ISNVD Abstract Book

ISNVD Consensus On Ultrasound
Chronic Cerebrospinal Venous
Insufficiency Screening Criteria
MOROVIC 1,2 S, MENEGATTI 1 E, VISELNER 3 G, NICOLAIDES 4 AN, ZAMBONI 1 P
The Intersociety Faculty*
1
Vascular Diseases Center, University of Ferrara, Ferrara, Italy; 2 Dept. of Neurology, UHC Sestre milosrdnice Zagreb, Croatia; 3 Neurological Institute Mondino,
University of Pavia, Pavia, Italy; 4 Vascular Screening and Diagnostic Centre, Cyprus
Chronic Cerebrospinal Venous Insufficiency (CCSVI) is a syndrome
characterized by stenoses or obstructions of the internal jugular vein
(IJV) and/or azygos veins (AZV) with disturbed flow and formation of
collateral venous channels. Most common venous lesions are truncular
vascular malformations (intraluminal defects, segmental hypoplasia).
In order to ensure a high reproducibility of duplex scanning with
comparable accuracy between centres, recommendations with a detailed
protocol, standard methodology, and criteria have been proposed.
Even though considered a gold standard for determining the anatomical site,
type and extent of lesions producing CCSVI, catheter venography is invasive
and cannot be used as a screening method. Ultrasound is therefore an ideal
screening tool; it is non-invasive, can be performed at beside, and allows a
real-time assessment of venous status. It is a valuable diagnostic test since
high sensitivity and specificity have been demonstrated, in presence of
which, catheter venography will only be needed when a decision has already
been made for intervention.
During a Consensus Meeting, on March 13 th 2011, at the 1 st ISNVD Meeting in Bologna, Italy, experts agreed on protocol recommendations for CCSVI
screening criteria using ultrasound. At least two criteria have to be positive for a diagnosis of CCSVI to be considered.
The new, revised and accepted criteria are:
1. A) Bidirectional flow in one or both of the IJVs in both postures, or bidirectional flow in one position with absence of flow in the other
position and/or B) reversal or bidirectional flow in one or both vertebral veins (VVs) in both positions.
Normal flow with insignificant reflux less than 0.2
sec.
Reflux of 0.4 sec duration.
Reflux of 0.84 sec duration.
2. Bidirectional flow in the intracranial veins and sinuses. (An additional criterion)
Bidirectional flow in the IJV seen in longitudinal
view. Red color indicated reflux.
*International Society for Neurovascular
Diseases (ISNVD) in cooperation with
International Union of Angiology (IUA), European
Venous Forum (EVF), International Union of
Phlebology (UIP), American College of Phlebology
(ACP), Austral- Asian College of Phlebology
(AAsCP), Società Italiana di Chirurgia Vascolare
ed Endovascolare (SICVE), Società Italiana di
Angiologia e Patologia Apparato Vascolare
(SIAPAV)
*Faculty: D. Neuhardt (USA)-ACP representative;
M. B. Griffin (UK)-EVF representative; C. Setacci
(Italy)-SICVE representative; A. Cavezzi (Italy)-
UIP representative; B. B: Lee (USA)-IUA
representative; P. Thibault (Australia)-AAsCP
representative; G. Andreozzi (Italy)-SIAPAV
representative; M. Al-Omari (Jordan); S.
Bastianello (Italy); C. B. Beggs (UK); P. Cecconi
(Italy); V. Demarin (Croatia); C. Franceschi
(France); A. Galassi (Italy); E. M. Haacke (USA);
A. Lagace (Canada); N. Liasis (Greece); T. Ludyga
(Poland); M. Lugli (Italy); O. Maleti (Italy); M.
Mancini (Italy); M. Marioni (Italy); K. Marr (USA);
S. McDonald (Canada); N. Morrison (USA); S.
Sclafani (USA); A. Scuderi (Brasil); S. Shepherd
(UK); M. Simka (Poland); A. Stella (Italy); R.
Zivadinov (USA).
Visualization of the Power
Doppler signal (instead of
Color Doppler for an
increased spatial resolution)
of the Superior Petrosal
Sinus (1), Inferior Petrosal
Sinus (2), contralateral
Inferior Petrosal Sinus (3)
and (partially) contralateral
Superior Petrosal Sinus (4),
from the Transcaranial
window at the level of the
condyloid process of the
mandible.
Example of Reflux: the blood flow at the
level of the Superior Petrosal Sinus
(SPS) shows opposite directions
between inspiration and expiration; this
finding shows the presence of reversed
blood flow within the examined vessel
between the two phases of respiration.
The blood flow direction of the Inferior
Petrosal Sinus (IPS) is not detectable
during Expiration. The blood flow
direction of the Contralateral Inferior
Petrosal Sinus (CIPS) is not detectable
during Inspiration and Expiration
Example of No Reflux: the blood
flow at the level of the Superior
Petrosal Sinus (SPS) shows the
same direction between
inspiration and expiration; the
blood flow direction of the Inferior
Petrosal Sinus (IPS) is not
detectable during Expiration; the
blood flow direction of the
Contralateral Inferior Petrosal
Sinus (CIPS) is not detectable
during Inspiration and Expiration
3. A) Reduction of IJV cross sectional area (CSA) in supine position to ≤0.3 cm 2 which does not increase with Valsalva manoeuvre
(performed at the end of the examination) and/or B) Intraluminal defects such as flaps, septa or malformed valves combined with
hemodynamic changes (block, reflux, increased blood flow velocity). Valve leaflet/s immobility confirmed by M-mode.
membrane
CSA reduction to ≤0.3 cm2
Intraluminal defect-B mode
M-mode evaluation of jugular valve showing
mobility of the leaflets (arrow).
Valve leaflets immobility demonstrated in M-
mode (arrow).
4. A) Absence of detectable flow in
the IJV and/or VV, despite numerous
deep inspirations, in both sitting and
upright positions, or B) In one
posture absence of detectable flow in
IJV and/or VV, despite numerous
deep inspirations and bidirectional
flow detected in the other position,
same side.
Absence of detectable flow in longitudinal scan
of an IJV in supine posture.
5. A) CSA of the IJV is greater in the sitting position than in the lying
position or B) Appears almost unchanged despite change in posture.
All measurements should be performed on both sides, and in
the sitting and lying position. Criteria 1 and 4 are positive
only if present in both positions.
Example of Cross Sectional Area (CSA)
measurement of the IJV in supine position.
Example of Cross Sectional Area (CSA)
measurement of the IJV in sitting position
Performance of CCSVI screening, by following these recommendations ensures a high
comparable accuracy between centres.
reproducibility of duplex scanning with