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Lymphedema is an uncommon extra-articular complication of rheumatoid arthritis (RA), but it can also be associated with psoriatic arthritis (PsA), although rarely. While lymphedema associated with RA is well characterized in literature, only few cases have been described among patients with PsA. Upper limbs are the most common sites involved, with asymmetric pattern, even if some patients may present lower limb oedema, or progressive bilateral oedema. Chronic established lymphoedema deriving from lymphatic vessel dysfunction should be clearly distinct from inflammatory distal pitting edema (IDPE), resulting from tenosynovitis and frequently encountered in PsA. In contrast to lymphedema, the latter condition generally presents an excellent response to steroid therapy, therefore it is essential to recognize the exact etiology of lymphoedema to approach the correct treatment. Here we report a case of lower limbs lymphedema in PsA and review the available literature upon the topic.

In this proof-of-concept study the impact of central venous pressure (CVP) on internal jugular veins cross-sectional area (CSA) and blood flow time-average velocity (TAV) was evaluated in eight subjects, with the aim of understanding the drivers of the jugular venous pulse. CVP was measured using a central venous catheter while CSA variation and TAV along a cardiac cycle were acquired using ultrasound. Analysis of CVP, CSA and TAV time-series signals revealed TAV and CSA to lag behind CVP by on average 0.129 s and 0.138 s, with an inverse correlation between CSA and TAV (r= –0.316). The respective autocorrelation signals were strongly correlated (mean r=0.729-0.764), with mean CSA periodicity being 1.062 Hz. Fourier analysis revealed the frequency spectrums of CVP, TAV and CSA signals to be dominated by frequencies at approximately 1 and 2 Hz, with those >1 Hz greatly attenuated in the CSA signal. Because the autocorrelograms and periodograms of the respective signals were aligned and dominated by the same underlying frequencies, this suggested that they are more easily interpreted in the frequency domain rather than the time domain.

Podoconiosis causes a painful massive swelling of the lower limbs, bilaterally and asymmetrically. It is caused by exposure to particles common in soils of volcanic origin and is second only to lymphatic filariasis as the leading cause of tropical lymphoedema. An estimated 4 million people live with podoconiosis globally in 32 potentially endemic countries. Podoconiosis is associated with positive family history of podoconiosis, bare foot, gender, poor housing condition, foot hygiene, income and educational status of the affected patients. There are also cultural barriers involved in maintaining a high epidemiology of the disease. Podoconiosis was never been prioritized either in intervention or research programmes. This may be due to the lack of resources for new health initiatives, which is a common problem in the low-income tropical countries in which this disease is present. Only Ethiopia, Cameroon, and Rwanda report podoconiosis within their routine health management information systems.We believe that comprehensive podoconiosis control strategies such as promotion of footwear and personal hygiene are urgently needed in endemic countries in the African Region. Mapping, active surveillance and a systematic approach to the monitoring of disease burden must accompany the implementation of podoconiosis control activities.

Background The elongation of the styloid process is historically associated with two variants of the Eagle syndrome. The classic one, mainly characterized by pain and dysphagia, and the carotid variant characterized by pain and sometimes by cerebral ischemia. We observed a further variant characterized by a styloid elongation coursing adjacent to the transverse process of C1, causing significant compression of the internal jugular vein. Methods We reviewed all the cases of Eagle syndrome, including the jugular variant, admitted in our Hospital in the last six years. We compared symptomatology, associated comorbidities and imaging. Data were statistically analyzed. Results Overall 23 patients were admitted to the Hospital for symptomatic elongation of the styloid process, 11 male and 12 females. The jugular variant of the Eagle syndrome is clinically delineated by significant differences, as compared to the classic variant and carotid variants. Headache was the more prominent symptom (p p Conclusions The elongation of the styloid process may have different paths which creates compression on the surrounding anatomical structures. There may be a possible association of jugular impingement by an elongated styloid process with symptoms. Trial registration Protocol n°45–2013.

