again to watch the Dr Zamboni interview where he talks about how to do the sonography. It's like anything... practice, practice, practice. After lots of practice then you will know what to do. Dr Zamboni recommends trying out the ultrasound on 100 normals first before examining any MS patients. So don't be discouraged if this doesn't work out right away. If your sonographer is smart, then he/she will take Dr Zamboni's advice.

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Postby Algis » Tue Dec 01, 2009 8:33 am

Thank you again :)

To be followed... :arrow:
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Postby CureIous » Tue Dec 01, 2009 10:53 am

Keep in mind also, that in Europe their UT/Doppler equipment is more advanced than our average UT equipment, simple $$ thing.

Then again we run headlong into the issue of training:
(copy)
The four basic types of Doppler ultrasound are:

"Bedside" or continuous wave Doppler. This type uses the change in pitch of the sound waves to provide information about blood flow through a blood vessel. The doctor listens to the sounds produced by the transducer to evaluate the blood flow through an area that may be blocked or narrowed. This type of ultrasound can be done at the bedside in the hospital with a portable machine to provide a fast estimate of the extent of blood vessel damage or disease.
Duplex Doppler. Duplex Doppler ultrasound uses standard ultrasound methods to produce a picture of a blood vessel and the surrounding organs. Also, a computer converts the Doppler sounds into a graph that gives information about the speed and direction of blood flow through the blood vessel being evaluated.
Color Doppler. Color Doppler uses standard ultrasound methods to produce a picture of a blood vessel. Also, a computer converts the Doppler sounds into colors that are overlaid on the image of the blood vessel and that represent the speed and direction of blood flow through the vessel.
Power Doppler. Power Doppler is a newer ultrasound technique that is up to 5 times more sensitive in detecting blood flow than color Doppler. Power Doppler can get some images that are hard or impossible to get using standard color Doppler. But power Doppler is most commonly used to evaluate blood flow through vessels within solid organs. Blood flow in individual blood vessels is most commonly evaluated by combining color Doppler with duplex Doppler. Together, these techniques are able to provide better information on the direction and speed of blood flow than when they are used separately.


Yet:

Objective. The main goal of this study was to determine end users’ knowledge regarding safety aspects of diagnostic ultrasound during pregnancy. End users’ attitudes toward the use of ultrasound in low-risk pregnancies were also assessed. Methods. A questionnaire was distributed to ultrasound end users attending review courses and hospital grand rounds between April and June 2006. Results. One hundred thirty end users completed the questionnaires (63% response rate). Sixty-three percent were physicians (n = 84), most of them obstetricians (81.7%). About 18% of participants routinely performed Doppler ultrasound examinations during the first trimester. Fifty percent of end users thought that the number of ultrasound examinations in low-risk pregnancy should be limited to 1 to 3 (mean ± SD, 2.6 ± 0.9). Almost 70% disapproved of "keepsake/entertainment" ultrasound. Although 32.2% of the participants were familiar with the term thermal index, only 17.7% actually gave the correct answer to the question on the nature of the thermal index. About 22% were familiar with the term mechanical index, but only 3.8% described it properly. Almost 80% of end users did not know where to find the acoustic indices. Only 20.8% were aware that they are displayed on the sonographic monitor during the examinations. End users with higher knowledge of safety issues thought that there should be limitations on the number of ultrasound examinations in low-risk pregnancies (odds ratio, 3.3; 95% confidence interval, 1.1–10.0; P = .028). Likewise, these end users were more likely to respond that ultrasound might have adverse effects during pregnancy (odds ratio, 3.2; 95% confidence interval, 1.1–12.5; P = .045). Conclusions. Ultrasound end users are poorly informed regarding safety issues during pregnancy. Further efforts in the realm of education and training are needed to improve end user knowledge about the acoustic output of the machines and safety issues.

Granted, that's a poor example from pregnancy exams, but just illustrates that times x when we are talking about reflux going back up into the brain which is the *real* issue, not merely pressure gradients which can be transient.

Point being it is going to take some time, maybe a long time before our average UT Tech can sit you down, flip on a machine, and dx CCSVI related reflux or anything close to that...

Mark.

Note that 81 % of "end users" were OB's...

As has oft been mentioned in here, our lack of a substantial knowledge base in dx'ing jugular stenosis/reflux, leads to at least see what we know, don't know about dx'ing carotid stenosis which is obviously more prevalent and examined. Considering that this was only in 2002, and the amount of variability involved even within a particular laboratory, having umpteen thousands of MS patients taking instructions into a tech or MD to get screened could lead to thousands of different interpretations. It's dicey to say the least...


http://radiology.rsna.org/content/229/2/340.full.pdf

Diagnostic Strata
Methods of Reporting
Issue.—Methods by which the degree of ICA stenosis is reported vary from laboratory to laboratory, as well as within some laboratories. Some report an estimate of the specific percentage of stenosis,
others stratify their estimates into five or six diagnostic categories or gradations of stenosis.

Recommendation.—Doppler US cannot be used to predict a single percentage of stenosis. Therefore, the consensus panelists
strongly recommend the use of defined diagnostic strata.
Laboratories should establish protocols for stratifying the degree of ICA stenosis, and, once established, these criteria should be consistently
applied.

Doppler Measurement Variability
Although investigators have confirmed that the average Doppler velocity rises in direct proportion to the degree of stenosis
as determined with angiography (18,26), there are very wide ranges of
Doppler values around those means,which makes it impossible to classify lesions into gradations as narrow as 10%
(Figure) (18,34).

Even in evaluations of the ability of Doppler US to help estimate
the degree of stenosis by using more expanded strata (eg, 50%, 50%–69%, and70% stenosis), the findings have been disappointing. US is most accurate when lesions are classified as being above or below a single level, such as 60% stenosis or 70% stenosis (18).Other issues that need to be addressed include the following:
1. There is considerable variation in Doppler measurements from machine to machine and manufacturer to manufacture.
This should be rectified, because such variation leads to inconsistencies
and inaccuracies in diagnosing ICA stenosis.
2. Phantoms for Doppler US need to be developed to facilitate calibration of Doppler US equipment.
3. Improved methods for calculating velocity with angle correction should be developed to eliminate or minimize theinconsistency in velocity measurements as the Doppler angle
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Postby Algis » Tue Dec 01, 2009 6:50 pm

Thank you :)
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Postby Dragonfly » Wed Dec 02, 2009 10:06 am

Algis,

Dr. Zamboni's most recently published article, the one in the December Journal of Vascular Surgery, has Zamboni's protocol for "Echo color Doppler for investigation of cerebral venous return." I would assume that any medical professionals you will be seeing would have access to this journal. You could direct them there.

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