DrSclafani answers some questions

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

Postby Kleiner » Sat Oct 30, 2010 10:26 am

Dr. Sclafani,

I posted this under it's own topic but was wondering if you could offer any insight/interpretation into the results I received from my Ultrasound. I am having trouble finding anyone around my location that can put it into english for me. Here is the original post:

http://www.thisisms.com/ftopict-14377.html

Thanks in advance for your assistance.
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Postby NZer1 » Sat Oct 30, 2010 12:55 pm

Food for thought?
Cervical Subluxations and CCSVI
uprightdoctor | October 30, 2010 at 6:49 pm | Categories: Uncategorized | URL: http://wp.me/p11lYi-BZ



In a previous post I discussed the role of the vertebral veins, also knowns as the vertebral venous plexus (VVP), in causing chronic craniocervical venous back pressure (CCVBP) and subsequent neurodegenerative conditions and diseases such as multiple sclerosis. Like CCSVI, CCVBP can lead to chronic venous backups and edema in the brain. It can also affect cerebrospinal fluid (CSF) pressure gradients and subsequent flow and volume. Correct CSF volume is essential to brain cushioning, protection and support. Consequently, in addition to MS, CCVBP may play a role in normal pressure hydrocephalus (NPH), which has been associated with Parkinson's and Alzheimer's disease.


verterbral arteries
I next discussed the vertebral-basilar arterial supply to the brain and its likely role in chronic ischemia which, like chronic edema from backed-up veins, is one of the main suspects in demyelination and other neurodegenerative conditions and subsequent diseases. Lastly, I posted pictures of the tight neurovascular tunnels the VVP and vertebral-basilar arteries must pass through in the upper cervical spine and foramen magnum in the base of the skull on its way to the motherboard of the brain, the brainstem.



In light of the above, the picture below on the right is of Greek techno music producer, CostumeNational of fightforccsvi.com. The picture was taken with his permission from Dr. Scalfani's MS website forum called, ThisIsMS.com.

The forum is a wonderful group of MS patients who have provided me with a rare opportunity and unbelievable insight into the mystery of MS that they openly and gladly share. Weakened by their condition, they are nonetheless strong and quite fiery in spirit. Together they have formed a formidable group that is shaking up scientists and researchers around the world. Their determined efforts are helping lead the way and shape future research not only for solving MS, but other devastating neurodegenerative conditions as well such as Alzheimer's and Parkinson's disease, NPH, Huntington's chorea, ALS, PLS and others to numerous to mention here. It is invaluable to say the least to have so many cases to study and follow in one location. They provide a wealth of information that demands further retrospective analysis and investigation such as I in the process of doing now on a much larger scale.

This particular type of picture is called an open mouth odontoid image because

the odontoid process of the second cervical vertebra, called axis or C2, is in the center of the image. It's called the odontoid process because it looks like a tooth that sticks straight up from the body of the vertebra.

The odontoid process fits neatly into a notch in its mate directly above called Atlas or C1 beneath the base of the skull. The odontoid process permits greater pivotal action in the upper cervical spine. In my opinion, the odontoid process also reduces the size of the body of the vertebra, which may help to reduce pressure in the area during head and neck movement. The red line indicates the center line of the spine. The triangular dart-like shapes pointing upward are the spinous process of the cervical vertebra. In a normal spine, they should all line up on the red line.

If you look through the open mouth you will see one of the darts is way off to one side. You will note by the marker on the film that it indicates the right side. That particular dart is the spinous process of the second cervical vertebra (C2) called axis. The degree of misalignment in this case is severe.

According to CostumeNational, about eight years ago or so, he was riding a motorcycle when he crashed into a car, which threw him to the ground landing on the right side of his shoulder and head. The force of the fall from the weight of his propelled body magnified by the speed he was traveling at severely snapped his neck to the left and left him unconscious.

As the x-ray evidence clearly shows, when he came to later in the hospital, although no one knew it at the time, his head and neck were no longer aligned properly. Instead it remained in the wicked tilt to the left the same as it was after impact. Eight years later he started to develop optic neuritis in his left eye on the low side of the head tilt. Head tilts cause the brain, blood and CSF inside the cranial vault to shift to the low side just like water in a glass, which can increase pressure on the optic nerve and may play a role in optic neuritis.