BACKGROUND High prevalence of valve absence was found in the internal jugular vein (IJV) of healthy volunteers by means of M-mode high-resolution Echo Colour Doppler (ECD). However, the prevalence of valve in neurovascular disorders linked to Chronic Cerebrospinal Venous Insufficiency (CCSVI) is still unknown. METHODS A cohort of 83 Healthy Controls (HC), 71 Multiple Sclerosis (MS), 99 Inner Ear Disorders (IED) underwent ECD investigation of the IJV valve, including M-mode evaluation and related hemodynamics. The primary outcome measure was characterization of valve presence, morphology and motility, whereas the secondary outcome was the rate of flow alteration. RESULTS Bilateral valve presence was found in 38% of HC, 58% of MS and 25% of IED, whereas, bilateral valve absence was recorded in 16% of HC, 10% of MS and 31% of IED (p

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Because the internal jugular vein (IJV) valve is the only protective valve between the brain and heart, recent studies have focused on the dynamic behaviour of the valve and its importance in regulating the cerebral blood outflow pathway. However, the mechanism underlying valve opening and closure, as well as the normal opening time, has not been investigated before. The aim of the study described here was to investigate IJV physiology in healthy young adults by means of ultrasound imaging. Twenty-four normal young adults (16 male, 8 female, 21.79 ± 0.79 y of age) were enrolled in this study. Each participant underwent IJV B- and M-mode ultrasound scans of the neck veins in supine position. Data on IJV leaflet movement and IJV blood velocity were extracted from images with the associated electrocardiogram traces to analyze the opening and closure cycles of IJV leaflets. The normal opening time calculated in this study includes 70% of the dynamic valve cycle. The normal opening time of the IJV valve could be a new physiologic metric and serves as a premise for further studies in the field of cerebral venous return.

Compliance is a characteristic of every deformable system. Compliance is very clear concept in physics and mechanics but in clinics, perhaps, is not the same. However, in veins compliance fits perfectly with the function of drainage of the venous system. Volumetric increase (dV) of the content is correlated with pressure increase (dP) inside the vein according to the equation C’= dV/dP. In humans 75% of the blood is located in the venous system, primarily because the molecular components of a vein media layer is significantly more compliant to that of arteries. This property is fundamental to understanding the change in blood volume in response to a change in posture. Measurements of venous compliance in clinical practice can be done by the means of ultrasound, as well as with the plethysmography. Ultrasound methods assimilate the cross sectional area to the volume of the vein, because it reflects the blood content. Changes in cross sectional area can be reliably measured in response to a change in posture, while pressure can be derived from the hydrostatic pressure changes. Venous compliance is of paramount importance also in pulsatile veins such as the inferior or superior vena cava and the jugular veins, where high resolution ultrasound may accurately derive the cross sectional area. Clinical implications of the mechanical properties of the venous wall are extensively discussed, including the need of dedicated venous stenting, which takes into account venous compliance as the main parameter of the venous function. In addition, venous compliance is the interpretative key for a better understanding of plethysmography curves, as well as of varicose veins and of their return to normal cross sectional area following ambulatory venous pressure reduction.

The aim of this study is to evaluate whether cerebral inflow and outflow abnormalities, assessed by the means of a validated ultrasound model, could be associated with Sudden Sensorineural Hearing Loss (SSNHL). According to Clark, a total of 42 patients affected by severe SSNHL and 19 healthy volunteers matched by gender without any history of sudden hearing impairment have been included in this study. Patients and controls underwent EchocolorDoppler assessment of brain hemodynamics. All subjects affected by SSNHL were also assessed with Auditory Brainstem Responses (ABR) and Magnetic Resonance Imaging (MRI) in order to exclude retrocochlear pathology. The head inflow through the common carotid artery was practically equivalent between groups, but at the level of the carotid bifurcation, the external carotid artery showed a highly significant flow rate in SSNHL 5.4±2 vs 3.9±1.1 ml/s in controls (p=0.01). The brain inflow was similar between patients and controls, but interestingly the flow rate of the vertebral artery was significantly reduced in SSNHL 1.6±0.8 vs 2.8±0.9 ml/s (p=0.01). The brain outflow was found significantly restricted at the level of the jugular outlet 6.6±6 vs 9.9±6 ml/s (p=0.002); consequently, the collateral flow index was significantly increased in SSNHL (p=0.001). The present study shows a discrepant distribution of the brain inflow which seems to penalize the posterior segments of the Willis polygon in patients affected by severe SSNHL. In addition, our study confirms the presence of chronic cerebrospinal venous insufficiency in SSNHL with significant activation of venous collateral circulation.

