Chronic cerebrospinal venous insufficiency in patients with multiple - PDF document

Downloaded from jnnp.bmj.com on February 16, 2010 - Published by group.bmj.com Chronic cerebrospinal venous insufficiency in patients with multiple sclerosis P Zamboni, R Galeotti, E Menegatti, et al. J Neurol Neurosurg Psychiatry 2009 80: 392-399 originally published online December 5, 2008 doi: 10.1136/jnnp.2008.157164 Updated information and services can be found at: http://jnnp.bmj.com/content/80/4/392.full.html These include: References This article cites 35 articles, 17 of which can be accessed free at: http://jnnp.bmj.com/content/80/4/392.full.html#ref-list-1 Article cited in: http://jnnp.bmj.com/content/80/4/392.full.html#related-urls Open Access This is an open-access article distributed under the terms of the Creative Commons Attribution Non-commercial License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. Email alerting Receive free email alerts when new articles cite this article. Sign up in the box at the top right corner of the online article. service Topic collections Articles on similar topics can be found in the following collections � Immunology (including allergy) (43635 articles) � Multiple sclerosis (1501 articles) � Hypertension (11767 articles) � Radiology (14764 articles) � Radiology (diagnostics) (9767 articles) Notes To order reprints of this article go to: http://jnnp.bmj.com/cgi/reprintform To subscribe to Journal of Neurology, Neurosurgery & Psychiatry go to: http://jnnp.bmj.com/subscriptions

Downloaded from jnnp.bmj.com on February 16, 2010 - Published by group.bmj.com Research paper Chronic cerebrospinal venous insufficiency in patients with multiple sclerosis P Zamboni, 1 R Galeotti, 1 E Menegatti, 1 A M Malagoni, 1 G Tacconi, 1 S Dall’Ara, 1 I Bartolomei, 2 F Salvi 2 ABSTRACT gradient favours venous return to the right heart, See Editorial Commentary, p 358 Background: The extracranial venous outflow routes in which can be easily assessed with high-resolution 1 Vascular Diseases Center, clinically defined multiple sclerosis (CDMS) have not echocolour Doppler (ECD) and transcranial colour- previously been investigated. coded Doppler sonography (TCCS), which represent University of Ferrara, Ferrara, Italy; 2 Department of Neurology, an ideal method by which to investigate the haemo- Methods: Sixty-five patients affected by CDMS, and 235 Bellaria Hospital, Bologna, Italy dynamics of cerebral venous return. 9–19 In addition, controls composed, respectively, of healthy subjects, ECD clarified the postural control of the extracranial healthy subjects older than CDMS patients, patients Correspondence to: outflow pathways, as follows: 8–12 affected by other neurological diseases and older controls Professor P Zamboni, Vascular Diseases Center, University of the internal jugular vein (IJV) is the predomi- not affected by neurological diseases but scheduled for c Ferrara, 44100 Ferrara, Italy; nant pathway in the supine position, con- venography (HAV-C) blindly underwent a combined zmp@unife.it firmed by an increased cross-sectional area of transcranial and extracranial colour-Doppler high-resolu- the internal jugular vein (CSA) related to tion examination (TCCS-ECD) aimed at detecting at least Received 2 July 2008 increased blood volume in that posture; and two of five parameters of anomalous venous outflow. Revised 7 November 2008 redirection of venous flow to the vertebral Accepted 10 November 2008 According to the TCCS-ECD screening, patients and HAV- c Published Online First veins (VVs) occurs in the upright position, with C further underwent selective venography of the azygous 5 December 2008 compliant reduction of the CSA of the IJV. and jugular venous system with venous pressure In contrast, MR and selective injection venogra- measurement. phy are of course limited in evaluating cerebral Results: CDMS and TCCS-ECD venous outflow anomalies venous haemodynamics under different postural were dramatically associated (OR 43, 95% CI 29 to 65, and respiratory conditions. However, the latter p , 0.0001). Subsequently, venography demonstrated in especially provide excellent morphological but CDMS, and not in controls, the presence of multiple static details. severe extracranial stenosis, affecting the principal We present the results of a study that evaluated cerebrospinal venous segments; this provides a picture of the abnormalities of the cerebral venous outflow in chronic cerebrospinal venous insufficiency (CCSVI) with patients with MS using ECD-TCCS and selective four different patterns of distribution of stenosis and venography. substitute circle. Moreover, relapsing-remitting and secondary progressive courses were associated with CCSVI patterns significantly different from those of METHODS primary progressive (p , 0.0001). Finally, the pressure Non-invasive screening gradient measured across the venous stenosies was Patients and controls slightly but significantly higher. We investigated 65 patients affected by clinically Conclusion: CDMS is strongly associated with CCSVI, a defined MS (CDMS) and diagnosed according to scenario that has not previously been described, the revised McDonald criteria. 20 This group characterised by abnormal venous haemodynamics included 35 patients with a relapsing-remitting determined by extracranial multiple venous strictures of (RR) clinical course, 20 with secondary progressive unknown origin. The location of venous obstructions plays (SP), and 10 with primary progressive (PP) a key role in determining the clinical course of the course. 21 22 A relative expanded disability disease disease. score (EDSS) was attributed to each group. 23 Detailed data regarding their clinical, demographic, and genetic characteristics, MRI examination, Multiple sclerosis (MS) is an inflammatory demye- presence of oligoclonal bands in the cerebrospinal linating disease of the central nervous system fluid (CSF) are provided in table 1. PP patients and (CNS) of unknown pathogenesis. 1 2 MR venogra- 18 out of 55 RR-SP were not under treatment at phy 3–6 and postmortem studies 7 have demonstrated the time of the evaluation. a topographic correspondence between MS plaques As controls, we investigated 235 subjects sub- and cerebral venous system. The drainage through divided as follows: the extracranial venous outflow routes has not 1. 60 healthy subjects matched for age and previously been investigated in MS patients. gender with MS patients (HM-C). Posture and the mechanic movement of respiration 2. 82 healthy subjects older than the median age play a fundamental role in ensuring the correct of onset of CDMS (HA-C); 21 had haemody- cerebrospinal venous outflow. 8 At the time of expira- namic anomalies been present in the second tion, the intrathoracic pressure is approximately control group, we would not have been able This paper is freely available 2 5 cm H 2 O, and inspiration causes a respiratory to maintain that they have a role in MS, since online under the BMJ Journals muscular action that can generate an even lower the disease is not more expected in this age unlocked scheme, see http:// intrathoracic pressure, 2 8 cm H 2 O. The resulting category. jnnp.bmj.com/info/unlocked.dtl 392 J Neurol Neurosurg Psychiatry 2009; 80 :392–399. doi:10.1136/jnnp.2008.157164