title: Chronic cerebrospinal venous insufficiency: pitfalls and perils of sonographic assessment.
abstract: OBJECTIVE
  Duplex sonography has been proposed as a diagnostic modality for detection of chronic cerebrovascular venous insufficiency, a recently proposed hypothesis of multiple sclerosis (MS) pathogenesis. We reviewed potential challenges of duplex sonography for diagnosis of chronic cerebrovascular venous insufficiency and used interim pooled data from a study aimed to apply cerebrovascular venous insufficiency criteria to a group of patients with MS and control patients without MS.
  
  
  METHODS
  Duplex sonography for chronic cerebrovascular venous insufficiency was performed in patients with MS and controls. Extracranial and deep cerebral veins were studied by using a published chronic cerebrovascular venous insufficiency protocol and criteria. Comparative imaging was performed to explore how physiologic factors and imaging techniques could affect key parameters. The effects of varying definitions on fulfilling chronic cerebrovascular venous insufficiency diagnostic criteria were also explored.
  
  
  RESULTS
  Forty-two patients were enrolled. Twenty-five (60%) had a reduction in internal jugular vein cross-sectional area by 50% or more, cross-sectional area of 0.3 cm(2) or less, and/or a B-mode abnormality. No patients had reflux longer than 0.88 seconds in both sitting and supine positions, the presence of duplex sonographic reflux on transcranial Doppler imaging, or a larger internal jugular vein cross-sectional area in the sitting versus supine position. Fourteen patients (33.3%) had either a flap or septum, and 1 had a web. Collateral veins to the vertebral veins were identified in 14 of 42 patients (33.3%). The use of transcranial Doppler imaging versus quality Doppler profiles resulted in fewer patients meeting criteria for chronic cerebrovascular venous insufficiency.
  