Preclinical and observational reports indicate that adipose tissue (AT) is a safe and promising tool to treat non-healing venous leg ulcers (VLUs).From an initial cohort of 38 patients, 16 patients affected by non-healing VLUs were randomly allocated to the experimental arm (5 men and 3 women) and control arm (5 men and 3 women). In the experimental arm, wounds were treated by debridement, centrifuged adipose tissue (CAT), advanced dressings and compression. No experimental treatment (CAT) was administered to the control arm. We investigated the functional and the immunophenotypical features of the harvested CAT-derived stem cells. The primary outcome measures were healing time and safety of the cell treatment. Secondary outcomes were pain evaluated by numeric rating scale (NRS), complete wound healing at 24 weeks by Margolis Index and wound-healing process expressed in square centimeters per week. The various immunophenotypic and functional characteristics of CAT-derived stem cells were then correlated with the clinical outcomes.No major adverse events were recorded. The healing time was significantly faster by applying CAT, 17.5 ± 7.0 weeks versus 24.5 ± 4.9 weeks recorded in the control arm (P0.036). NRS dropped after the first week to 2.7 ± 2.0 in the experimental arm versus 6.6 ± 3.0 in the control group (P0.01). The rate of healing at the 24th week was not significantly different between arms. Interestingly, we found a strong reverse correlation between the percent of CD34CAT is safe and may accelerate healing time in VLUs as well as reduce wound pain. The percentage of CD34

The purpose of the work described here was to investigate the feasibility of assessing the jugular venous pulse (JVP) using ultrasound (US) equipment. Three young healthy subjects underwent a B-mode US scan of the internal jugular vein (IJV) to acquire a sonogram sequence in the transverse plane. On each acquired sonogram, the IJV contour was manually traced, and both the cross-sectional area (CSA) and the perimeter were measured. The CSA data set represents the US jugular diagram (USJD). The arterial distension waveform of the subjects was compared with its USJD. The correlation between the CSA and the perimeter was assessed during the cardiac cycle to verify IJV distension. For each subject, a short sonogram sequence of a few seconds was recorded, and the USJD obtained exhibited periodic behavior. Furthermore, for all subjects, the CSA was found to be correlated with the perimeter (Pearson coefficient, R > 0.9), indicating that the IJV in supine position is distended. We compared 390 manually traced contours of the IJV cross-sectional area with corresponding values semi-automatically calculated by an algorithm developed in-house. For all subjects, the sensitivity, specificity and accuracy were around 95%, 85% and 90% respectively. We found that a diagram reflecting the JVP can be obtained by analyzing a B-mode sonogram sequence of the IJV; such a diagram can result in a new methodology to assess the IJV functionality.

Successful wound and ulcer repair remains a major biomedical challenge in the 21st Century. Innovative and alternative treatment options have been investigated over the last decade and stem cells application has been suggested as a possible novel therapy for regenerative medicine. In particular, stem cells derived from adipose tissue have been attracting a lot of attention in recent years as an alternative to the use of cells derived from bone marrow. This technical note describes the procedure introduced by Coleman for intraoperatory harvesting of adipose derived-stem-cells and proposes a rationale for using it in difficult wound healing and recalcitrant ulcers.

