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Background: Pancreatic ductal adenocarcinoma (PDAC) stromal disposition is thought to influence chemotherapy efficacy and increase tissue stiffness, which could be quantified noninvasively via MR elastography (MRE). Current methods cause position-based errors in pancreas location over time, hampering accuracy. It would be beneficial to have a single breath-hold acquisition. Purpose: To develop and test a single breath-hold three-dimensional MRE technique utilizing prospective undersampling and a compressed sensing reconstruction (CS-MRE). Study Type: Prospective. Population: A total of 30 healthy volunteers (HV) (31 ± 9 years; 33% male) and five patients with PDAC (69 ± 5 years; 80% male). Field Strength/Sequence: 3-T, GRE Ristretto MRE. Assessment: First, optimization of multi breath-hold MRE was done in 10 HV using four combinations of vibration frequency, number of measured wave-phase offsets, and TE and looking at MRE quality measures in the pancreas head. Second, viscoelastic parameters delineated in the pancreas head or tumor of CS-MRE were compared against (I) 2D and (II) 3D four breath-hold acquisitions in HV (N = 20) and PDAC patients. Intrasession repeatability was assessed for CS-MRE in a subgroup of healthy volunteers (N = 15). Statistical Tests: Tests include repeated measures analysis of variance (ANOVA), Bland–Altman analysis, and coefficients of variation (CoVs). A P-value

Purpose To image multidimensional flow in fetuses using golden-angle radial phase contrast cardiovascular magnetic resonance (PC-CMR) with motion correction and retrospective gating. Methods A novel PC-CMR method was developed using an ungated golden-angle radial acquisition with continuously incremented velocity encoding. Healthy subjects (n = 5, 27 ± 3 years, males) and pregnant females (n = 5, 34 ± 2 weeks gestation) were imaged at 3 T using the proposed sequence. Real-time reconstructions were first performed for retrospective motion correction and cardiac gating (using metric optimized gating, MOG). CINE reconstructions of multidimensional flow were then performed using the corrected and gated data. Results In adults, flows obtained using the proposed method agreed strongly with those obtained using a conventionally gated Cartesian acquisition. Across the five adults, bias and limits of agreement were − 1.0 cm/s and [− 5.1, 3.2] cm/s for mean velocities and − 1.1 cm/s and [− 6.5, 4.3] cm/s for peak velocities. Temporal correlation between corresponding waveforms was also high (R~ 0.98). Calculated timing errors between MOG and pulse-gating RR intervals were low (~ 20 ms). First insights into multidimensional fetal blood flows were achieved. Inter-subject consistency in fetal descending aortic flows (n = 3) was strong with an average velocity of 27.1 ± 0.4 cm/s, peak systolic velocity of 70.0 ± 1.8 cm/s and an intra-class correlation coefficient of 0.95 between the velocity waveforms. In one fetal case, high flow waveform reproducibility was demonstrated in the ascending aorta (R = 0.97) and main pulmonary artery (R = 0.99). Conclusion Multidimensional PC-CMR of fetal flow was developed and validated, incorporating retrospective motion compensation and cardiac gating. Using this method, the first quantification and visualization of multidimensional fetal blood flow was achieved using CMR. Electronic supplementary material The online version of this article (10.1186/s12968-018-0498-z) contains supplementary material, which is available to authorized users.

