ISNVD Abstract Book

FINDINGS ON VENOGRAPHY IN MS PATIENTS UNDERGOING AN EVALUATION
FOR CHRONIC CEREBROSPINAL VENOUS INSUFFICIENCY (CCSVI):
Correlation with MS Subtype and the Presence of Visual Symptoms at the Time of MS Diagnosis
Kenneth Mandato, MD; Arvin Bagherpour, MD; Lisa Kurian, MD;
Meridith Englander, MD; Gary P. Siskin, MD
Department of Radiology, Albany Medical Center, Albany, NY
PURPOSE: To compare the findings on venography of the internal
jugular and azygos veins with clinical symptoms and subtype
of Multiple Sclerosis (MS) in patients undergoing an evaluation
for chronic cerebrospinal venous insufficiency (CCSVI).
MATERIALS AND METHODS: A retrospective study of all MS
patients being evaluated for CCSVI during a 6-month period
was performed. Findings on venography were classified based
on the distribution of stenoses within the internal jugular and
azygos veins, a system described by Bartolomei, et al. (see Table
1) These findings were compared with MS subtype and with the
presence or absence of visual symptoms at the time MS was initially
diagnosed. Positive findings on venography included the
criteria used for treatment with angioplasty a 50% stenosis or
a flow abnormality in association with a 50% stenosis in each
studied vein.
CONCLUSIONS: The presence of visual symptoms at the time
of diagnosis, and the subtype of MS, are not predictive of the
findings seen on catheter venography performed as part of an
evaluation for CCSVI. This contradicts previously published findings,
which neatly correlated symptoms at presentation and the
patients’ MS subtype with the location of venous disease on
venography. This study leads to questions regarding the role
that CCSVI plays in directly causing the clinical manifestations
of MS. A prospective trial assessing the ability of clinical findings
to predict venography findings and treatment outcome is
recommended.
TABLE 1: PATTERNS OF CCSVI OBSERVED IN MS CASES
Type A: Stenosis of proximal azygous vein associated with unilateral internal
jugular vein (IJV) stenosis
Type B: Significant stenoses of both IJVs and the proximal azygous vein
Type C: Bilateral IJV stenoses with normal azygous vein
Type D: Multifocal azygous vein stenoses with or without IJV abnormalities
1A
1B
RESULTS: 318 patients were treated during the study period; the
study population consisted of 251 patients (mean 49.4 years;
3% male and 63% female) with complete historical data available
for analysis. The distribution of MS subtypes was as follows
122/251 (49%) had relapsing remitting MS, 6/251 (30%)
had secondary progressive MS, and 53/251 (21%) had primary
progressive MS. 0 patients had visual symptoms at the time of
initial diagnosis of MS (39 patients had visual symptoms alone;
31 patients had visual and other symptoms). Based on the previously
described classification system for venography findings,
38/251 (15.1%) patients had a Type A pattern (see Figures 1A-
1D), 100/251 (39.8%) patients had a Type B pattern, 108/251
(43.0%) patients had a Type C pattern, and 5/251 (2.0%) patients
had a Type D pattern. An analysis of this data determined
that the findings on venography were not associated with MS
subtype (p=0.590) or with the presence or absence of visual
symptoms (p= 0.0912).
1C
FIGURE 1A: Conventional azygous venography in the left anterior oblique projection shows
a “kinking” form of stenosis with retrograde flow into intercostal vessels. FIGURE 1B:
Hemodynamically significant severe stenosis in the left internal jugular vein in the same patient
with proximal azygous vein stenosis (type A) FIGURE 1C: 10mm balloon angioplasty of
the proximal azygous vein was performed. FIGURE 1D: Significant improvement in azgyous
diameter and antegrade flow with regression of intercostal collaterals following angioplasty.
The patient also underwent left IJV angioplasty (not shown) with marked clinical improvement
within 24 hours.
REFERENCES: EREN
RENC
: Bartolomei I, et al. Int Angiol 2010; 29183-188
amboni, et al. ournal eurol eurosurg Psychiatry 2009; 80 392-399
1D