The jugular venous pulse (JVP) is one of the main parameters of cardiac function and is used by cardiologists in diagnosing heart failure. Its waveform comprises three positive waves (a, c and v) and two negative waves (x and y). Recently, it was found that JVP can be extrapolated from an ultrasound (US) video recording of the internal jugular vein (IJV), suggesting its application in space missions, on which US scanners are already widely used. To date, the feasibility of assessing JVP in microgravity (microG) has not been investigated. To verify the feasibility of JVP assessment in microG, we tested a protocol of self-performed B-mode ultrasound on the International Space Station (ISS). The protocol consisted of a video recording of IJV synchronized with electrocardiogram that produces a cross-sectional area time trace (JVP trace) (in cm2). The scans were acquired in six experimental sessions; two pre-flight (BDC1 and -2), two in space (ISS1 and -2) and two post-flight (Houston PF1, Cologne PF2). We measured the mean and standard deviation of the JVP waves and the phase relationship between such waves and P and T waves on the electrocardiogram. We verified that such parameters had the same accuracy on Earth as they did under microG, and we compared their values. The sensitivity, specificity and accuracy of JVP trace in microgravity are higher than those on Earth. The sequence of (a, c, and v) ascents and (x and y) descents along the cardiac cycle in microG is the same as that on Earth. The cause-and-effect relationship between the P and T waves on the electrocardiogram and a and v waves, respectively, of JVP is also confirmed in microG. Our experiment indicated the feasibility of deriving a JVP trace from a B-mode US examination self-performed by an astronaut in microG.

Reports of extra-cranial venous outflow disturbances have recently been linked to sudden sensorineural hearing loss (SSNHL). Aims of the present study are: i) to quantify, with mathematical model, the impact of jugular valve function on the pressure of the superior and inferior petrosal sinuses (SPS, IPS) and the main auricolar veins; ii) to verify the feasibility of the application of mathematical model in the clinical setting in terms of consistency respect to the usual measures of SSNHL outcome. Extra-cranial venous outflow and post analysis were respectively blindly assessed by echo colour-Doppler (ECD) and a validated mathematical model for the human circulation. The pilot study was conducted on 1 healthy control and in a group of 4 patients with different outcome of SSNHL. The main finding was the significant increased pressure calculated in the SPS and IPS of patients with ipsilateral jugular obstruction due to not mobile valve leaflets (6.55 mmHg), respect to the other subjects without extracranial complete obstruction (6.01 mmHg), P=0.0006. Moreover, we demonstrated an inverted correlation between the extrapolated pressure values in the SPS/IPS and the mean flow measured in the correspondent internal jugular vein (r= –0.87773; r-squared= 0.7697; P=0.0009). The proposed mathematical model can be applied to venous extra-cranial ECD investigation in order to derive novel clinical information on the drainage of the inner ear. Such clinical information seems to provide coherent parameters potentially capable to drive the prognosis. This innovative approach was proven to be feasible by the present pilot investigation and warrants further studies with an increased sample of patients.

Background Recurrent varicose veins occur up to 80% of procedures. The sapheno-femoral junction can be involved in more than 50% of cases. A detailed pathophysiological explanation of the phenomenon is still missing. The aim of the present work is to evaluate the role of femoral vein incompetence as risk factor for sapheno-femoral junction recurrence. Methods Three-hundred-eighty-one patients presenting an incompetent great saphenous vein system and eventually also an incompetent femoral tract (C2-6EpAsdPr) underwent a great saphenous vein high ligation with flush ligation also of the incompetent tributaries along the leg, sparing the saphenous trunk. Pre-operatively, all patients underwent a sonographic evaluation assessing the superficial and deep venous systems, including a detailed analysis of the iliac-femoral vein tract above the sapheno-femoral junction. A retrospective statistical analysis assessed the recurrence risk associated with iliac-femoral vein tract incompetence. Results In a 5.5 ± 1.9 years follow-up, great saphenous vein trunk reflux recurrence was detected in 45/381 (11.8%) cases. The reflux source was found in a reconnected sapheno-femoral stump in 11/45 cases (24.5%), in the pelvic network in 8/45 cases (17.8%), in a neovascularization process in 7/45 (15.5%) and in a newly incompetent great saphenous vein tributary in 19/45 (42.2%). At the pre-operative assessment, iliac-femoral vein tract reflux was present in 7 (26.9%) of the 26 cases who developed a sapheno-femoral junction recurrence and in 25 (7%) of the 355 patients who did not demonstrate sapheno-femoral junction recurrence (odds ratio: 4.8; confidence interval 95%: 1.8–12.6; p Discussion Despite many technical diagnostic and therapeutic refinements, varicose veins recurrence remains a frequent event. The present investigation points out the association among iliac-femoral vein tract incompetence and sapheno-femoral junction recurrences after high ligation.