The ductus arteriosus (DA) functionally closes during the transition from fetal to postnatal life because of lung aeration and corresponding cardiovascular changes. The thorough and explicit measurement and visualization of the right and left heart output during this transition has not been previously accomplished. We combined 4D flow MRI (dynamic volumetric blood flow measurements) and T2 relaxometry (oxygen delivery quantification) in surgically instrumented newborn piglets to assess the DA. This was performed in Large White‐Landrace‐Duroc piglets (n = 34) spanning four age groups: term‐9 days, term‐3, term+1, and term+5. Subject's DA status was classified using 4D flow: closed DA, forward DA flow, reversed DA flow, and bidirectional DA flow. Over all states, vessel diameters and flows normalized to body weight increased with age (for example in the ascending aorta flow—term‐9: 126.6 ± 45.4; term+5: 260.2 ± 80.0 ml/min per kg; p = 0.0005; ascending aorta diameter—term‐9: 5.2 ± 0.8; term+5: 7.7 ± 0.4 mm; p = 0.0004). In subjects with reversed DA blood flow there was lower common carotid artery blood flow (forward: 37.5 ± 9.0; reversed: 20.0 ± 7.4 ml/min per kg; p = 0.032). Linear regression revealed that as net DA flow decreases, common carotid artery flow decreases (R2 = 0.32, p = 0.004), and left (R2 = 0.33, p = 0.003) and right (R2 = 0.34, p = 0.003) pulmonary artery flow increases. Bidirectional DA blood flow changed oxygen saturation as determined by MRI between the ascending and descending aorta (ascending aorta: 90.1% ± 8.4%; descending aorta: 75.6% ± 14.2%; p, At birth, the lungs and surrounding vasculature work to functionally close the ductus arteriosus (DA). This process is delayed in preterm newborns. MRI techniques, namely 4D flow and T2 relaxometry, can be used to comprehensively assess cardiac blood flow and oxygen delivery in newborns. These approaches are demonstrated across preterm and term‐born piglets, and whole heart blood flow visualization is paired alongside flow and oxygenation quantification.

The ductus venosus (DV) is a dynamic fetal shunt that allows substrate-rich blood from the umbilical vein to bypass the hepatic circulation. In vitro studies suggest a direct role of prostaglandin IDuring fetal development, the maintenance of adequate oxygen and nutrient supply to vital organs is regulated through specialized fetal shunts. One of these shunts, the ductus venosus (DV), allows oxygen-rich blood to preferentially stream from the placenta toward the heart and brain. Herein, we combine magnetic resonance imaging (MRI) techniques that measure blood flow (4D flow) and oxygen saturation (T

Key points The comprehensive visualization and quantification of in vivo fetal hepatic haemodynamics, particularly the shunting of ductus venosus blood, has been elusive and is not yet fully understood. We introduce the combination of chronically instrumented fetal sheep and 4D flow MRI of the whole fetal liver, which allows retrospective blood flow measurement in all visible vessels as well as qualitative assessment. The applicability and usefulness of this technique is exhibited in normally grown fetal Merino sheep in mid- and late-gestation with detailed dynamic distribution of hepatic blood flow presented. The feasibility of this approach in clinical pathology is demonstrated in two growth-restricted fetuses at mid-gestation. Further exemplification of blood flow quantification is performed over major hepatic vessels. Abstract Although the fetal vasculature has been demarcated and well understood for several decades, the corresponding haemodynamics permitting oxygen- and nutrient-rich blood delivery to the fetal organs has been comparatively difficult to study. We married two well-established methods: 4D flow MRI, a volumetric and dynamic blood-flow measurement technique, and chronically instrumented sheep to broadly assess fetal hepatic circulation. We performed this technique in mid- and late-gestation fetal Merino sheep under normoxemic conditions and major hepatic vasculature was segmented to quantify blood flow and related parameters. Dynamic blood flow was visualized, exhibiting an acceleration of umbilical vein blood through the ductus venosus as well as spiralling into the inferior vena cava where its stream remained separate from that of the hepatic veins and lower body. Ductus venosus changes from mid- to late-gestation included larger diameter (mid: 5.8 ± 0.9 vs. late: 7.1 ± 1.1 mm; P = 0.003) and cross-sectional area (mid: 27.1 ± 8.6 vs. late: 40.4 ± 11.8 mm2 ; P = 0.003), and lower velocity averaged over the cardiac cycle (mid: 15.7 ± 5.4 vs. late: 9.8 ± 7.0 cm s-1 ; P = 0.020). This resulted in higher magnitude blood flow (indexed to umbilical vein input) at mid-gestation in the ductus venosus (mid: 0.73 ± 0.21; late: 0.46 ± 0.21; P = 0.008). The visualization and quantification results support the further use of this technique to better understand regional blood flow changes during normal or abnormal fetal growth, as well as to observe acute haemodynamic responses to physiological challenges or drug interventions.