Interestingly, he had no lesions in the brain but he did show hyperintensity signal precisely at the location of the kink in the upper cervical spine. The highly suspicious characteristic symptom of optic neuritis was next followed by cerebral, as well as cord signs and symptoms identical to MS. Nonetheless, without brain lesions, his case falls into the uncertain category of cracks, a no-man's land not considered to be classic MS, which is crazy.

There is a major principle in neurology when it comes to the brain and the cranial vault, called the Monroe-Kellie principle. According to the Monroe-Kellie principle there are essentially three elements inside the cranial vault which include the brain, blood and CSF. Since the cranial vault is a closed container for the most part, if the volume of one of the elements increases, then one or both of the other two elements must decrease in volume. A brain tumor for example can compress blood vessels as can Chiari malformations mentioned in previous posts. Likewise an increase in blood or CSF volume can compress the brain.

The same principle holds true for the spine and spinal canal, which, like the cranial vault, is for the most part a closed container. In other words, there is no free space inside the spinal canal. Instead, the space between the inside walls of the spinal canal and the cord is filled with the VVP. Therefore a kink in the upper cervical spinal canal as in the case above puts a kink in the drainage system of the brain and cord. It also causes venous back pressure and hypertension around the cord. Lastly, it increases resistance to CSF flow on its way back to the brain from the cord.

In my next post I will discuss precision line analysis used by upper cervical chiropractors to analyze mechanical strains such as the one above. After that we will then look at some of the common signs and symptoms of MS which share a lot in common with AD and PD.
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Postby saks » Sat Oct 30, 2010 6:36 pm

Dear Dr S:
I'm wondering if it's possible or likely to get vein thrombosis after CCSVI ballooning- no stents. I read about it. How can this happen?
Thank you very much.
Synthia
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Postby drsclafani » Sat Oct 30, 2010 8:10 pm

Kleiner wrote:Dr. Sclafani,

I posted this under it's own topic but was wondering if you could offer any insight/interpretation into the results I received from my Ultrasound. I am having trouble finding anyone around my location that can put it into english for me. Here is the original post:

http://www.thisisms.com/ftopict-14377.html

Thanks in advance for your assistance.


LET ME TRY TO INTERPRET THIS INTO ENGLISH FOR YOU. MY TRANSLATION WILL FOLLOW PART OF THE REPORT IN ALLCAPS


REPORT


SUPINE STUDY:

Right IJV Cross-sectional area: 17.5mm^2
Left IJV Cross-sectional area: 30.5mm^2


IN THE LYING DOWN POSITION, THE LAB HAS MEASURED THE AREA OF THE CIRCUMFERENCE OF THE JUGULAR VEIN. AS YOU CAN SEE THE AREA OF THE LEFT IS ALMOST TWICE THAT OF THE RIGHT. HOWEVER COMPARISON OF RIGHT AND LEFT DO NOT HAVE SIGNIFICANCE. COMPARISON OF LYING DOWN AND SITTING UP IS IMPORTANT.

Prominent echogenic bands in the J1 segment of the left IJV
ECHOGENIC BANDS ARE SOUND REFLECTIONS OF TISSUE, IT COULD BE BANDS, ABNORMAL VALVES, SEPTATIONS, ETC THIS IS A B-MODE ABNORMALITY


Intermittent retrograde flow in the J2 segment of the left IJV
PERIODIC FLOW BACK UP TOWARD THE HEAD IN THE MIDDLE OF THE JUGULAR VEIN. THIS IS ABNORMAL. WE CALL IT REFLUX.

Normal antegrade flow in the right IJV, vertebral, and deep cerebral veins.
BUT THAT REVERSED FLOW ONLY OCCURS IN THE LEFT INTERNAL JUGULAR VEIN. THE OTHER MEASURED VEINS HAVE FLOW IN THE CORRECT DIRECTION. THIS ZAMBONI CRITERIA IS MET WHEN ANY OF THE VEINS FLOW BACKWARD. YOU DO NOT HAVE TO HAVE IT IN MORE THAN ONE OF THE VEINS.



UPRIGHT STUDY: USUALLY DONE SITTING UP, NOT STANDING.

Right IJV Cross-sectional area: 21.4mm^2 (change from supine= -3.9mm^2

THE CROSS SECTIONAL AREA DIFFERENCE BETWEEN UPRIGHT AND LYING DOWN ON THE RIGHT (ALSO KNOWN AS DELTA CSA). WHEN YOU SUBTRACT THE UPRIGHT FROM THE SUPINE AND GET A NEGATIVE NUMBER, THAT MEANS THAT THE CSA IS LARGER UPRIGHT THAN SUPINE. NORMALLY THE VEIN GETS SMALLER WHEN YOU ARE UPRIGHT BECAUSE THE FLOW NORMALLY GOES THROUGH THE VERTEBRAL VEIN WHEN SITTING AND STANDING.

