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Non-Invasive Diagnosis of Chronic Venous Disorders

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Non-Invasive Diagnosis of Chronic Venous Disorders 162 NEWS IN ANGIOLOGY • ChrONIC vENOuS dISEASES nTheon-invasive mem-neT programdiagnosis 12 for chronicof cerebro-spinalchronic venous venous disorders insufficiency 43 color flow dopplerP.l. antignani imaging assessmenT s . Mandolesi, a. d’alessandro Chronic venous insufficiency (CVI) is the con- of investigation is the color Doppler ultrasound dition in which one or more veins become unable imaging (CDUI)). For more proximal vessels such to fulfill their three specific functions:1 as those of the pelvis magnetic resonance imaging – drainage from the tissues of toxic substances; (MRI) is very reliable for the detection of throm- – filling of the heart cavities; bosis. – thermoregulation of tissues; In 1988 with the birth of the conservative he- in any physical activity or position of the subject. modynamic ambulatory treatment of varicose What is the event that causes the CVI? veins, Claude Franceschi has realized the first Any condition that poses an obstacle to the cartographic maps of venous hemodynamics of drainage of one or more veins it is the cause that the lower limbs.1 In 1992, the authors showed for in time will determine the appearance of clinical the first time the venous compression syndrome disorders manifested as CVI. (VCS) of the lower limbs 2 and in 2011 that of the The CVI has been studied mainly for its effects veins draining cerebral spinal flow.3 The VCS has on the circulation of the lower limbs. Specifically, widened the field of interest of the phlebologists lower limb varicose veins are characterized first by and lead to static and dynamic biomechanic stud- the dilation of the veins and gradually, over the ies. Phlebological treatments have been performed years, from the serious adverse effects on the skin by dermatologists, general surgeons, vascular sur- of the lower limbs. Varicose veins if not treated in geons, angiologists, cardiologists or radiologists, time with elastic-compression stockings, sclero- but how can we define a phlebologist today? therapy, surgical, laser or a conservative hemody- “Phlebologist is an expert in venous system dis- namic method they will progress. eases who is able to realize and interpret a CFDI How does the varicose disease evolve over time? venous hemodynamic map”.4 – They first appear as dilated and tortuous veins; Why is it so important that a phlebologist is – after a while the skin pigment becomes darker able to realize and interpret a venous CFDI map? due to leakage of blood into the tissues (hemosi- The hemodynamic venous map today is the lowest derin deposits); common denominator of venous investigation for – then there is chronic inflammation of the skin understanding the pathological condition of the which becomes red and painful (ekzema) and subject’s vein. hardened (lipodermatosclerosis); – finally, tissue necrosis results in a destructive ■■ ChrOniC CerebrO-sPinAl and painful deep wound of the skin, the vari- venOus insuffiCienCy (CCSVi) cose ulcer, which is followed by very slow heal- ing with repair scar tissue. In recent years, the CVI has been recognized to be present in many parts of the body. It is now Superficial vein thrombosis of the veins of the well-defined also at the level of the venous system lower extremities is a frequent event which is pain- draining the cerebro-spinal blood and is called ful and disabling, but with low risk of major com- chronic cerebro-spinal venous insufficiency (CC- plications such as pulmonary embolism. Throm- SVI). It is a CVI that determines its effects in the bosis that affects the deep veins of the legs or pelvis brain and spinal cord and it is linked to blocked (DVT) is at high risk of pulmonary embolism and drainage or venous stasis in the territory of the der- should be promptly recognized and treated. ivation of the internal jugular and vertebral veins. How to recognize the presence of a varicose vein or The CCSVI is characterized by multiple ste- thrombosis of a vein of the lower limbs? nosis/obstructions affecting the principal extra- The fastest and accurate non-invasive method cranial outflow pathways of the cerebrospinal ve- ANTIGNANI 2014.indd 162 06/07/14 12:05 43 • thE mEm-NEt prOGrAm fOr ChrONIC CErEbrO-SpINAL vENOuS INSuffICIENCY COLOr flow dOppLEr ImAGING ASSESSmENt 163 nous system, the internal jugular veins (IJVs), the important biomechanical factors involved are dis- vertebral veins (VVs) and the azygos vein (AZY). location of the first and the other distal cervical It is distributed in four main hemodynamic pat- vertebrae. They cause venous compression due to terns.5 Furthermore, CCSVI determines signifi- traction of muscle bands or dislocation of the cer- cant changes in cerebral venous hemodynamic, vical muscles. with a very high incidence of reflux in both intra- Recently the authors are working on a biome- and extra-cranial venous segments as well as loss chanical test that will indicate the best manipu- of