Along the years, scientific clinical data have been collected concerning the possible saphenous flow restoration without any ablation and according with the CHIVA strategy. Moreover, in 2013 a Cochrane review highlighted the smaller recurrence risk following a CHIVA strategy rather than a saphenous stripping. Nevertheless, the saphenous sparing strategy surely remains a not-so-worldwide-spread and accepted therapeutic option, also because considered not so immediate and easy to perform. Aim of this paper is to provide an easily accessible guide to an everyday use of a saphenous sparing strategy for chronic venous disease, highlighting how even apparently too complicated reflux patterns classifications can be fastly and successfully managed and exploited for a hemodynamic correction.

Importance Chronic cerebrospinal venous insufficiency (CCSVI) is characterized by restricted venous outflow from the brain and spinal cord. Whether this condition is associated with multiple sclerosis (MS) and whether venous percutaneous transluminal angioplasty (PTA) is beneficial in persons with MS and CCSVI is controversial. Objective To determine the efficacy and safety of venous PTA in patients with MS and CCSVI. Design, Setting, and Participants We analyzed 177 patients with relapsing-remitting MS; 62 were ineligible, including 47 (26.6%) who did not have CCSVI on color Doppler ultrasonography screening. A total of 115 patients were recruited in the study timeframe. All patients underwent a randomized, double-blind, sham-controlled, parallel-group trial in 6 MS centers in Italy. The trial began in August 2012 and concluded in March 2016; data were analyzed from April 2016 to September 2016. The analysis was intention to treat. Interventions Patients were randomly allocated (2:1) to either venous PTA or catheter venography without venous angioplasty (sham). Main Outcomes and Measures Two primary end points were assessed at 12 months: (1) a composite functional measure (ie, walking control, balance, manual dexterity, postvoid residual urine volume, and visual acuity) and (2) a measure of new combined brain lesions on magnetic resonance imaging, including the proportion of lesion-free patients. Combined lesions included T1 gadolinium-enhancing lesions plus new or enlarged T2 lesions. Results Of the included 115 patients with relapsing-remitting MS, 76 were allocated to the PTA group (45 female [59%]; mean [SD] age, 40.0 [10.3] years) and 39 to the sham group (29 female [74%]; mean [SD] age, 37.5 [10.6] years); 112 (97.4%) completed follow-up. No serious adverse events occurred. Flow restoration was achieved in 38 of 71 patients (54%) in the PTA group. The functional composite measure did not differ between the PTA and sham groups (41.7% vs 48.7%; odds ratio, 0.75; 95% CI, 0.34-1.68;P = .49). The mean (SD) number of combined lesions on magnetic resonance imaging at 6 to 12 months were 0.47 (1.19) in the PTA group vs 1.27 (2.65) in the sham group (mean ratio, 0.37; 95% CI, 0.15-0.91;P = .03: adjustedP = .09) and were 1.40 (4.21) in the PTA group vs 1.95 (3.73) in the sham group at 0 to 12 months (mean ratio, 0.72; 95% CI, 0.32-1.63;P = .45; adjustedP = .45). At follow-up after 6 to 12 months, 58 of 70 patients (83%) in the PTA group and 22 of 33 (67%) in the sham group were free of new lesions on magnetic resonance imaging (odds ratio, 2.64; 95% CI, 1.11-6.28;P = .03; adjustedP = .09). At 0 to 12 months, 46 of 73 patients (63.0%) in the PTA group and 18 of 37 (49%) in the sham group were free of new lesions on magnetic resonance imaging (odds ratio, 1.80; 95% CI, 0.81-4.01;P = .15; adjustedP = .30). Conclusion and Relevance Venous PTA has proven to be a safe but largely ineffective technique; the treatment cannot be recommended in patients with MS. Trial Registration clinicaltrials.gov Identifier:NCT01371760