Background The structure of the valve leaflets and sinuses are crucial in supporting the proper function of the semilunar valve and ensuring leaflet durability. Therefore, an enhanced understanding of the structural characteristics of the semilunar valves is fundamental to the evaluation and staging of semilunar valve pathology, as well as the development of prosthetic or bioprosthetic valves. This paper illustrates the process of combining computer-aided design (CAD), 3D printing and flow assessment with 4-dimensional flow magnetic resonance imaging (MRI) to provide detailed assessment of the structural and hemodynamic characteristics of the normal semilunar valve. Methods Previously published geometric data on the aortic valve was used to model the ‘normal’ tricuspid aortic valve with a CAD software package and 3D printed. An MRI compatible flow pump with the capacity to mimic physiological flows was connected to the phantom. A peak flow rate of 100 mL/s and heart rate of 60 beats per minute were used. MRI measurements included cine imaging, 2D and 4D phase-contrast imaging to assess valve motion, flow velocity and complex flow patterns. Results Cine MRI data showed normal valve function and competency throughout the cardiac cycle in the 3D-printed phantom. Quantitative analysis of 4D Flow data showed net flow through 2D planes proximal and distal to the valve were very consistent (26.03 mL/s and 26.09 mL/s, respectively). Measurements of net flow value agreed closely with the flow waveform provided to the pump (27.74 mL/s), confirming 4D flow acquisition in relation to the pump output. Peak flow values proximal and distal to the valve were 78.4 mL/s and 63.3 mL/s, respectively. Particle traces of flow from 4D-phase contrast MRI data demonstrated flow through the valve into the ascending aorta and vortices within the aortic sinuses, which are expected during ventricular diastole. Conclusion In this proof of concept study, we have demonstrated the ability to generate physiological 3D-printed aortic valve phantoms and evaluate their function with cine- and 4D Flow MRI. This technology can work synergistically with promising tissue engineering research to develop optimal aortic valve replacements, which closely reproduces the complex function of the normal aortic valve.

Key points The ductus venosus (DV) is a dynamic fetal shunt that allows substrate-rich blood from the umbilical vein to bypass the hepatic circulation. In vitro studies suggest a direct role of prostaglandin I2 (PGI2 ) in the regulation of DV tone; however, the extent of this regulation has not been determined in utero. 4D flow and T2 oximetry magnetic resonance imaging can be combined to determine blood flow and oxygen delivery within the fetal circulation. PGI2 increases DV shunting of substrate-rich blood but this does not increase cerebral oxygen delivery. Abstract During fetal development, the maintenance of adequate oxygen and nutrient supply to vital organs is regulated through specialized fetal shunts. One of these shunts, the ductus venosus (DV), allows oxygen-rich blood to preferentially stream from the placenta toward the heart and brain. Herein, we combine magnetic resonance imaging (MRI) techniques that measure blood flow (4D flow) and oxygen saturation (T2 oximetry) in the fetal circuit to determine whether umbilical vein infusion of prostaglandin I2 (PGI2 , regulator of DV tone ex utero) directly dilates the DV and thus increases the preferential streaming of oxygen-rich blood toward the brain. At 114-115 days gestational age (dGA; term = 150 days), fetal sheep (n = 6) underwent surgery to implant vascular catheters in the fetal femoral artery, femoral vein, amniotic cavity and umbilical vein. Fetal MRI scans were performed at 119-124 dGA. 4D flow and T2 oximetry were performed to measure blood flow and oxygen saturation across the fetal circulation in both a basal state and whilst the fetus was receiving a continuous infusion of PGI2 . The proportion of oxygenated blood that passed through the DV from the umbilical vein was increased by PGI2 . Cerebral oxygen delivery was unchanged in the PGI2 state. This may be a result of decreased flow from the right to left side of the heart as blood flow through the foramen ovale was decreased by PGI2 . We have shown that although PGI2 acts on the DV to increase the proportion of oxygen-rich blood that bypasses the liver, this does not increase cerebral oxygen delivery in the fetal sheep.

SURVIVAL IMPROVEMENT in patients with congenital heart disease (CHD) has led to a growing number of adults living with CHD. 4D flow magnetic resonance imaging (MRI)1-5 has been used for the evaluation of various challenging CHD types. Quantitative measures of flow perturbations using 4D flow can aid in surveillance and treatment decision-making, and have been shown to be similar to standard clinical 2D phase-contrast (PC) MRI with acceptable test–retest repeatability.6-8 Using 4D flow, it is possible to assess flow volume in large thoracic vessels, comprising the pulmonary-systemic shunt ratio (Qp/Qs), shunt flow, peak flow, valvular regurgitant flow, and collateral flow volumes. Intracardiac flow patterns, including flow connectivity and distribution, pressure gradients, vortex/helical flow patterns, directionality, and turbulent and laminar energy losses can also be assessed. The aim of these recommendations from the ISMRM Flow & Motion Study Group is to standardize 4D flow in CHD with recommended acquisition, reconstruction, and postprocessing. This document focuses on CHD assessment with 4D flow, which requires, for example, coverage of a large volume in the thorax, and a wide range of velocities. Details on aortic 4D flow acquisitions can be found in the 2015 4D flow consensus statement.

