DrSclafani answers some questions

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

Postby NZer1 » Fri Sep 17, 2010 1:07 pm

Thanks Cece the question was from the angle why in NZ do we have to use two techinians to look at the two areas which are in the case of CCSVI interrelated. The loss of knowledge / lack of knowledge compounds when there are more specialties, here the medicos are behind the eight ball and have huge amounts of catching up to do. The frustration compounds when we have the equipment but not the skills or people watching trends in their speciality. There are times when PwMS have more info on CCSVI and have read more about the technicalities and challenges.
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Postby PCakes » Fri Sep 17, 2010 1:46 pm

Good day!
Supposition posed..
Say a person...
1) easily bruises - what/where the heck did I?
2) easily ruptures veins in their fingers ie/ carrying, say a plastic grocery bag, in the crook of a knuckle joint causing a rupture - instant swelling/purple finger that just as quickly resolves
3) has well distributed tiny superficial blood spots "Petechiae" capillary hemmhorage
... all signs of a tendency to easily rupture blood vessels?

Now.. enter cerebrospinal.. could this tendency to rupture these small vessels, with little cause, extend to these areas? resulting in small ruptures, resulting in blood deposits requiring immuno cleanup?
Could this be a possible explanation for those without clear indicators of venous insufficiency?
My thougths are drawn from personal experience and from comments on TiMS regarding.. "my symptoms first appeared after neck/back trauma" and "my symptoms first appeared after a very stressful time" (hypertension)

Lay 'Lay'dy Lay :)

Thank you for your time...
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Postby Johnson » Fri Sep 17, 2010 2:48 pm

girlgeek33 wrote:
thank you but I guess I should have been more specific. I have what feels like scar tissue under the skin. feels like a little ball, solid, inside, maybe a half inch above incision site. So, considering that, do I have anything to be concerned with? I had a serious bruise after the procedure. I recall a nurse noting that something must have "slipped" but it is a vague memory. After the bruise started to heal, and I could touch the area without pain, I felt the "ball" inside. it was larger than it is now. initially, maybe the size of a small grape. now about the size of a pea. My doc seems to think it shouldn't be a problem. Since I can't find too much information about this, I wanted to ask for more clarification. To be clear, my actual incision site has been fine. It healed nicely, never bothered me.

Thanks!!!!

I had that "little ball" at my incision site too - about half the size of a pea, and it resolved over a matter of weeks. As yours has gone from the size of a grape to the size of a pea, I would bet that it will resolve completely in time. My bruise at the incision site was only about the size of a dime, if that.
My name is not really Johnson. MSed up since 1993
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Postby 1eye » Fri Sep 17, 2010 3:23 pm

Cece wrote:
drsclafani wrote:
NZer1 wrote:Welcome Dr. have to say I was a bit worried you seemed to be gone for some time, thought someone may have hijacked you and put you in a sweat shop treating PwMS 24/7. :lol:


i could live with that. I like steam rooms and would love to treat patients ASAP!!

No need to sedate your patients if you follow through on this plan, the heat will do that for ya! :)

drsclafani wrote:SIR is convening a group to establish foci for research and recommendations for training. I have been invited to attend, mid October.

As your partner in crime: please give me some of the things that you want assessed and researched. i will share during the meeting

This is a remarkable offer.


Yes, it is. Please get to the bottom of the heat sensitivity thing in a formal way, so that people can know what it is and what it is not. My current belief is that it is a problem with drainage of the thyroid gland. When it cannot drain hotter blood out it cannot get cool. So I find cooling my thyroid directly is a short-term fix. Recently it has been speculated that something else is wrong in the drainage from within the brain. I don't know about that but of all my symptoms, left leg and foot paralysis and heat sensitivity are the most fixed and unchanging. To know more about why these happen is primary for me.

Next, I wonder why my task-switching is so slow and laboured. I have also heard this described as slow processing of new data. It, as well as all my other symptoms, seem to be heat-sensitive. So that above 73 degrees, I really fall apart. It's quite dramatic.

