CASE 9897 Published on 05.03.2012

Ultrasonic evaluation of internal jugular veins in multiple sclerosis



Case Type

Clinical Cases


Oreste D, Pavone S

Via Giulio Petroni 120, 70124 Bari (BA), Italy;

35 years, female

Area of Interest Cardiovascular system ; Imaging Technique Ultrasound, Ultrasound-Power Doppler, Ultrasound-Colour Doppler
Clinical History
A 35-year-old female patient with a 11-year story of Multiple Sclerosis (MS) (Relapsing Remitting type) underwent an ultrasonic evaluation of the neck and intracranial veins to establish if a diagnosis of CCSVI (a recently discovered pathological condition supposed to be related to MS) could be done.
Imaging Findings
The Internal Jugular (IJV) and Vertebral (VV) veins were explored with axial and longitudinal scans with the patient in supine and upright position, as suggested by the Zamboni protocol [1]. Each anatomical finding was related with the EcoColorDoppler (ECD) and PowerDoppler (PD) evaluation, in order to establish the haemodynamic effect of such anomalies. In the middle segment (J2) of the left IJV a strong wall thickening with a stenosis at the same level was demonstrated (Fig. 1) configuring the so called "annuls". In the distal tract (J1) of the right IJV an intraluminal membrane was found (Fig. 2) with a partial exclusion of a part of the lumen from blood flow.
Other patients were after arruolated in our screening study and a lot of other anomalies were found like hypomobile valves (Fig. 3a, 3b), vascular compressions (Fig. 4), intraluminal septa (Fig.5), all producing haemodynamic effects like blood reflux or "blocked flow".
Chronic cerebrospinal venous insufficiency (CCSVI) is characterised by anomalies of the internal jugular and/or azygos veins with reflux toward brain or "blocked flow". Many studies using ultrasound in patients affected by MS have demonstrated an high prevalence of CCSVI (mean 70%; range 0-100%; N.=1496), despite of the prevalence in patients without MS (mean 10%; range 0-36%; N.=635) [1]. Ultrasound has proved to be helpful because of its combination of blood flow parameters measurement and anatomical imaging which allow relating each vessel anomaly with its haemodynamic effect. Even if the origin of such venous anomalies is still not completely known, the obstruction to the drainage of cerebrospinal veins found in patients with MS seems to suggest that venous obstruction could be an important aetiopathogenic factor for this disease. Our screening study of prevalence of CCSVI in patients affected by MS (grouped independently from the clinical form and duration of the disease) demonstrated an increased prevalence (mean 87%; N.= 104) of anatomical and physiological obstructions mostly located in the IJV system, sometimes bypassed, depending on their severity, with the collaterals activation (Fig. 6). It has been demonstrated [2] that in the supine position,the predominant cerebral venous outflow is through the IJVs, while in the upright position the VVs become the predominant pathway. This means that a complete study in both the positions is needed to assess the haemodynamic effects of such intraluminal or parietal anomalies.
Sometimes, during the ECD examination, no flow signal is detected, even with PRF set to very low values (Fig.7). The so called "blocked flow", depending on the too slow speed of blood flow in that vein tract, could be a signal of a stenosis located in a more distal segment of the same vessel or of its junctional tract with other veins; however, some of these patients don't present any detectable B-mode anomaly at IJVs, VVs, or intracranial veins. It has been reported in literature that a kind of obstruction of the azygos system could be associated in these patients.
Catheter Venography (CV) is considered the gold standard [3] for assessment of the anatomical site, type and extent of lesions. However, CV is invasive and provides poor details about wall and intraluminal defects. In addition, dysmorphic valve cusps can be crossed by the catheter and kept open, that way bypassing the stenosis. Instead, ultrasound demonstrates a noninvasive method of screening because of its combination of blood flow parameters measurement and anatomical imaging.
Differential Diagnosis List
Chronic cerebrospinal venous insufficiency
Collapsing veins
Final Diagnosis
Chronic cerebrospinal venous insufficiency
Case information
DOI: 10.1594/EURORAD/CASE.9897
ISSN: 1563-4086