Left IJV Cross-sectional area: 4.8mm^2(change from supine= +25.7mm^2
THIS IS WHAT IS NORMALLY SUPPOSED TO HAPPEN. THE VEIN IS BIGGER SUPINE THAN UPRIGHT.

Normal antegrade flow in the IJV and vertebral veins

ANTEGRADE FLOW MEANS THAT THE FLOW IN THE VEIN IS BACK TO THE HEART. tHIS IS THE DIRECTION VENOUS BLOOD IS SUPPOSED TO GO.

Retrograde flow in the deep cerebral veins
THE FLOW IN THE DEEP CEREBRAL VEINS IS GOING BACK TOWARD THE HEAD. THIS IS NOT WHAT IS SUPPOSED TO HAPPEN;. THIS IS ABNORMAL. THIS IS THE PART OF THE TEST THAT IS DONE WITH THE PROBE AGAINST THE TEMPLE OR NEAR THE EAR. IT IS CALLED TRANSCRANIAL DOPPLER.


INTERPRETATION:

1. Criteria for CCSVI 4/5 (qualifying factor for CCSVI is 2/5)
THE FIVE CRITERIA ARE
1. REVERSAL OF FLOW IN AN IJV OR VERTEBRAL VEIN (YOU HAVE THIS)
2. REVERSAL OF FLOW IN THE DEEP CEREBRAL VEINS (YOU HAVE THIS)
3. ABSENCE OF FLOW FOR PART OF THE VASCULAR CYCLE(YOU DO NOT HAVE THIS)
4. A NEGATIVE DELTA OF CSA (YOU HAVE THIS)
5. B-MODE ABNORMALITIES LIKE STENOSES, THICK VALVES, (YOU HAVE THIS)

I hope this helps[/b]
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Postby drsclafani » Sat Oct 30, 2010 8:16 pm

saks wrote:Dear Dr S:
I'm wondering if it's possible or likely to get vein thrombosis after CCSVI ballooning- no stents. I read about it. How can this happen?
Thank you very much.
Synthia


it is possible to get thrombosis after ccsvi ballooning.
it happens when slow flow is present and the inner lining of the vein is injured, as it always is, after angioplasty;

Stasis. ie slow flow and activation of the clotting system by intimal damage, result in thrombosis.

Zamboni and I both recommend anticoagulation to reduce the risk of clotting while the vessel is trying to heal itself after angioplasty. Some use antiplatelet drugs such as aspirin or plavix, but i use fondaparinux, a artificial heparin like material that is effective but safer that coumadin, heparin or lovenox. it is given by injection once a day into the abdominal fat. I start it immediately before i perform the procedure.
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Azygos

Postby Thekla » Sat Oct 30, 2010 8:31 pm

I am still occupied with the azygos issues idea--maybe because Dr Tariq's percentage is so high and I was only diagnosed with mild ijv blockages. I posted this several days ago but I think it got lost at the bottom of the page.

It is my impression that the IJV blockages are the low hanging fruit of ccsvi treatment. Dr Sclafani, can you comment more on the azygos issue and its diagnosis, treatment and implications. I have heard some claim that azygos issues are more common in those with lower body mobility problems.

Are patterns being identified correlating blockages/disrupted flow with any symptoms. Maybe ijv with fatigue or mental fog? azygos? what about sigmoid sinus? Is there a connection with any blockages and lower extremities swelling--many experience feet or ankles swelling? It could be a totally unrelated issue.
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Postby NZer1 » Sat Oct 30, 2010 11:28 pm

