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      <h1 class="highwire-cite-title" id="page-title">Training and Learning Curve in Chronic Cerebrospinal Venous Insufficiency Assessment</h1>  
    	<div class="highwire-cite-authors"><span  class="highwire-citation-authors"><span class="highwire-citation-author first" data-delta="0">P.M. Bavera</span></span></div>
  
    	<div class="highwire-cite-metadata"><span  class="highwire-cite-metadata-journal highwire-cite-metadata">American Journal of Neuroradiology </span><span  class="highwire-cite-metadata-date highwire-cite-metadata">June 2013,  </span><span  class="highwire-cite-metadata-volume highwire-cite-metadata">34 </span><span  class="highwire-cite-metadata-issue highwire-cite-metadata">(6) </span><span  class="highwire-cite-metadata-pages highwire-cite-metadata">E69; </span><span  class="highwire-cite-metadata-doi highwire-cite-metadata">DOI: https://doi.org/10.3174/ajnr.A3570 </span></div>
  
  
  
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<div id="hw-article-author-popups-top-node-12517--6410501084" style="display: none;"><div class="author-tooltip-0"><div class="author-tooltip-name">P.M. Bavera </div><div class="author-tooltip-affiliation"><span class="author-tooltip-text"><div class='author-affiliation'><span class='nlm-sup'>a</span>Vascular Surgery
University of Milan
Milan, Italy</div></span></div><ul class="author-tooltip-find-more"><li class="author-tooltip-gs-link first"><a href="/lookup/google-scholar?link_type=googlescholar&amp;gs_type=author&amp;author%5B0%5D=P.M.%2BBavera%2B" target="_blank" class="" data-icon-position="" data-hide-link-title="0">Find this author on Google Scholar</a></li><li class="author-tooltip-pubmed-link"><a href="/lookup/external-ref?access_num=Bavera%20P&amp;link_type=AUTHORSEARCH" target="_blank" class="" data-icon-position="" data-hide-link-title="0">Find this author on PubMed</a></li><li class="author-site-search-link last"><a href="/search/author1%3AP.M.%2BBavera%2B" rel="nofollow" class="" data-icon-position="" data-hide-link-title="0">Search for this author on this site</a></li></ul></div></div></div>  </div>

  
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    <div class="highwire-markup"><div xmlns="http://www.w3.org/1999/xhtml" data-highwire-cite-ref-tooltip-instance="highwire_reflinks_tooltip" class="content-block-markup" xmlns:xhtml="http://www.w3.org/1999/xhtml"><div class="article fulltext-view "><span class="highwire-journal-article-marker-start"></span><p id="p-1">I read with interest the article entitled “Mystery of Chronic Cerebrospinal Venous Insufficiency: Identical Venographic and Ultrasound Findings in Patients with MS and Controls” by McAuliffe and Kermode<sup><a id="xref-ref-1-1" class="xref-bibr" href="#ref-1">1</a></sup> published on-line in January by the <em>American Journal of Neuroradiology.</em> I can, therefore, disagree with both the methodology and conclusions of the authors.</p><p id="p-2">It is not clear whether the duplex operators had sufficient training for searching eventual jugular vein abnormalities and actually did the search following the usual required protocol. The authors did not cite the protocol guidelines published by 7 international scientific societies.<sup><a id="xref-ref-2-1" class="xref-bibr" href="#ref-2">2</a></sup> In addition, it has been proved that training is mandatory to improve reproducibility of chronic cerebrospinal venous insufficiency (CCSVI) screening. The κ coefficient found was significantly different when comparing interobserver variation in trained-versus-untrained sonographic operators.<sup><a id="xref-ref-3-1" class="xref-bibr" href="#ref-3">3</a></sup></p><p id="p-3">Thirty cases are not enough to reach statistically significant results. In addition, it has been proved that training is mandatory to improve reproducibility of CCSVI screening. This methodology is very different from that of Zamboni et al in their seminal article.<sup><a id="xref-ref-4-1" class="xref-bibr" href="#ref-4">4</a></sup> CCSVI was proposed with a multimodality approach combining sonography abnormalities with imaging performed by catheter venography.</p><p id="p-4">After 30 years' experience as a vascular surgeon and diagnostician,<sup><a id="xref-ref-5-1" class="xref-bibr" href="#ref-5">5</a></sup> I can comment on the work of the authors because after &gt;1500 examinations for CCSVI research, I have matched 90% of abnormalities to patients with MS. Half of these were post-percutaneous venous angioplasty controls, all of whom submitted to venographic examinations that confirmed CCSVI.</p><p id="p-5">Conclusions are made with large numbers and require time, proper training, and a learning curve, as well as comparison of Doppler sonography with the criterion standard catheter venography.</p><div class="section ref-list" id="ref-list-1"><h2>REFERENCES</h2><ol class="cit-list ref-use-labels"><li><span class="ref-label">1.</span><a class="rev-xref-ref" href="#xref-ref-1-1" title="View reference 1. in text" id="ref-1">↵</a>