The aim of this study was to assess feasibility and efficacy of an endovenous laser (EL) assisted saphenous-sparing strategy in chronic venous disease (CVD). Fourteen CVD patients (C2,3,4s Ep As Pr1,2,3) underwent a saphenofemoral junction (SFJ) treatment by EL just from below the superficial epigastric vein downward for a limited tract, together with a flush ligation of the incompetent tributaries of the great saphenous vein (GSV) along the leg. The following GSV parameters were assessed 15 cm below the SFJ: reflux time, caliber, peak systolic velocity (PSV), end diastolic velocity (EDV), resistance index (RI). Venous clinical severity score and the Clinical, Etiological, Anatomical, and Pathophysio logical (CEAP) classification clinical classes were assessed. At 1 year follow up 3 cases were considered failures because of a GSV thrombosis, even if they presented a GSV recanalization with a laminar flow within at the 2 years follow-up. Eleven procedures succeeded because neither minor nor major peri-procedural complications were reported, apart 2 cases of self-healing bruising. In these last 11 cases the procedure led to a GSV reflux suppression (from 3.1±0.4 s to a retrograde laminar draining flow), to a GSV caliber reduction (from 9.4±0.5 to 3.1±0.2 cm, P

Currently brain perfusion can be assessed by the means of radio-invasive methods, such as single-photon emission computed tomography and positron emission tomography, or by hightech methods such as magnetic resonance imaging. These methods are known to be very expensive, with long examination time, and finally, cannot be used for assessing brain oxygen distribution in relation to exercise and/or cognition-tests. The near infrared spectroscopy (NIRS) is a non-invasive diagnostic technique. In real time it is capable of measuring tissue oxygenation using portable instrumentation with a relative low cost. We and other groups previously adopted this instrument for investigation of the oxygen consumption in the muscles at rest and during exercise. NIRS can be now used to assess brain perfusion through the intact skull in human subjects by detecting changes in blood hemoglobin concentrations. Changes in perfusion can be related to both arterial and venous problems. This novel equipment features allow for a wide field of innovative applications where portability, wearability, and a small footprint are essential. The present review shows how to use it in relation to exercise protocols of the upper and lower extremities, measured in healthy people and in conditions of arterial and chronic cerebro-spinal venous insufficiency.

Amigos de Salud and Vene e Linfatici Foundation took part in a volunteer medical trip in Nicaragua. A detailed description of the provided healthcare is reported.

In humans the mechanism governing the internal jugular vein (IJV) valve opening and closure is still unclear. M-mode is used in echo-cardiology for the heart valves assessment. Sometimes it was performed also in deep peripheral veins and in vena cava assessment, but never in the IJV valve. Aim of the present study is to investigate the IJV valves physiology in healthy volunteers, by means of both B and M-mode ultrasound. Eighty-three (83) healthy volunteers (35 Male, 48 Female, 25.7±6.7 y.o.), for a total of 166 IJVs, were enrolled. The entire cohort underwent IJVs high-resolution B and M-mode evaluation, in standardized postural and respiratory conditions. Presence, motility, and number of cusps, as well as their opening and closure mechanism have been assessed. Bilateral valve absence occurred in 13/83 (16%), whereas at least a one side absence was recorded in 38/83 (46% of the cohort) (p

Color Doppler methodology to assess the vessel blood flow rate is based on the time averaged velocity of the blood measured in the longitudinal plane and the cross sectional area measurement taken either in the longitudinal plane, by assuming circular cross sectional area, or in the transversal plane. The measurement option in longitudinal plane is based on the assumption of circular cross sectional area, while the transversal one needs to evaluate both time-averaged velocity and cross sectional area in the same vessel point. A precise and validated assessment methodology is still lacking. Four healthy volunteers underwent internal jugular vein colour Doppler scanning. The cross sectional area was assessed by means of B-mode imaging in the transversal plane all along the vessel cervical course. During this assessment, cross sectional area, major and minor axis of the vessel were measured and recorded. The distance between the internal jugular vein wall and the skin surface were measured together with the intra-luminal diameter and statistically correlated with the cross sectional area data. The internal jugular vein cross sectional area measured on the transversal plane were significantly different from the cross sectional area calculated using the assumption of circular shape. The intra-luminal distance showed high correlation with the measured cross sectional area. The proper anatomical point in the cross sectional area transversal measurement can be identified by using the internal jugular vein intra-luminal distance as landmark.