Thanks.
"Try - Just A Little Bit Harder" - Janis Joplin
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Postby NZer1 » Fri Sep 17, 2010 3:46 pm

I would have to echo 1Eye here. Somewhere, sometime this is going to be necessary. To identify the specific areas that cause these symptoms. My interest in the Dr. Flanagan views on CCSVI and its effects such as Heat or LHermitte's are good examples on blood flow that could also be within the spinal cord and effected in tandem with cord compression or flow restrictions in the cord.
There might be links with the blood flow and the CSF flow . And there could also be vascular and external forces involved at the same time.
It is too much of a co-incidence that chiropractics can give logical explanations for our symptoms and vascular flow improvements achieve improvements.
I'm not sure I am making sense yet with my thinking, I believe its too much of a commonality that the same symptoms can happen with the two specialities having positive outcomes through different treatment types 'some' of the time, but for unexplained reasons not all the time.
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Postby 1eye » Fri Sep 17, 2010 4:21 pm

some semantics are necessary:
i differentiate narrowing that may be caused by many things, some of which are not permanent or abnormal from stenosis which implies to me a fixed narrowing. This is very important concept. Valves that do not open because they are malformed lead to stenoses. Scar tissue or atherosclerosis causes stenosis of arteries and dialysis grafts. Narrowing might be due to the fact that there is little blood filling a vein or due to a higher pressure structure like the carotid artery indenting it. If you fill the vein it distends from a physiological narrowing but will not if it is malformed vein.

This is a difficult perceptual concept and does lead to confusion. Sorry but true. and you are not alone in this confusion. Many doctors also are confused


Yes, thank you. I thought there might be a hint of terminology implied by these words. I have been criticized (by doctors!) for using the term stenosis so I have kind of avoided the issue and called everything a narrowing. I think this is a very correct opportunity for neologisms (for both). I also think we need a new word for blockage, also commonly interchanged with stenosis. In fact, go nuts and invent words for all the weirdnesses you see, for which no words, but useful operations are available. And make sure they cannot be confused or mixed up. OK? And by Thursday. Great.
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Postby drbart » Fri Sep 17, 2010 5:10 pm

drsclafani wrote:i think that these azygos webs are a great challenge.


ooooo! i sense a blinded study opportunity that might have useful implications for establishing a standard of care.

instead of outright sham procedures, how about real procedures that differ only in whether azy webs get cleaned out?
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Postby Cece » Fri Sep 17, 2010 5:18 pm

1eye wrote:OK? And by Thursday. Great.

He's a busy guy, we should give him until Friday. :wink:

NZer1, thanks for clarifying, I didn't know about the subspecialties.

DrS, I'd like to see the SIR group figure out how to get to standardization quickly. What's the best imaging, the best ballooning techniques, the best catheter tools, the best after-care? How do you get every patient here the best outcome they can achieve? Where is the 'just right' between under-treatment and over-treatment?

If we are moving out of the era of travelling for treatment and into an era where most major metropolitan areas will have a CCSVI treatment site, then how much more emphasis should there be on after-care? There is restenosis, there is thrombosis, this has never been a one-treatment-and-done deal.

If there are any areas, such as the azygous, that tend to be underdiagnosed, then how can this best be taught to help every IR treating any of us to find all the CCSVI malformations that are present?

Another big issue is stents. 'First do no harm' -- what if stents turn out to be a terrible choice in CCSVI veins? What are the long-term consequences? What if stents are fine but they're being placed in physiological narrowings instead of true stenoses?
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Postby girlgeek33 » Fri Sep 17, 2010 5:47 pm

Johnson wrote:
girlgeek33 wrote:
I have what feels like scar tissue under the skin. feels like a little ball, solid, inside, maybe a half inch above incision site. So, considering that, do I have anything to be concerned with? I had a serious bruise after the procedure. I recall a nurse noting that something must have "slipped" but it is a vague memory. After the bruise started to heal, and I could touch the area without pain, I felt the "ball" inside. it was larger than it is now. initially, maybe the size of a small grape. now about the size of a pea. My doc seems to think it shouldn't be a problem.

I had that "little ball" at my incision site too - about half the size of a pea, and it resolved over a matter of weeks. As yours has gone from the size of a grape to the size of a pea, I would bet that it will resolve completely in time. My bruise at the incision site was only about the size of a dime, if that.