<div class="cit ref-cit ref-journal" id="cit-34.6.E69.1"><div class="cit-metadata"><ol class="cit-auth-list"><li><span class="cit-auth"><span class="cit-name-surname">McAuliffe</span>  <span class="cit-name-given-names">W</span></span>, </li><li><span class="cit-auth"><span class="cit-name-surname">Kermode</span>  <span class="cit-name-given-names">AG</span></span></li></ol><cite>. <span class="cit-article-title">Mystery of chronic cerebrospinal venous insufficiency: identical venographic and ultrasound findings in patients with MS and controls</span>. <abbr class="cit-jnl-abbrev">AJNR Am J Neuroradiol</abbr> <span class="cit-month">January</span> <span class="cit-day">31</span> <span class="cit-pub-date">2013</span> <span class="cit-comment">[Epub ahead of print]</span></cite></div><div class="cit-extra"></div></div></li><li><span class="ref-label">2.</span><a class="rev-xref-ref" href="#xref-ref-2-1" title="View reference 2. in text" id="ref-2">↵</a>

<div class="cit ref-cit ref-journal" id="cit-34.6.E69.2"><div class="cit-metadata"><ol class="cit-auth-list"><li><span class="cit-auth"><span class="cit-name-surname">Zamboni</span>  <span class="cit-name-given-names">P</span></span>, </li><li><span class="cit-auth"><span class="cit-name-surname">Morovic</span>  <span class="cit-name-given-names">S</span></span>, </li><li><span class="cit-auth"><span class="cit-name-surname">Menegatti</span>  <span class="cit-name-given-names">E</span></span>, </li><li><span class="cit-etal">et al</span></li></ol><cite>. <span class="cit-article-title">Screening for chronic cerebrospinal venous insufficiency (CCSVI) using ultrasound: recommendations for a protocol</span>. <abbr class="cit-jnl-abbrev">Int Angiol</abbr> <span class="cit-pub-date">2011</span>;<span class="cit-vol">30</span>:<span class="cit-fpage">571</span>–<span class="cit-lpage">97</span>. <span class="cit-comment">Erratum in: <em>Int Angiol</em> 2012;31:201</span></cite></div><div class="cit-extra"><a href="/lookup/external-ref?access_num=22233619&amp;link_type=MED&amp;atom=%2Fajnr%2F34%2F6%2FE69.atom" class="cit-ref-sprinkles cit-ref-sprinkles-medline"><span>PubMed</span></a></div></div></li><li><span class="ref-label">3.</span><a class="rev-xref-ref" href="#xref-ref-3-1" title="View reference 3. in text" id="ref-3">↵</a>

<div class="cit ref-cit ref-journal" id="cit-34.6.E69.3"><div class="cit-metadata"><ol class="cit-auth-list"><li><span class="cit-auth"><span class="cit-name-surname">Menegatti</span>  <span class="cit-name-given-names">E</span></span>, </li><li><span class="cit-auth"><span class="cit-name-surname">Genova</span>  <span class="cit-name-given-names">V</span></span>, </li><li><span class="cit-auth"><span class="cit-name-surname">Tessari</span>  <span class="cit-name-given-names">M</span></span>, </li><li><span class="cit-etal">et al</span></li></ol><cite>. <span class="cit-article-title">The reproducibility of colour Doppler in chronic cerebrospinal venous insufficiency associated with multiple sclerosis</span>. <abbr class="cit-jnl-abbrev">Int Angiol</abbr> <span class="cit-pub-date">2010</span>;<span class="cit-vol">29</span>:<span class="cit-fpage">121</span>–<span class="cit-lpage">26</span></cite></div><div class="cit-extra"><a href="/lookup/external-ref?access_num=20351668&amp;link_type=MED&amp;atom=%2Fajnr%2F34%2F6%2FE69.atom" class="cit-ref-sprinkles cit-ref-sprinkles-medline"><span>PubMed</span></a></div></div></li><li><span class="ref-label">4.</span><a class="rev-xref-ref" href="#xref-ref-4-1" title="View reference 4. in text" id="ref-4">↵</a>

