Chronic Cerebrospinal Venous Insufficiency

I read with interest the article published by Kugler et al. [1]. Regarding the duplex ultrasound examination the author didn't consider the paper by Zamboni et al. [2] published in December 2011 on international angiology. In this document the authors noted that a high prevalence ranging from 62% to 100% of obstructive lesions has been found by some teams in patients with multiple sclerosis (MS) compared with a lower prevalence of 0%-25% in controls. However, absence of such lesions or a lower prevalence (16%-52%) has been reported by others. This variability could be the result of differences in technique, training, experience or criteria used. The current lack of a methodology shared among experts is a confounding element in epidemiologic studies, and does not permit further Bayesan or other kind of analysis. In order to ensure a high reproducibility of Duplex scanning with comparable accuracy between centers, a detailed protocol with standard methodology and criteria is proposed. This is also necessary for training. It has been shown that inter-rater variability increases post-training (from k=0.47 to k=0.80), while within-rater reproducibility in trained operators was k=0.75. Finally, the consensus document proposes a reporting standard of Duplex measurements, and future research to answer areas of uncertainty. Dr. Paolo Zamboni do and did not have any personal financial conflict of interest. His centre received only equipment from Esaote (and not from SoNos) as wrote by Kugler et al. [1] exclusively for research and educational purposes. This was stated in the articles cited by Kugler et al. [1]. Regarding the study published by Rodger et al. [3], Dr. Paolo Zamboni and Dr. Mirko Tessari wrote a reply letter published in Plos One comments: Regarding the study by Traboulsee et al. [4], according to Zamboni [5] the rate of stenosis in angiography is calculated by comparing the diameter of the stricture with that of the segment immediately preceding it. In this article it has been proposed a novel method which compares, along the entire anatomical length of the internal jugular vein, the widest with the narrowest point. However, the jugular in normal cases is characterized by a big variability in size, with >50% variation of the diameter by comparing the bulb with any other point of the vein. This is the reason because the proposed methodology was unable to separate healthy controls from MS cases. If someone should be interested in the assessment of primary venous obstruction …