Edited.
Dr. with the changes in flow pathways from having treatment of faulty valves etc is there a way to measure that the volume/time of flow post angio has changed?
Is there a way to measure total brain flow volume/time before and after?
If the system is regulated by other means than flow capability will there need to be a settling time after angio for the flow to adjust and the reflux to be 'cured'?
If blood pressure is not the regulator of volume of blood through the brain can it be proved that angio has actually changed the volume passing through the brain and reflux has ceased?
The veins that are being angioed are not functional full time or for all of the flow (lying down versus standing etc) so the temporary improvement that some people see could be to do with the time the body takes to adjust to the balance of flow improvement because of angio removing a resistance that was found 'which could cause reflux' (but the body has already found/created a bypass for flow, through the use of the collaterals).
If blood pressure does not increase to compensate for malformations in the return circuit and the blood return flow is literally falling back to the heart, there must be regulation in and around the brain/skull to maintain the volume in the skull before it overflows to return to the heart.
I would imagine somewhere near that 'place or system of regulation of blood volume within the skull' there would need to be a one way valve 'system' to stop the reflux and back jets re-entering the brain and causing the MS phenomenon.
Maybe this is what the body needs or is missing?
So my understanding is that tests on total volume/flow through the brain before and after will also be important.
Is Doppler Ultrasound able to identify before and longitudinally after angio that the reflux has stopped?
There seems to be mixed opinions on the quality of information from Doppler testing.
Are PwMS having problems with good blood supply in general compared with 'normals'?
The body developing collaterals would enable blood flow that could not return through malformations, but this does not give a good flow path in a gravity type system and it would be a possible cause of the reflux. To be able to maintain what angio actually achieves long term and answer why there are differing results post angio for PwMS over time could be explained as, the body needs to adjust and balance itself because of the new flow direction and ability to flow. As well as the effect of the 'flush concept' from improved flow could be a factor.
I think we PwMS need to know whether there is a change in volume passing through the brain so we have a better understanding and can enlist help from other medical specialties if we need more knowledge and input to complete the picture. The flow of fresh blood in PwMS versus 'normals' could easily be a factor in disease progression on top of reflux depleting fresh quality blood flows and cause progressing disability. The studies so far are only a snap shot of incidence in PwMS, there needs to be more longitudinal studies
Dr Haacke has already said that there are likely to be 50 plus subsets of CCSVI malformations, so the concept of them changing over time is a whole new area of study. It already seems that we are learning only a part of the problem with Zamboni's malformations, I think the system of flow is being underestimated at present.
Last edited by NZer1 on Sun Oct 31, 2010 2:24 pm, edited 1 time in total.
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Postby NZer1 » Sun Oct 31, 2010 2:31 am

Just had a realization, for the back jets/reflux to occur there would need to be a zero pressure or a vacuum so that the flow could reverse in a fluid.
The collaterals have created a path for the blood to return to the heart (there is no pressure otherwise the reflux could not happen, unless the vein is expanding and pumping and also creating a vacuum with the heart beat) therefore there needs to be a one way valve fitted above the collaterals to stop the reflux. No need to do anything to the malformed vein (values, webs, septums etc) the flow is already occurring just not in a direct route, otherwise the back jet/reflux could not happen.
Simple. Inline one way valve.
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ccsvi

Postby zinamaria » Sun Oct 31, 2010 4:50 am

Dr. Sclafani, are you currently doing the procedure? i am way behind on this thread. so I apologize now, and if anyone else can answer me (cece?) I would appreciate it. I also tried to email Holly and it came back to me, does anyone have her email? I do not want the good doctor to have to waste his time with such practical questions not to do with veins...
thank you to whoever can help or update me.
zina
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Postby NINOU » Sun Oct 31, 2010 6:17 am

Dear Dr Sclafani,
I'm living in France.
I would like to get your opinion on my CCSVI.
Please find here a picture : http://ivcc.fr/images/ccsvi_jcm.jpg

One doctor said I maybe have a TOS
Another didn't want to make the liberation treatment, because too risky, my stenosed vein was due to a congenital problem.

What do you think ? Should I try anyway ? Is there a high risk of re-stenose ?

In advance, thank you
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Answer to call for placebo-controlled studies

Postby Squeakycat » Sun Oct 31, 2010 7:53 am

Dr. S, in your opinion, would a detailed case study of a case such as this one in which MS symptoms wax and wane with stent thrombosis be persuasive in answering the question of placebo effect of venoplasty in treating CCSVI or is the only way to answer it a placebo-controlled study?


mila77 wrote:Hi guys,

Maybe some of you remember the story of my CCSVI treatment, but for those who dosnt I will tell it again.

My MS started 12 years ago at the age of 18 with optic neuritis in the right eye. I was not diagnosed at that time and I had next 10 years of my life symptom free, then 2 years ago I had my second mild relapse - some numb hand and feet but nothing extreme. My MS was developing quite slowly.

