ISNVD Abstract Book

8. Classification of outflow abnormalities.
According to the published classification, abnormal venographic flow patterns were categorized into
four grades:
grade 1: venous outflow slowed down, no reflux detected;
grade 2: venous outflow slowed down, mild reflux and/or pre-stenotic dilation of the vein;
grade 3: venous outflow slowed down, with reflux and outflow through collaterals;
grade 4: no outflow through the vein, huge outflow through collaterals.
9. Should we assess stenoses of intracranial sinuses
Catheterization, mechanical and chemical thrombolysis, angioplasty and stenting of intracranial
venous sinuses are performed by neurointerventionalists for venous thrombosis, pseudotumor cerebri
associated with venous stenosis and a few other uncommon disorders. However, the magnitude of
possible complications is significantly higher than the same interventions in extracranial veins. The
most dreaded complication is perforation of the jugular bulb or sinus or wire perforation of a cortical
or cerebellar vein with devastating and usually fatal intracerebral hemorrhage. In addition, the
anatomical features of extracranial veins, such as plasticity, compliance and deformability are simply
not there for these venous channels encased partly in bone and partly in rigid leafs of dura permeated
by delicate and unpredictable draining veins. Therefore, the questions regarding management of
intracranial sinuses are:
- Should we perform venography of these veins routinely, or only in very selected cases, since
most of the doctors will not manage a lesion in this location even if detected, while the risk of
diagnostic venography in this particular area cannot be neglected.
- Should we perform therapeutic procedures in this territory, or rather should we wait until an
evidence of clinical benefit from the treatments for CCSVI performed in other venous
territories will be more obvious.
- Pre-procedural evaluation of intracranial vein routinely consists of MR venography. It is wellknown
that there is a lot of artifacts associated with this imaging test, for example very often
left transverse sinus does not show at MRV, while actually it is perfectly patent; what is the
best way to evaluate these veins before and after endovascular treatment?
10. How to evaluate and manage stenoses in the upper part of the internal jugular vein,
especially at the level of jugular foramen.
In some patients the upper (cranial to the facial vein) internal jugular vein is narrow, hypoplastic,
sometimes with associated flow impairment. The questions regarding this particular problem are:
- Should we interpret such a vein as pathologic according to diameter measurements (if yes,
which cutoff should be applied)
- Alternatively, should we rather look at flow disturbances, especially at backflow of injected
contrast
- What is the best mode of management of such stenosed venous segment: standard balloon
angioplasty (pro – a relatively safe procedure; contra – high rate of restenosis), stenting (pro –
more efficient than PTA; contra – risk of migration, risk of thrombotic or hyperplastic
occlusion), cutting balloon (pro more efficient than PTA, more safe than stenting; contra –
thrombotic or bleeding complications possible; still, not very likely).
11. The role for IVUS in the assessment of CCSVI
Should IVUS be an integral part of venography? What are advantages and disadvantages of such an
approach?