<div class="cit ref-cit ref-journal" id="cit-34.6.E69.4" data-doi="10.1136/jnnp.2008.157164"><div class="cit-metadata"><ol class="cit-auth-list"><li><span class="cit-auth"><span class="cit-name-surname">Zamboni</span>  <span class="cit-name-given-names">P</span></span>, </li><li><span class="cit-auth"><span class="cit-name-surname">Galeotti</span>  <span class="cit-name-given-names">R</span></span>, </li><li><span class="cit-auth"><span class="cit-name-surname">Menegatti</span>  <span class="cit-name-given-names">E</span></span>, </li><li><span class="cit-etal">et al</span></li></ol><cite>. <span class="cit-article-title">Chronic cerebrospinal venous insufficiency in patients with multiple sclerosis</span>. <abbr class="cit-jnl-abbrev">J Neurol Neurosurg Psychiatry</abbr> <span class="cit-pub-date">2009</span>;<span class="cit-vol">80</span>:<span class="cit-fpage">392</span>–<span class="cit-lpage">99</span></cite></div><div class="cit-extra"><a href="/lookup/ijlink/YTozOntzOjQ6InBhdGgiO3M6MTQ6Ii9sb29rdXAvaWpsaW5rIjtzOjU6InF1ZXJ5IjthOjQ6e3M6ODoibGlua1R5cGUiO3M6NDoiQUJTVCI7czoxMToiam91cm5hbENvZGUiO3M6NDoiam5ucCI7czo1OiJyZXNpZCI7czo4OiI4MC80LzM5MiI7czo0OiJhdG9tIjtzOjE5OiIvYWpuci8zNC82L0U2OS5hdG9tIjt9czo4OiJmcmFnbWVudCI7czowOiIiO30=" class="cit-ref-sprinkles cit-ref-sprinkles-ijlink"><span><span class="cit-reflinks-abstract">Abstract</span><span class="cit-sep cit-reflinks-variant-name-sep">/</span><span class="cit-reflinks-full-text"><span class="free-full-text">FREE </span>Full Text</span></span></a></div></div></li><li><span class="ref-label">5.</span><a class="rev-xref-ref" href="#xref-ref-5-1" title="View reference 5. in text" id="ref-5">↵</a>

<div class="cit ref-cit ref-journal" id="cit-34.6.E69.5"><div class="cit-metadata"><ol class="cit-auth-list"><li><span class="cit-auth"><span class="cit-name-surname">Bavera</span>  <span class="cit-name-given-names">PM</span></span>, </li><li><span class="cit-auth"><span class="cit-name-surname">Agus</span>  <span class="cit-name-given-names">GB</span></span>, </li><li><span class="cit-auth"><span class="cit-name-surname">Alpini</span>  <span class="cit-name-given-names">D</span></span>, </li><li><span class="cit-etal">et al</span></li></ol><cite>. <span class="cit-article-title">Results from 823 consecutive duplex exams for CCSVI in a vascular centre</span>. <abbr class="cit-jnl-abbrev">Acta Phlebologica</abbr> <span class="cit-pub-date">2012</span>;<span class="cit-vol">13</span>:<span class="cit-fpage">141</span>–<span class="cit-lpage">48</span></cite></div><div class="cit-extra"></div></div></li></ol></div><ul class="copyright-statement"><li class="fn" id="copyright-statement-1">© 2013 by American Journal of Neuroradiology</li></ul><span class="highwire-journal-article-marker-end"></span></div><span class="related-urls"></span></div></div>  </div>

  
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