4 months ago in April I had my CCSVI Treatment done in Euromedic clinic in Katowice (Dr Simka team). I had no symptoms before procedure and I did it as a precaution - to avoid future relapses.

I left the operating room with slightly numb right hand and it stayed like that for a long time. Then I started developing some numbness in my right leg. So I went back after 2 months for a check-up with dr Simka who after 10 min ultrasound assured me that everything is ok with my blood flow and there are no angiologic reasons for my numbness.

So I came back to Warsaw and decided to wait and give it a time. In the meantime I developed another numbness in the torso on both sides and in both legs. After a month it was going away and another symptom was starting.

So I decided not to wait any longer and called AMEDS clinic to ask for the second opinion. Yesterday I went to their clinic for a battery of tests (ultrasound, MRI, MRV, EKG, Blood tests, Neurologic exam). And today I went there for the results. It turned out that I developed thrombosis in the stent area. Originally the stent had 14 mm diameter and now it is just 4 mm wide and my MRI showed 3 active leasions. I will be on blood thinners starting tomorrow and after a month we will repeat the ultrasound and see if it is posspible to reballoon the stent. Right now it is too dangerous to do it.

I would like to express here my grattitude to the AMEDS team, especially dr Agnieszka who took great care of me and had the time to sit and answer all my questions, discuss options for treatment etc etc.

All the tests at AMEDS were executed thoroughly and all the results were given back to me. To the contrary I do not have my 10 min Ultrasound results from Euromedic so the doc at AMEDS did not have anything to compare it. I realize that docs From Katowice have more experience bec the executed more treatments so far but when I was there I felt like i was in a factory "one done, next please".

Maybe it sounds like AMEDS advertisement but it isn't. Those are just my impressions comparing those 2 Polish clinics.

I will update u about my thrombosis development in this plot later on.
Thanks for listening ;-)

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Postby fogdweller » Sun Oct 31, 2010 11:55 am

Can a properly done doppler distinguish between restenosis caused by structural renarrowing and thrombosis? How is thrombosis caused restenosis treated?
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Re: ccsvi

Postby Cece » Sun Oct 31, 2010 1:50 pm

zinamaria wrote:Dr. Sclafani, are you currently doing the procedure? i am way behind on this thread. so I apologize now, and if anyone else can answer me (cece?) I would appreciate it. I also tried to email Holly and it came back to me, does anyone have her email? I do not want the good doctor to have to waste his time with such practical questions not to do with veins...
thank you to whoever can help or update me.
zina

Holly's email is ccsviliberation@gmail.com

For catching up on where he's at, here are some of the recent answers he's given:
http://www.thisisms.com/ftopicp-136770.html#136770
http://www.thisisms.com/ftopicp-138011.html#138011
http://www.thisisms.com/ftopicp-138003.html#138003
http://www.thisisms.com/ftopicp-138210.html#138210
http://www.thisisms.com/ftopicp-139182.html#139182

Can you tell he gets asked this a lot! I too am hoping for an answer in the affirmative someday soon.

And for how I feel when a question for cece gets added into a question for drsclafani: :D
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Re: ccsvi

Postby nancymno » Sun Oct 31, 2010 2:05 pm

Cece wrote:
zinamaria wrote:Dr. Sclafani, are you currently doing the procedure? i am way behind on this thread. so I apologize now, and if anyone else can answer me (cece?) I would appreciate it. I also tried to email Holly and it came back to me, does anyone have her email? I do not want the good doctor to have to waste his time with such practical questions not to do with veins...
thank you to whoever can help or update me.
zina

Holly's email is ccsviliberation@gmail.com

For catching up on where he's at, here are some of the recent answers he's given:
http://www.thisisms.com/ftopicp-136770.html#136770
http://www.thisisms.com/ftopicp-138011.html#138011
http://www.thisisms.com/ftopicp-138003.html#138003
http://www.thisisms.com/ftopicp-138210.html#138210
http://www.thisisms.com/ftopicp-139182.html#139182

Can you tell he gets asked this a lot! I too am hoping for an answer in the affirmative someday soon.

And for how I feel when a question for cece gets added into a question for drsclafani: :D


Holly prefers using ccsvi@aac-llc.com
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ccsvi

Postby zinamaria » Sun Oct 31, 2010 3:02 pm

Thank you Cece! You are one energetic woman, and I want you to know how appreciated you are by me as 'grand' facilitator!
Zina
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