the postural regulation of cerebral venous out- lative treatment. Also what exercises could have flow.5 Zamboni and his team in 2011 suggested a an effect to decompress these vessels. Initially one protocol including five CFDI venous criteria that should aim with only spinal manipulation and characterize this syndrome as follows: postural exercises to obtain sufficient resolution of – criterion 1: reflux in the IJV and/or VV; a) bi- the venous compression that causes the hemody- directional flow in one or both of the IJVs in namical disturbance. If failed and only then a sur- both postures or bidirectional flow in one posi- gical option to resect the bands should be offered. tion with absence of flow in the other position. The CCSVI is a condition found in many neu- These findings suggest IJV stenosis; b) reversal rological diseases, as we have seen with varying or bidirectional flow in one or both of VVs in incidence in Alzheimer’s disease (AD), in the pseu- both positions. These findings suggest stenosis do-tumor cerebri, in Meniere’s disease, macular in the azygos vein, based on reports control- degeneration of the retina, in the Arnold-Chiari ling the Doppler parameter in comparison with syndrome and multiple sclerosis (MS). catheter venography; Its possible correlation with these diseases needs – criterion 2: intracranial reflux; several years of scientific longitudinal studies to – criterion 3: IJV stenosis a) severe reduction of be verified. What we can extrapolate from our the cross sectional area (CSA) of the IJV in the current knowledge from CVI in the lower limbs supine position <0.3 cm 2 which does not in- is that similar hemodynamic, morphological and crease with a Valsalva maneuver, performed at clinical situations can be applied to CCSVI. the end of the examination; b) intraluminal de- In the literature there evidence of the following: fects such as webs, septa or malformed valves – formation of plaques in the cerebral spinal tis- combined with hemodynamic changes like in- sue that is inflamed and becomes active causing creased velocity, absence of flow, reflux/ bidirec- a so-called contrastographic enhancement; tional flow etc. An M-mode investigation of the – dilated veins in the center of the plates and the leaflets may clarify if they are mobile or not; surface regions of the brain; – criterion 4: absence of detectable flow in the IJV – iron deposits around cerebral veins and in cer- and/or VVs. Outflow obstruction in the cervical ebral plaques; veins indicated by: a) absence of Doppler signal – there gliosis zones representing scarring of the in the IJV and/or the VVs, even after deep in- brain tissue. spiration, in both sitting and supine positions or b) in one posture but with bidirectional flow de- The presence of contributing factors such as tected in the other position. These findings are metabolic, genetic or biomechanical could lead associated with stenosis proximal to the point of to different clinical presentation of CCSVI in assessment; patients with the same venous abnormalities. To – criterion 5: negative difference of the CSA of the identify these contributing factors may explain IJVs measured at the J2 point, that is a change the different clinical manifestations; some patients in the area between the supine and orthostatic have long periods of well being while in others hypotension. The presence of two of them is there is rapid transition to progression of the dis- enough to diagnose CCSVI.6 ease. Many subjects without any symptoms may have It is well known the compressive venous syn- CCSVI, therefore, it is prudent to be diagnosed drome affecting the veins of the lower limbs.2 early with a CFDI assessment. Similarly in CCSVI it has been shown with The CFDI examination to assess CCSVI is a CFDI that venous compression can be detected very difficult and tedious test that needs about an 7 in approximately 48% of the subjects. The most hour’s work by an expert ultrasonographer. ANTIGNANI 2014.indd 163 06/07/14 12:05 164 NEWS IN ANGIOLOGY • ChrONIC vENOuS dISEASES It involves venous CFDI assessment of the main The last but not the least problem currently is veins draining the brain in the supine and upright the presence in the literature, of two groups of cri- position, the Manconi breathing test, the neck ro- teria for the CFDI diagnosis of CCSVI. tation test, a Valsalva maneuver, transcranical deep The first list of five criteria is the original one veins assessment and 3 rd ventricle measurements. proposed by Zamboni in 2009. The main problem of the assessment is to remem- The second list was approved in 2011 by a con- ber the CCSVI five Criteria that may frequently be sensus of experts of the international vascular sci- misinterpreted. entific societies. This last list of criteria is extensive. The CFDI written reports at present are either too simple and repetitive or very complex and only ■■ Map history comprehensible to an expert; sometimes they are shown on complex diagrams that are difficult to Since 1988 the authors have reported, by hemo- understand.
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