Human fetal circulatory physiology has been investigated extensively using grey-scale ultrasound, which provides excellent visualization of cardiac anatomy and function, while velocity profiles in the heart and vessels can be interrogated using Doppler. Measures of cerebral and placental vascular resistance, as well as indirect measures of intracardiac pressure obtained from the velocity waveform in the ductus venosus are routinely used to guide the management of fetal cardiovascular and placental disease. However, the characterization of some key elements of cardiovascular physiology such as vessel blood flow and the oxygen content of blood in the arteries and veins, as well as fetal oxygen delivery and consumption are not readily measured using ultrasound. To study these parameters, we have historically relied on data obtained using invasive measurements made in animal models, which are not equivalent to the human in every respect. Over recent years, a number of technical advances have been made that have allowed us to examine the human fetal circulatory system using cardiovascular magnetic resonance (CMR). The combination of vessel blood flow measurements made using cine phase contrast magnetic resonance imaging and vessel blood oxygen saturation and hematocrit measurements made using T1 and T2 mapping have enabled us to emulate those classic fetal sheep experiments defining the distribution of blood flow and oxygen transport across the fetal circulation in the human fetus. In addition, we have applied these techniques to study the relationship between abnormal fetal cardiovascular physiology and fetal development in the setting of congenital heart disease and placental insufficiency. CMR has become an important diagnostic tool in the assessment of cardiovascular physiology in the setting of postnatal cardiovascular disease, and is now being applied to the fetus to enhance our understanding of normal and abnormal fetal circulatory physiology and its impact on fetal well-being.

Background: Recent advances in cardiovascular magnetic resonance (CMR) imaging have facilitated CINE imaging of the fetal heart. In this work, a preliminary investigation of the utility of multislice CINE CMR for assessing fetal congenital heart disease is performed and compared with echocardiography. Methods and Results: Multislice CINE CMR and echocardiography images were acquired in 25 pregnant women wherein the fetus had a suspected congenital heart defect based on routine obstetric ultrasound. Pathognomonic images were identified for each subject for qualitative comparison of CMR and echocardiography. Quantitative comparison of CMR and echocardiography was then performed by 2 reviewers using a binary scoring of 9 fetal cardiac anatomic features (identifiable/not-identifiable). Pathognomonic images demonstrated the ability of CMR to visualize a variety of congenital heart defects. Overall CMR was able to identify the majority of the 9 assessed fetal cardiac anatomic features (reviewer 1, 7.1±2.1; reviewer 2, 6.7±2.3). Although both reviewers identified more anatomic features with echocardiography (reviewer 1, 7.8±2.3; reviewer 2, 7.5±2.4; P =0.01), combining information from both modalities enabled identification of additional anatomic features across subjects (reviewer 1, 8.4±1.3; reviewer 2, 8.4±1.2). The primary limiting factor for CMR was inadequate coverage of the fetal cardiac anatomy or noncontiguous slices because of gross fetal movement. Conclusions: CINE CMR enables visualization of fetal congenital heart disease. This work demonstrates the potential of CMR for diagnosing congenital heart disease in utero in conjunction with echocardiography during late gestation.

PurposeTo describe, validate, and implement a centerline processing scheme (CPS) for semiautomated segmentation and quantification in carotid siphons of healthy subjects. 4D flow MRI enables blood ...