  
  CONCLUSIONS
  There are several important variables, including physiologic, technical, and criterion definitions, in the application of sonographic assessment of chronic cerebrovascular venous insufficiency that may affect diagnostic accuracy.
authors.affiliation: Heart and Vascular Institute, Noninvasive Vascular Laboratory (E.S.H.K., A.G.), Cleveland Clinic Lerner College of Medicine of Case Western Reserve University (C.D.), Imaging Institute, Neurovascular Laboratory (L.B., L.R.), Mellen Center for Multiple Sclerosis (R.J.F., A.R.-G.), and Neurological Institute, Cerebrovascular Center (I.K., M.L.), Cleveland Clinic, Cleveland, Ohio USA. kims@ccf.org.
authors.forename: Esther S H
authors.initials: ES
authors.lastname: Kim
authors.affiliation: Heart and Vascular Institute, Noninvasive Vascular Laboratory (E.S.H.K., A.G.), Cleveland Clinic Lerner College of Medicine of Case Western Reserve University (C.D.), Imaging Institute, Neurovascular Laboratory (L.B., L.R.), Mellen Center for Multiple Sclerosis (R.J.F., A.R.-G.), and Neurological Institute, Cerebrovascular Center (I.K., M.L.), Cleveland Clinic, Cleveland, Ohio USA.
authors.forename: Claudiu
authors.initials: C
authors.lastname: Diaconu
authors.affiliation: Heart and Vascular Institute, Noninvasive Vascular Laboratory (E.S.H.K., A.G.), Cleveland Clinic Lerner College of Medicine of Case Western Reserve University (C.D.), Imaging Institute, Neurovascular Laboratory (L.B., L.R.), Mellen Center for Multiple Sclerosis (R.J.F., A.R.-G.), and Neurological Institute, Cerebrovascular Center (I.K., M.L.), Cleveland Clinic, Cleveland, Ohio USA.
authors.forename: Leasa
authors.initials: L
authors.lastname: Baus
authors.affiliation: Heart and Vascular Institute, Noninvasive Vascular Laboratory (E.S.H.K., A.G.), Cleveland Clinic Lerner College of Medicine of Case Western Reserve University (C.D.), Imaging Institute, Neurovascular Laboratory (L.B., L.R.), Mellen Center for Multiple Sclerosis (R.J.F., A.R.-G.), and Neurological Institute, Cerebrovascular Center (I.K., M.L.), Cleveland Clinic, Cleveland, Ohio USA.
authors.forename: Robert J
authors.initials: RJ
authors.lastname: Fox
authors.affiliation: Heart and Vascular Institute, Noninvasive Vascular Laboratory (E.S.H.K., A.G.), Cleveland Clinic Lerner College of Medicine of Case Western Reserve University (C.D.), Imaging Institute, Neurovascular Laboratory (L.B., L.R.), Mellen Center for Multiple Sclerosis (R.J.F., A.R.-G.), and Neurological Institute, Cerebrovascular Center (I.K., M.L.), Cleveland Clinic, Cleveland, Ohio USA.
authors.forename: Alia
authors.initials: A
authors.lastname: Grattan
authors.affiliation: Heart and Vascular Institute, Noninvasive Vascular Laboratory (E.S.H.K., A.G.), Cleveland Clinic Lerner College of Medicine of Case Western Reserve University (C.D.), Imaging Institute, Neurovascular Laboratory (L.B., L.R.), Mellen Center for Multiple Sclerosis (R.J.F., A.R.-G.), and Neurological Institute, Cerebrovascular Center (I.K., M.L.), Cleveland Clinic, Cleveland, Ohio USA.
authors.forename: Irene
authors.initials: I
authors.lastname: Katzan
authors.affiliation: Heart and Vascular Institute, Noninvasive Vascular Laboratory (E.S.H.K., A.G.), Cleveland Clinic Lerner College of Medicine of Case Western Reserve University (C.D.), Imaging Institute, Neurovascular Laboratory (L.B., L.R.), Mellen Center for Multiple Sclerosis (R.J.F., A.R.-G.), and Neurological Institute, Cerebrovascular Center (I.K., M.L.), Cleveland Clinic, Cleveland, Ohio USA.
authors.forename: Larry
authors.initials: L
authors.lastname: Raber
authors.affiliation: Heart and Vascular Institute, Noninvasive Vascular Laboratory (E.S.H.K., A.G.), Cleveland Clinic Lerner College of Medicine of Case Western Reserve University (C.D.), Imaging Institute, Neurovascular Laboratory (L.B., L.R.), Mellen Center for Multiple Sclerosis (R.J.F., A.R.-G.), and Neurological Institute, Cerebrovascular Center (I.K., M.L.), Cleveland Clinic, Cleveland, Ohio USA.
authors.forename: Alexander
authors.initials: A
authors.lastname: Rae-Grant
authors.affiliation: Heart and Vascular Institute, Noninvasive Vascular Laboratory (E.S.H.K., A.G.), Cleveland Clinic Lerner College of Medicine of Case Western Reserve University (C.D.), Imaging Institute, Neurovascular Laboratory (L.B., L.R.), Mellen Center for Multiple Sclerosis (R.J.F., A.R.-G.), and Neurological Institute, Cerebrovascular Center (I.K., M.L.), Cleveland Clinic, Cleveland, Ohio USA.
authors.forename: Mei
authors.initials: M
authors.lastname: Lu
mesh_terms: D002561:Cerebrovascular Disorders / Q000150:complications / Q000000981:diagnostic imaging*; D002908:Chronic Disease; D005260:Female; D006801:Humans; D008297:Male; D008875:Middle Aged; D009103:Multiple Sclerosis / Q000209:etiology; D018608:Ultrasonography, Doppler; D018084:Ultrasonography, Interventional; D014689:Venous Insufficiency / Q000150:complications / Q000000981:diagnostic imaging*
keywords: Doppler sonography; chronic cerebrospinal venous insufficiency; multiple sclerosis; sonography; vascular ultrasound