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2010 revisions to mcDonald criteria for diagnosis of multiple sclerosis: Impact of 3‐tesla magnetic resonance imaging

with those initially reported by Zamboni (ie, CCSVI in 100% MS and 0% HC), who claimed a causative effect of CCSVI on MS. The second step was to perform in all CCSVI-positive patients blinded selective venography (VGF), considered the unquestionable gold standard by Zamboni himself. VGF was invariably normal: no individual with pMS had evidence of abnormal cerebrospinal venous drainage. Therefore, the comparison should be done between 0 of 50 pMS vs 0 of 50 HC. Curiously, Dr Avruscio, who says he has read our article carefully, has clearly underestimated this important detail of our work. We take this opportunity to underline the importance of designing studies aimed at a more detailed and correct understanding of cerebrospinal venous anatomy and physiology. Indeed, over the last 2 years, we had the possibility—by means of VGF—to observe dramatic pictures of abnormal chronic cerebrospinal venous drainage in individuals with different pathologies, but not affected by MS (Fig). In conclusion, our findings exclude any association between CCSVI and pMS. Moreover, we strongly recommend extreme caution in interpreting an ultrasound-based diagnosis of CCSVI as absolute evidence of a pathological process involving the brain and the spinal cord, which in our opinion requires confirmation by VGF.