title: Cross-sectional area variations of internal jugular veins during supine head rotation in multiple sclerosis patients with chronic cerebrospinal venous insufficiency: a prospective diagnostic controlled study with duplex ultrasound investigation.
abstract: BACKGROUND
  Normally, chronic cerebrospinal venous insufficiency (CCSVI) has been studied using echo-colour Doppler (ECD). Subjects are examined in the supine and sitting positions, in accordance with a static protocol without rotation of the head. A dynamic approach, to assess venous sizes with different degrees of head rotation, has only been performed to improve jugular venous catheterisation. These echographic studies have suggested that head rotation to the contralateral side increases the cross-sectional area (CSA) of the internal jugular veins (IJVs) in supine subjects. Our goal was to evaluate the behaviour of CSA of the IJVs during supine head rotation in multiple sclerosis (MS) patients with CCSVI, compared to healthy controls (HCs).
  
  
  METHODS
  The IJVs of 313 MS patients with CCSVI (male 43.8%, male/female 137/176; mean age 45 years old, range 19-77 years) and 298 HCs, matched by gender (male 43.6%, male/female 130/168) and age (mean age 46 years old, range 20-79 years), were compared using ECD. Their CSAs were evaluated with the subjects seated in a tiltable chair, first in the supine position at the level of the cricoid cartilage, with the head in a neutral position, and then after contralateral rotation to 90° from midline.
  
  
  RESULTS
  Significant differences between the jugular CSAs before and after head rotation were observed only in the MS patients for the IJVs with wall collapse (F[6,1215] = 6414.57, p < 0.001), showing on longitudinal scans a typical "hourglass" aspect that we defined as "miopragic". No significant difference was found in the distribution of these miopragic veins with regard to MS duration. There was a strong association between the CCSVI scores and the complexity of jugular morphological types (Χ2 [9, N = 313] = 75.183, p < 0.001). Wall miopragia was mainly observed in MS patients with SP (59.3%) and PP (70.0%) clinical forms, compared to RR (48.3%) forms (p = 0.015).
  
  
  CONCLUSIONS
  A dynamic ECD approach allowed us to detect IJVs with a significant increase in their CSAs during head rotation, but only in MS subjects. This feature, most likely the expression of congenital wall miopragia, could be secondary to dysregulation of collagen synthesis, but further histochemical studies will be needed to confirm this hypothesis.
authors.affiliation: Phlebolymphology Diseases Centre, Monza Polyclinic, Monza, Italy. massimiliano.farina@centrostudipatologievenolinfatiche.it.
authors.forename: Massimiliano
authors.initials: M
authors.lastname: Farina
authors.forename: Eugenio
authors.initials: E
authors.lastname: Novelli
authors.forename: Raffaello
authors.initials: R
authors.lastname: Pagani
mesh_terms: D000328:Adult; D000368:Aged; D002908:Chronic Disease; D005260:Female; D019416:Head Movements / Q000502:physiology*; D006801:Humans; D007601:Jugular Veins / Q000000981:diagnostic imaging*; D008297:Male; D008875:Middle Aged; D009103:Multiple Sclerosis / Q000000981:diagnostic imaging* / Q000453:epidemiology; D011446:Prospective Studies; D016683:Supine Position / Q000502:physiology*; D018616:Ultrasonography, Doppler, Duplex / Q000379:methods; D014689:Venous Insufficiency / Q000000981:diagnostic imaging* / Q000453:epidemiology; D055815:Young Adult