A possibly causal relationship between multiple sclerosis and chronic cerebrospinal venous insufficiency has recently been hypothesized. Studies investigating chronic cerebrospinal venous insufficiency have reported conflicting results and few have employed multiple diagnostic imaging modalities across a large patient and control population. In this study, three complementary imaging modalities were used to investigate the chronic cerebrospinal venous insufficiency hypothesis in patients with multiple sclerosis and two age- and sex-matched control groups: healthy volunteers and patients with other neurological diseases. Strictly blinded Doppler ultrasound according to the original chronic cerebrospinal venous insufficiency hypothesis; four-dimensional flow magnetic resonance imaging of venous flow in the head, neck, and chest; and contrast-enhanced magnetic resonance venography for neck and chest venous luminography were acquired. An internal jugular vein stenosis evaluation was also performed across modalities. Percentage of subjects meeting ultrasound-based chronic cerebrospinal venous insufficiency criteria was small and similar between groups. In group-wise and pairwise testing, no four-dimensional flow magnetic resonance imaging variables were statistically significantly different, for any measurement location. In contrast-enhanced magnetic resonance venography of the internal jugular and azygos veins, no statistically significant differences were observed in stenosis scores between groups. These results represent compelling evidence against the chronic cerebrospinal venous insufficiency hypothesis in multiple sclerosis.

BACKGROUND AND PURPOSE: The chronic cerebrospinal venous insufficiency hypothesis raises interest in cerebrospinal venous blood flow imaging, which is more complex and less established than in arteries. For accurate assessment of venous flow in chronic cerebrospinal venous insufficiency diagnosis and research, we must account for physiologic changes in flow patterns. This study examines day-to-day flow variability in cerebrospinal veins by use of 4D MR flow and contrast-enhanced MRA under typical, uncontrolled conditions in healthy individuals. MATERIALS AND METHODS: Ten healthy volunteers were scanned in a test-retest fashion by use of a 4D flow MR imaging technique and contrast-enhanced MRA. Flow parameters obtained from phase contrast-vastly undersampled isotropic projection reconstruction and contrast-enhanced MRA scoring measurements in the head, neck, and chest veins were analyzed for internal consistency and interscan reproducibility. RESULTS: Internal consistency was satisfied at the torcular herophili, with an input-output difference of 2.2%. Percentages of variations in flow were 20.3%, internal jugular vein; 20.4%, azygos vein; 6.8%, transverse sinus; and 5.1%, common carotid artery. Retrograde flow was found in the lower internal jugular vein (4.8%) and azygos vein (7.2%). Contrast-enhanced MRA interscan κ values for the internal jugular vein (left: 0.474, right: 0.366) and azygos vein (−0.053) showed poor interscan agreement. CONCLUSIONS: Phase contrast–vastly undersampled isotropic projection reconstruction blood flow measurements are reliable and highly reproducible in intracranial veins and in the common carotid artery but not in veins of the neck (internal jugular vein) and chest (azygos vein) because of normal physiologic variation. Retrograde flow normally may be observed in the lower internal jugular vein and azygos vein. Low interrater agreement in contrast-enhanced MRA scans was observed. These findings have important implications for imaging diagnosis and experimental research of chronic cerebrospinal venous insufficiency.

Summary A technique for evaluation of respiratory impact on cardiac-gated phase contrast flow acquisitions is proposed. An example study was performed showing the effect of active respiration on CSF flow through the spinal canal. Background The effect of the respiratory cycle on flow is well documented for cerebrospinal venous return [1] and CSF flow [2]. However, cranial phase contrast (PC) MR flow measurements neglect the influence of respiration. Breath-held acquisitions are possible, but mask physiological flow changes that occur during active respiration. Here we demonstrate a technique to evaluate the effects of active respiration on CSF flow measurements throughout the cardiac cycle for 2 respiration states. Methods Our approach relies on pseudo-random sampling of radial projections, which allows reconstruction of subsets with little artifact due to even filling of k-space (Fig. 1a). Cardiac triggers and respiratory position are recorded throughout the acquisition. Each projection then has a corresponding cardiac position (time since last trigger) and respiratory position. In the current implementation, all projections are sorted into 2 respiratory phases based on the median respiratory position. Each phase corresponds to the plateau surrounding endinspiration or -expiration. Each respiratory phase is represented by a cardiac gated image series that is reconstructed using a temporal filtering similar to view sharing in Cartesian acquisitions [3]. Three volunteers were scanned on a clinical 3T system with 2D radial PC acquisitions [4] between the C2 and C3 vertebrae: TR/TE = 9.4/6.1 ms, tip = 5°, resolution = 0.9x0.9x5 mm, and Venc = 8cm/s. Data were acquired during inspiration and expiration breath holds (1500 projections, 30 s), and during regular free and deep breathing (8000 projections, 2:32 min). Triggering was accomplished with pulse oximeter and bellow signals. Results Fig. 2 shows the resulting flow waveforms acquired during deep breathing for two volunteers. Though the waveforms show variation, the trend of increased flow during inspiration holds in both examples. Average forward (Qf), reverse (Qr), and net (Qnet) flow were calculated for both phases in the free breathing scans. For the inspiration phase, these values were: Qf = 3.06, Qr = 1.53, and Qnet = 1.53 ml/min. For the bin surrounding end-expiration, these values were: Qf = 2.53, Qr = 2.02, Qnet = 0.51 ml/min. Conclusions

