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The perfect crime? CCSVI not leaving a trace in MS
  1. Christoph A Mayer1,
  2. Waltraud Pfeilschifter1,
  3. Matthias W Lorenz1,
  4. Max Nedelmann2,
  5. Ingo Bechmann3,
  6. Helmuth Steinmetz1,
  7. Ulf Ziemann1
  1. 1Department of Neurology, Goethe-University Frankfurt, Frankfurt am Main, Germany
  2. 2Department of Neurology, Justus-Liebig-University Giessen, Giessen, Germany
  3. 3Institute of Anatomy, University of Leipzig, Leipzig, Germany
  1. Correspondence to Dr Christoph A Mayer, Department of Neurology, Goethe-University Frankfurt, Schleusenweg 2–16, 60528 Frankfurt am Main, Germany; christoph.mayer{at}


Background Multiple sclerosis (MS) is a chronic, inflammatory demyelinating disease of the central nervous system, believed to be triggered by an autoimmune reaction to myelin. Recently, a fundamentally different pathomechanism termed ‘chronic cerebrospinal venous insufficiency’ (CCSVI) was proposed, provoking significant attention in the media and scientific community.

Methods Twenty MS patients (mean age 42.2±13.3 years; median Extended Disability Status Scale 3.0, range 0–6.5) were compared with 20 healthy controls. Extra- and intracranial venous flow direction was assessed by colour-coded duplex sonography, and extracranial venous cross-sectional area (VCSA) of the internal jugular and vertebral veins (IJV/VV) was measured in B-mode to assess the five previously proposed CCSVI criteria. IJV-VCSA≤0.3 cm2 indicated ‘stenosis,’ and IJV-VCSA decrease from supine to upright position ‘reverted postural control.’ The sonographer, data analyser and statistician were blinded to the patient/control status of the participants.

Results No participant showed retrograde flow of cervical or intracranial veins. IJV-VCSA≤0.3 cm2 was found in 13 MS patients versus 16 controls (p=0.48). A decrease in IJV-VCSA from supine to upright position was observed in all participants, but this denotes a physiological finding. No MS patient and one control had undetectable IJV flow despite deep inspiration (p=0.49). Only one healthy control and no MS patients fulfilled at least two criteria for CCSVI.

Conclusions This triple-blinded extra- and transcranial duplex sonographic assessment of cervical and cerebral veins does not provide supportive evidence for the presence of CCSVI in MS patients. The findings cast serious doubt on the concept of CCSVI in MS.

  • multiple sclerosis
  • venous congestion
  • venous stenosis
  • ultrasonic angiology

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  • See Editorial Commentary, p 355

  • CAM and WP contributed equally.

  • Linked articles 228098, 223479.

  • Competing interests None.

  • Patient consent Obtained.

  • Ethics approval Ethics approval was provided by the Ethics Committee of the Medical Faculty, Goethe-University of Frankfurt, Frankfurt am Main, Germany.

  • Provenance and peer review Not commissioned; externally peer reviewed.

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