I bruise easy, I don't know how much that had to do with the bruise I had, but it was huge. About an inch & a 1/2 tall by 4" wide. And ugly! Really dark & nasty. I also had bad bruising from the blood pressure cuff. It kept pinching me, to the point of hurting while on the sedation & pain meeds they gave me. So they changed it out. After they were shocked at the bruising I had from it all!
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Postby drsclafani » Sat Sep 18, 2010 2:53 am

girlgeek33 wrote:
drsclafani wrote:
girlgeek33 wrote:Can you tell me how common it is to get scar tissue around or near the incision site? When there, what can be done about it? When is this serious? Can this create issues for the blood flow, especially since that's what trying to be corrected?

Thanks! Welcome back! Hope it was a good trip!

scar forms whenever there is disruption of tissue and skin. if you have a long cut, scar will form. how intense, thick, wide the scar becomes is highly variable, as you probably already know.

many IRs make a cut in skin from 2-3 mm to 10mm long. if the edges do not come together, the defect is filled with scar tissue. if the puncture site were to get infected, then the scar might be larger. Some people produce very thick hypertrophied scars called keloids.

I do not make a skin incision. I just put the needle through the skin and then put a wire into the vein and push the catheter over it into the vein without cutting the skin. my argument is that the cut is unnecessary and the likelihood of scar is much lower. it is basically like putting in an IV

nothing wrong with either technique. the cutting is the traditional way. no one ever accused me of being traditional.

however the scar is usually trivial, it is unlikely to cause problems for the veins


thank you but I guess I should have been more specific. I have what feels like scar tissue under the skin. feels like a little ball, solid, inside, maybe a half inch above incision site. So, considering that, do I have anything to be concerned with? I had a serious bruise after the procedure. I recall a nurse noting that something must have "slipped" but it is a vague memory. After the bruise started to heal, and I could touch the area without pain, I felt the "ball" inside. it was larger than it is now. initially, maybe the size of a small grape. now about the size of a pea. My doc seems to think it shouldn't be a problem. Since I can't find too much information about this, I wanted to ask for more clarification. To be clear, my actual incision site has been fine. It healed nicely, never bothered me.

Thanks!!!!

this sounds like a collection of blood (hematoma) formed. as it clots it forms a semisolid mass that gets to form a scar tissue. It should slowly ds"organize and get smaller. it might completely resolve or there might be a small bump there forever. time will tell. it should not be a major problem
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Postby drsclafani » Sat Sep 18, 2010 2:59 am

NZer1 wrote:There was one more that got lost somewhere Dr,
A friend has asked me to ask;
"Why do sonographers look at the internal jugulars only? And why do the IRs look at the internal jugulars and azygos veins only? There are so many veins that drain blood from the cranium and the CSF around the spinal cord. Why do they restrict themselves? "


actually sonographers should be looking at the jugular and vertebral veins and the deep cerebral veins during the doppler. the doppler is used primarily to assess the presence of insufficiency or reflux. the other veins are inconstant

angiographers are recommended to study the internal jugular veins, the azygos vein, the left iliac, left ascending lumbar and the lumbar veins and the left renal vein. other veins are seen but are inconstant. no recommendations for treatment have yet been identified for them
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Postby Robnl » Sat Sep 18, 2010 5:28 am

drsclafani wrote:i think i am caught up

have a little mercy, i have got to go to work
i am working on some exciting things right now


Is ithis a clifhanger???? :lol: :lol: :lol:

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Postby vivavie » Sat Sep 18, 2010 11:09 am

drsclafani wrote:
vivavie wrote:
drsclafani wrote:
vivavie wrote:Hello DrS, I finally got my stent unblock (candy wrap stenosis) AND:
70% left jug stenosis: balloon twice 8/10X40mm
50% right jug: balloon 3X (8/10/12X40 mm)
both in the area of prior radiation+ curietherapy and neck dissection from previous tongue cancer.


Vivavie:
can you tell us whether your MS symptoms started before or after the radical neck surgery. If you and the group may recall, one of the arguments brought up to refute ccsvi is that patients with neck cancers have both their jugular veins tied off during surgery and they do not develop any symptoms. However it is known that sometimes these patients develop symptoms such as headaches, cog fog, balance problems and fatigue too.

Please let us know

He ALSO found a kink/irregularity in my Azygos 8X40mm (not checked in Poland)
It cracked - it poped - it hurt. (He also check MT and lombar =fine)

I was this doc 1st, he was pretty thorough (2 1/2hr) and he felt he did an aggressive job. Nice, competent, entousiast IR.

I was sure this time I was Fully Liberated but NO! Nothing:Pain -fatigue- brain fog are the same. headache increase.