An analysis of the effect of respiratory function on MR flow measures of the internal jugular vein (IJV) is presented. A novel 2D radial acquisition and reconstruction method allows for retrospective gating to both the cardiac and respiratory cycle. In-vivo scans of human volunteers verify the efficacy of the algorithm, showing increased IJV flow during inspiration and decreased flow during expiration for each cardiac time frame.

Background Respiratory motion compensation is essential for reproducible and robust cardiovascular MRI. Traditionally, breathholds or prospective gating by bellows or navigator signals limit data acquisition to the quiescent phase of respiration [1]. These approaches do not capture any variations of blood flow over the respiratory cycle, yet respiration has been shown to significantly affect flow in the great vessels [2]. The purpose of this pilot study was to adapt a 3D radially undersampled PC MR sequence (PC VIPR [3,4]) for use with our retrospective dual-gated (cardiac and respiratory) reconstruction to evaluate respiratory effects on net flow and cardiac flow waveforms.

Background Pulmonary arterial hypertension (PAH) is a potentially severe disease that can lead to exercise intolerance, venous congestion, and heart failure. As a result of increased pulmonary pressures, dilation of the pulmonary arterial vasculature occurs. The extraction of these anatomical changes from magnetic resonance angiogram (MRA) may eliminate the need for invasive measurements. The aim of this study was to explore the use of volumetric imaging of the pulmonary trunk and proximal right and left arteries using MRA as an ew metric for diagnosing PAH. Methods Following IRB approval, eight PAH patients referred for right heart catheterization (RHC) for systemic sclerosis were evaluated with 3D contrast-enhanced MRA. For comparison, eight healthy volunteers underwent the same MRA protocol. All MRA exams were performed on 3.0T clinical scanners (GE Healthcare, Waukesha, WI) following the administration of gadolinium-based contrast agent at 1.5 ml/sec (gadobenate dimeglumine, Bracco, Milan). Scan parameters of the SPGR sequence included TR/TE of 2.9/1.0 ms, average field of view = 34 × 27 cm, slice thickness = 2.0 mm, 140-160 slices, flip angle = 28°, and true spatial resolution of 1.3 × 1.8 × 2.0 mm 3 , which was interpolated to 0.7 × 0.7 × 1.0 mm 3 by zero-filling. Approximate breath-hold time was between 15-21 seconds for each scan. These exams were not cardiac gated. Post-processing was evaluated using dynamic magnitude images in a commercial software (Mimics, Materialise, Belgium) to calculate diameter (main, left, and right pulmonary artery: MPA, LPA, RPA), volume, surface area, branch sum, and area sum pant-leg (P-L) measurements (Figure 1a). Each P-L was obtained by centerline semi-automated measurements two centimeters in each direction of bifurcation (Figure 1b). These parameters were evaluated as mean ± standard deviation. Differences in these measurements were statistically analyzed using a paired Student’s t-test. Results

Background 3D cardiac MRI has long held promise for improved heart coverage, higher resolution, and reduced sensitivity to poor breath-hold reproducibility. However, its use has been limited by reduced blood pool to myocardium contrast for spoiled and balanced steady-state free precession (bSSFP) implementations. T2-preparation techniques [1] are capable of increasing contrast but are unfortunately limited by lengthy preparation periods and resulting scan inefficiencies. In this work, we develop a paradigm for high contrast 3D cardiac function that relies on the alternative use of magnetization transfer (MT) preparation [2] combined with accelerated 3D spoiled gradient echo imaging (SPGR).

Summary Presented is a novel MR imaging protocol to comprehensively assess vessel lumen and hemodynamics of the cerebrospinal veins. The 3 station exam is designed to cover middle cerebral, jugular, and azygous veins in order to investigate the CCSVI hypothesis for the association of insufficient venous return with multiple sclerosis.