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Updated: Apr 14, 2026
Magnetic Resonance Imaging of Multiple Sclerosis at 7.0 Tesla
Published on: February 19, 2021
Brain Hyperechogenicities are not Associated with Venous Insufficiency in Multiple Sclerosis: A Pilot Neurosonology
Christos Krogias1, Ralf Gold1, Andrew Chan1
1Department of Neurology, St. Josef-Hospital, Medical Faculty, Ruhr University, Bochum, Germany.
Background And Purpose:
The "venous hypothesis" of multiple sclerosis (MS) postulates that intracranial venous congestion disintegrates the blood-brain barrier, resulting in iron accumulation in brain parenchyma triggering the inflammatory process of MS. Transcranial sonography (TCS) reveals brain parenchyma hyperechogenic alterations (BPHA) that are thought to reflect iron accumulation. We sought to investigate potential association of BPHA with chronic cerebrospinal venous insufficiency (CCSVI) in MS.
Methods:
MS patients were evaluated according to established TCS protocol for extrapyramidal disorders examining the presence of hyperechogenicities in different basal ganglia regions. Cerebral and cervical venous system was assessed according to proposed ultrasound protocol for CCSVI detection.
Results:
In a total of 32 MS patients (age = 40 ± 14 years; male = 41%; EDSS-score = 3.1 ± 2.2) brain parenchyma hyperechogenic alterations were detected in twelve (38%) patients. The two sonographers agreed independently in 28 (87.5%) of the 32 examinations, resulting in a substantial to almost perfect agreement (Cohen's weighted kappa: substantia nigra = 0.904, Lentiform nucleus = 0.871, Thalamus = 0.784, caudate nucleus = 0.651). Two (6%) patients fulfilled the neurosonology criteria of CCSVI, while in 7 patients (22%) one positive criterion was detected. No BPHA were observed in any MS patient fulfilling CCSVI criteria. The prevalence of one positive CCSVI feature did not differ (P = .999) among patients with present (25%) or absent (20%) BPHA.
Conclusion:
There was no association of BPHA with CCSVI findings. Our findings do not support the "venous hypothesis" resulting in iron accumulation even in the few MS patients fulfilling CCSVI-criteria.
Insights
This study found no association between brain parenchyma hyperechogenic alterations and chronic cerebrospinal venous insufficiency in multiple sclerosis patients. These findings do not support the venous hypothesis of MS related to iron accumulation.
Area of Science:
- Neurology
- Radiology
- Vascular Medicine
Background:
- The venous hypothesis of multiple sclerosis (MS) suggests intracranial venous congestion leads to blood-brain barrier disruption and iron accumulation, triggering MS inflammation.
- Brain parenchyma hyperechogenic alterations (BPHA), detected via transcranial sonography (TCS), are hypothesized to indicate iron accumulation.
Purpose of the Study:
- To investigate the potential association between BPHA and chronic cerebrospinal venous insufficiency (CCSVI) in MS patients.
Main Methods:
- MS patients underwent TCS to assess BPHA in basal ganglia regions.
- Cerebral and cervical venous systems were evaluated using ultrasound for CCSVI detection.
Main Results:
- BPHA were detected in 38% of 32 MS patients.
- Only 6% of patients met CCSVI criteria; 22% had one positive criterion.
- No BPHA were observed in MS patients fulfilling CCSVI criteria, and no significant difference in CCSVI prevalence was found between patients with or without BPHA.
Conclusions:
- No association was found between BPHA and CCSVI in MS patients.
- These results do not support the venous hypothesis of MS concerning iron accumulation and CCSVI.
