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Dr. Simka presenting on "Is consensus on venographic protocol possible?"

Dr. Simka Interpretations of abnormalities inconsistent among IRs, ie degree of narrowing; valves; turbulence

Dr. Simka: Which narrowings s/b treated? Most severe? Easiest? Safest?

Dr. Simka: Some doctors treat normal valves: others do not. We don't know what is better

Dr. Simka: Clinical benefit from additional procedures unclear

Dr. Simka: IRs using IVUS are very optimistic about it

Dr. Simka: Any IR publishing needs to put full details on protocols used so IRs can reach consensus faster MS

A prospective study comparing ultrasound and angiography (Marian Simka, POLAND)

This study was aimed at evaluation of diagnostic accuracy of currently used CCSVI sonographic criteria. We also
tried to identify alternative sonographic parameters associated with impaired outflow in the internal jugular
veins. Firstly, we compared extracranial Zamboni’s and ISNVD criteria with the results of reference test: catheter
venography. We evaluated internal jugular and vertebral veins in 58 multiple sclerosis patients. Then, we
assessed 41 different sonographic variables in 115 patients. We found that although sonographic patterns
suggesting outflow abnormalities were very common: at least one positive Zamboni’s criterion was found in
92.2% of assessed veins, their diagnostic accuracy was limited. For example, positive and negative predictive
values of one positive Zamboni’s criteria were: 79.4% and 33.3%, and of at least two positive criteria: 81.8% and
21.7%. Accuracy of ISNVD criteria were not much better. Multivariate regression analysis of 41 sonographic
parameters revealed variables associated with increased prevalence of venographic abnormalities: no flow
detected in all three segments of internal jugular vein in upright position, peak flow velocity in the upper and
middle segments in upright position less than 24 cm/s, and in lower segment less than 88 cm/s, peak flow
velocity in the upper segment in supine position less than 24 cm/s, cross-sectional area of the upper segment
in the supine position less than 8 cm2. However, even using these parameters we were unable to create a
reliable set of criteria. Of note, many variables used by the current sonographic criteria were not proven to be
associated with increased prevalence of venographic pathology, for example: reduced or bidirectional flow in
the vertebral veins. Our research is showing a clear gap in the understanding hemodynamics in this particular
venous territory. Consequently, more research is needed to improve diagnostic accuracy of Doppler
sonography for the diagnosis of CCSVI.

Dr. Simka: Found correlation between optic neuritis history and left side stenosis during venogram

Retinal abnormalities in multiple sclerosis patients with associated chronic cerebrospinal venous insufficiency
(Marian Simka, POLAND)
This study was aimed at the assessment of retinal abnormalities in multiple sclerosis patients in the context of
chronic cerebrospinal venous insufficiency using optical coherence tomography (OCT) of the retina and the
optic nerve. We examined 239 multiple sclerosis patients, including 220 patients with associated chronic
cerebrospinal venous insufficiency and 19 MS patients without venous pathology. The following OCT
parameters were assessed: average ganglion cell complex thickness, global loss volume, focal loss volume and
average retinal nerve fibre layer thickness. Abnormalities in azygous and internal jugular veins were evaluated
using catheter venography. We found a much higher prevalence of abnormal OCT parameters in the patients
with previous history of optic neuritis, not only on the side of inflammatory event, but also in the contralateral
eye. This finding is in line with already existing body of evidence. The new and intriguing discovery is that we
found statistically significant higher prevalence of abnormal OCT values in multiple sclerosis patients with
unique type of vascular abnormality, namely: with unilateral stenosis of internal jugular vein. Patients who were
not found venous abnormalities, as well as those presenting with pathologic azygous or bilateral internal
jugular venous outflows, did not demonstrate a changed frequency of abnormal OCT parameters. Potential
association between venous malformations and eye manifestations of multiple sclerosis, as has been
demonstrated in this report, justifies further studies on this topic.
Financial disclosure: American Access Care, Euromedic Specialist