Mini-invasiveness, ease of use and execution speed represent the reasons for endovenous laser ablation success. Nevertheless, the strategic choice remains the ablation of the saphenous trunk. Hemodynamic correction (CHIVA) represents an option, based on a saphenous-sparing therapeutic strategy. We tested the feasibility of a modified CHIVA strategy by means of endovenous lasers (EL) shrinkage of segmental great saphenous vein (GSV) tracts, in networks characterized by sapheno-femoral incompetence and re-entry perforators focused on the GSV. We report the follow up of the first 2 chronic venous disease [C1,2,3sEpAsPr1,2,3, venous clinical severity score (VCSS) 8 and 9 respectively] treated cases. At 1-year follow up both patients were C1,2,3sEpAsPr1,2,3 and the VCSS were 1 and 2 respectively. The non-treated GSV tracts maintained their patency. ELs were herein used within a saphenous-sparing therapeutic plan, thanks to an accurate pre-operative hemodynamic assessment, which allowed the shrinkage of only the first saphenous trunk tract only. Proper technical and hemodynamic considerations are discussed.

BackgroundMagnetic resonance imaging and echo color Doppler (ECD) scan techniques do not accurately assess the cerebral venous return. This generated considerable scientific controversy linked with the diagnosis of a vascular syndrome known as chronic cerebrospinal venous insufficiency (CCSVI) characterized by restricted venous outflow from the brain. The purpose of this study was to assess the cerebral venous return in relation to the change in position by means of a novel cervical plethysmography method.MethodsThis was a single-center, cross-sectional, blinded case-control study conducted at the Vascular Diseases Center, University of Ferrara, Italy. The study involved 40 healthy controls (HCs; 18 women and 22 men) with a mean age of 41.5 ± 14.4 years, and 44 patients with multiple sclerosis (MS; 25 women and 19 men) with a mean age of 41.0 ± 12.1 years. All participants were previously scanned using ECD sonography, and further subset in HC (CCSVI negative at ECD) and CCSVI groups. Subjects blindly underwent cervical plethysmography, tipping them from the upright (90°) to supine position (0°) in a chair. Once the blood volume stabilized, they were returned to the upright position, allowing blood to drain from the neck. We measured venous volume (VV), filling time (FT), filling gradient (FG) required to achieve 90% of VV, residual volume (RV), emptying time (ET), and emptying gradient (EG) required to achieve 90% of emptying volume (EV) where EV = VV − RV, also analyzing the considered parameters by receiver operating characteristic (ROC) curves and principal component mathematical analysis.ResultsThe rate at which venous blood discharged in the vertical position (EG) was significantly faster in the controls (2.73 mL/second ± 1.63) compared with the patients with CCSVI (1.73 mL/second ± 0.94; P = .001). In addition, respectively, in controls and in patients with CCSVI, the following parameters were highly significantly different: FT 5.81 ± 1.99 seconds vs 4.45 ± 2.16 seconds (P = .003); FG 0.92 ± 0.45 mL/second vs 1.50 ± 0.85 mL/second (P < .001); RV 0.54 ± 1.31 mL vs 1.37 ± 1.34 mL (P = .005); ET 1.84 ± 0.54 seconds vs 2.66 ± 0.95 seconds (P < .001). Mathematical analysis demonstrated a higher variability of the dynamic process of cerebral venous return in CCSVI. Finally, ROC analysis demonstrated a good sensitivity of the proposed test with a percent concordant 83.8, discordant 16.0, tied 0.2 (C = 0.839).ConclusionsCerebral venous return characteristics of the patients with CCSVI were markedly different from those of the controls. In addition, our results suggest that cervical plethysmography has great potential as an inexpensive screening device and as a postoperative monitoring tool.