DrSclafani answers some questions

A forum to discuss Chronic Cerebrospinal Venous Insufficiency and its relationship to Multiple Sclerosis.

Postby drsclafani » Mon Mar 15, 2010 7:49 pm

n the absence of any pressure, the vein walls will collapse to their natural position. But in many of the venogram images, the jugular vein is obstructed in one particular location, caused by some external force, such as a bony protusion, malfunctioning valve, etc. These images still show blood flow above and below the narrowing. Shouldn't the image show no blood flow below the narrowing, if the vein was to collapse in the absence of any flow?

Also, if blood blow is being driven to the vetebral veins, in the presence of flow resistance in the jugulars, why is CCSVI a problem? Aren't the vetebral veins capable of handling this blood flow like when the person is supine?


Those MRVs are a static image taken after the gadolinium has percolated through the area. if you take a snapshot you might see what you expect, but there is slow flow rather than no flow.

good question about the vertebral vein flow. I see that you will make me think by this exercise and i will figure things out or need to learn things along the way......we really are partners in crime, eh.

I would postulate and argue that these vertebral veins have extra flow that they are not prepared to handle. and not all the blood can exit as fast as necessary. the theory is that this "breakdown" in the blood brain barrier leads to problems.

you guys are tough and insatiable
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Postby Vonna » Mon Mar 15, 2010 7:58 pm

Hello Dr. Sclafani,
I am the one that asked if you were associated with Dr. Mahta. The reason for this question is that when you first posted, on the other thread, it was a thread about Dr. Mahta. I appreciate you clearing this up, and for all the explanations and time you are devoting to us here. It is truly appreciated!
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Postby hope410 » Mon Mar 15, 2010 8:49 pm

drsclafani wrote:[you guys are tough and insatiable


Ha! I would describe us as "driven", no longer accepting a "party line" but requiring much more to satisfy our information needs in order for us to make informed decisions.

Many thanks from me as well for your willingness to educate us so that we can, indeed, make informed decisions.

And a doc with a sense of humour! We like that too! :) I am very glad that you are a part of our journey into this very exciting future unfolding before us!
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Postby Cece » Mon Mar 15, 2010 9:00 pm

drsclafani wrote:If you have resistance to outflow from the brain, you will develop reduction of inflow. Inflow to the brain is a good thing.


Interesting!! I never made this full connection, that it's not just a matter of backflow, but of reduced inflow...and exercise or fight/flight response or anything that would drive more blood flow in would still meet up with the CCSVI condition on the way out.

Just for a blockage in the neck to cause toes to be cold at the opposite end of the body...it drives home the notion that the vascular system is one big loop.
Last edited by Cece on Mon Mar 15, 2010 9:48 pm, edited 2 times in total.
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Portacath Placement

Postby weeble » Mon Mar 15, 2010 9:02 pm

Hello Dr Sclafani. You can't imagine how much I appreciate you entertaining questions from this forum.

I have an appt scheduled for you in May (but am rebooking for July/Aug for some personal reasons). My question for you is this:
I have a portacath (Power Port) that was implanted for chemotherapy as an MS treatment. It sits below my left clavicle, enters my left subclavian and stops in my superior vena cava, 5 mm above my right atrium. Does this eliminate me as a candidate for a venogram or just make me more challenging?

To add insult to injury, the surgeon had the guide wire go up my external jugular during the surgery, there was some trauma, a clot, and now my left external jugular is completely occluded. I am an x-ray tech and was aware of this risk. I never thought to complain about my painful neck so I take partial blame. Stuff happens.

The radiologist reading the doppler assured me that the occlusion is scarred and very old. My left external jugular is collapsing distal to the obstruction. This port surgery was October 2008.

Before I come out to see you, I guess I should find out the answer to this question.
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Postby Cece » Mon Mar 15, 2010 9:41 pm

Another thought discussed here has been that some of the damage of m.s. is occurring during sleep. If the jugulars are only open during sleep/lying supine, then this is when a blockage would be causing problems. As an expert, do you give any credence to the notion of inclining one's bed to improve circulation and drainage from the brain while sleeping? (I am currently sleeping on a bed with 6 inch wood blocks raising the top end, so that my husband and I are sleeping at a bit of an angle. I started out thinking it was goofy but I'd give it a try; I've found that I'm dreaming again and waking more refreshed.)

Without asking you to comment on details or provide care, do you see this as fitting in with CCSVI theory? If inclined bed helps, might it indicate that there could be a problem with the jugular veins, since those are the ones that should be able to carry the load during sleep?

(edited: because I had it reversed and was talking about the vertebral veins carrying the load during sleep, when it's really the jugular veins...)
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Re: Portacath Placement

Postby eric593 » Mon Mar 15, 2010 10:38 pm

weeble wrote: Does this eliminate me as a candidate for a venogram or just make me more challenging?



My close friend has a port and she required a venogram (for another reason) which made it easier as they just went directly through the port instead of threading it up through the leg.
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Postby costumenastional » Mon Mar 15, 2010 11:44 pm

Dear Dr,

venogram is the gold standard for diagnosing CCSVI in IJVs and azygos you say and of course it makes sense.
What about vertebral plexous problems? Atresia, agenesis or whatever.
Would you suggest a specific test (like ct scan or MRV) just to make sure especially when venogram is not indicative for CCSVI?