What eludes me is my stent is now clear, how come I don't have the previous improvements I had for 6 weeks (bladder, saliva, bowel, no headache, sleep)? During the 1st procedure they only found a faulty valva.


of course, i havent seen your pictures so it is hard to say much. but the diameter of the balloons used may have been too small. I cannot tell without knowing the measurements of your veins. While Dr sinan is moving toward 18 and 20 mm balloons, your doctor seems to have stayed on the side of smaller balloons, perhaps for safety.
What should be my next step? Is it possible that the veins did not hold their new shape? How about balloon size? lenght? Would it be a good time to use cutting balloon because those veins must be hardened by radiation?
I am not ready to give up yet! help!
Thank you


it is really difficult to answer you without seeing the picture. if your veins are narrowed by radiation, it is likely that stents will be needed. however, remember, i am just a bystander hearing about the work of another plumber



Tongue cancer was 5 years before ms. I was 30yo. Normally it is 60+ yo man who have smoke and DRINK all their life. That is probably why they never face CCVSI as complication for playing in their neck....
Yes, the Dr said my left jug was pretty small 6mm
How about stent stenosis while on Plavix?
Why did I not get my previous improvements back??
You already have all my CD from Poland and I shipped you this one yesterday with the details. Even the Doppler in July when I was told my veins were 100% NORMAL.

Did you wrestle with the bears or the Indians to be so tired after vacation?!?
I hope you enjoy your rice!


i was really pushing the envelope before i went to the adirondacks and exhaustion was closer to the fact. The time in China was really relaxing. standing on my head does that to me.

i apologize if i did not review your cds. it is very difficult to review them and to put the real person and their CDs with the THISISMS usernames. Very difficult to keep it all straight.

[/b]


Thank you Dr S for your dedication, you are a saint!
Quick follow up:
After last procedure I was declining fast, Dr did not believe me but graciously scheduled a venogram (3 weeks after): left jug had narrowed to 2-3 mm in greatest dia. extensive vertebral collaterals, reflux in sigmoid and accross to right jug.
Stents (3) 10 X42 placement overlaping + 1 from Poland.

Day after: trombosis upper margin of stent, small amount of mural thrombus. Even after treatment the predominance of the flow goes through the vertebral collaterals.

Conclusion: left jug is now useless.

Last hope: right jug and Azygos. No change from august procedure.
Angio 12X40mm. I sent you the CD's. I will PM my personnal info. If you see anything or have any suggestions it would be greatly appreciated it. I have sworn not to leave any stone unturned before I make my final reverence.

my apologies for lenght, I am not a pro at that quoting stuff.
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Postby Renoandi » Sat Sep 18, 2010 1:13 pm

Dear Dr. Scalfani,

I had my procedure on the 14th of this month. I believe my IR spoke with you the morning of it. He did say that he found the narrowing in all the standard places that you have been finding it. I am in Nevada

He did have to use the cutting balloon on the right side to cut through some fiborous tissue so get the other balloon through. I think the largest balloon used was the 14 mm. I did have quite a bit of pain when he was opening the right side and was concerned about that and causing damage to the vein.

My left side was the most narrowed but seemed to open much easier. It has been 4 days since the procedure and I have seen no improvements at all.

I have people telling me that it can take time so I am hopeful, but I wonder if is caution and not using a larger balloon could be the reason?

I was on the table for about 4 hours, so he took his time and really looked at everything. My azygos was clear and the juglars were only about 60 & 50 % narrowed.

Most of my lesions and symptoms are from spinal cord damage, have you seen improvement from others with these types of lesions and do you think he should have gone with a bigger balloon?

My doppler did show refulx on both sides with the left being the worse. Refulx just in a upright position breathing normal as well as the vein being larger that it should.

MRV did show some narrowing but was not much of a help he said. I do have a follow up in October and if I have no improvement by then will ask for another doppler to see how the flow is. My question is do you think I should have the procedure again and ask for a larger balloon if there is no improvement and still refulx.

Sincerely,
Andrea
www.youtube.com/MSVlogSupport<br />LIJ 60%/ RIJ 50%, angio on Sept 14th no signs of improvement yet.
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Postby elliberato » Sat Sep 18, 2010 2:26 pm

Sal,
you know more than all these guys combined. Why in the hell arent you treating?
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