I know it s early days, but given the fact that blood drains from the vertebral vains when in upright position isn't imaging of these veins also, of special importance?

Please, forgive me if this is already answered and just ignore it. I ll take my time to go through your thread a bit later.

Your presence here is a great honor.
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Dr.Sclafani

Postby miranda » Tue Mar 16, 2010 5:14 am

Dr. Sclafani
THANK YOU for coming on board. It has been impossible to obtain any
information regarding ccsvi in Greece . Your valuable knowledge is much appreciated by everyone on thisisms Holly has been great trying to
help me. Looking forward to meeting you soon I am positive that once
again you will get the last laugh together with all the doctor's accepting
Dr. Zamboni's theory

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Re: valves

Postby Loobie » Tue Mar 16, 2010 5:18 am

drsclafani wrote:
I worry that these valves are going to be a real bugger, incomplete treatments, recurrent obstructions. One gets the sense that something will be ultimately needed to fix the abnormal valve against the wall and stop it from restricting blood flow. perhaps stents are the answer, or some endovenous procedure that resects the valve, or some other technique beyond my imagination at the moment. Surgery on veins, i am told by my vascular surgical colleagues is not without failure.


I had one of those things that looked like a valve but was just a roadblock. I have a stent sticking right in the middle of that valve and it flows now. Before it was a complete stop. That is why I did the two trips to see Dr. Dake. He wanted to put one in that valve the first time, but was unsure. The second time that's what he did and it was dramatic in terms of flow on that side.
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Postby patientx » Tue Mar 16, 2010 8:31 am

drsclafani wrote:
n the absence of any pressure, the vein walls will collapse to their natural position. But in many of the venogram images, the jugular vein is obstructed in one particular location, caused by some external force, such as a bony protusion, malfunctioning valve, etc. These images still show blood flow above and below the narrowing. Shouldn't the image show no blood flow below the narrowing, if the vein was to collapse in the absence of any flow?

Also, if blood blow is being driven to the vetebral veins, in the presence of flow resistance in the jugulars, why is CCSVI a problem? Aren't the vetebral veins capable of handling this blood flow like when the person is supine?


Those MRVs are a static image taken after the gadolinium has percolated through the area. if you take a snapshot you might see what you expect, but there is slow flow rather than no flow.

good question about the vertebral vein flow. I see that you will make me think by this exercise and i will figure things out or need to learn things along the way......we really are partners in crime, eh.

I would postulate and argue that these vertebral veins have extra flow that they are not prepared to handle. and not all the blood can exit as fast as necessary. the theory is that this "breakdown" in the blood brain barrier leads to problems.

you guys are tough and insatiable

Thanks for the reply.
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Postby drsclafani » Tue Mar 16, 2010 9:45 am

venogram is the gold standard for diagnosing CCSVI in IJVs and azygos you say and of course it makes sense.
What about vertebral plexous problems? Atresia, agenesis or whatever.
Would you suggest a specific test (like ct scan or MRV) just to make sure especially when venogram is not indicative for CCSVI?

I know it s early days, but given the fact that blood drains from the vertebral vains when in upright position isn't imaging of these veins also, of special importance?


I asked the same question on sunday to a certain well known investigator. awaiting an answer

these vertebral veins are pretty small. I wonder whether they would stay open after angioplasty
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Postby gibbledygook » Tue Mar 16, 2010 10:35 am

Thank you so much for answering our questions, Doctor Sclafani!
My question also relates to low blood pressure. I enjoyed marvellous symptom relief from 2 stents into the high jugulars for 3 months until I became pregnant. Since pregnancy all of my MS symptoms have deteriorated and now quite significantly. I am 24 weeks pregnant and my most recent blood pressure reading was 70 over 40.
Do you think that low blood pressure would reduce mean transit time of blood through the brain and increase hypoperfusion?
3 years antibiotics, 06/09 bilateral jug stents at C1, 05/11 ballooning of both jug valves, 07/12 stenting of renal vein, azygos & jug valve ballooning,
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Re: Portacath Placement

Postby weeble » Tue Mar 16, 2010 11:32 am

eric593 wrote:
weeble wrote: Does this eliminate me as a candidate for a venogram or just make me more challenging?



My close friend has a port and she required a venogram (for another reason) which made it easier as they just went directly through the port instead of threading it up through the leg.

Perhaps the port could be used to access my right internal jugular, but if a wire was put in my port, it would exit the catheter into my right atrium and it would have to turn right back and trace along the catheter in my left subclavian to reach the base of my left internal jugular.

I want a radiologist to say "No problem." I suspect it is though.

I could have the port removed because I am done chemotherapy, but that's another surgery. Oh, the choices. :roll:
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Postby LR1234 » Tue Mar 16, 2010 12:10 pm

........
Last edited by LR1234 on Mon Mar 05, 2012 11:15 pm, edited 1 time in total.
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