DrSclafani answers some questions

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

Postby Cece » Mon Nov 08, 2010 9:37 am

Interesting, Malden. Yes, fernando is right, this supports what Dr. Sclafani said.

If you click on "pressure (PE) difference" on the page you linked to, it links to a page with this near the bottom:
A normal valve, like a normal large artery, has a very small resistance to flow, and therefore the pressure gradient across the valve is very small. In contrast, in vascular or valvular stenosis the pressure gradient is increased because of the increased resistance to flow (e.g., by decreased vessel radius or valve cross-sectional area). Furthermore, as flow increases across the stenotic lesion (e.g., when cardiac output increases during exercise), the pressure gradient (ΔP) increases. Other factors such as turbulence can further enhance the pressure gradient for any given flow.
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Postby malden » Mon Nov 08, 2010 2:42 pm

Sry... I let it drop...
Last edited by malden on Mon Nov 08, 2010 3:09 pm, edited 1 time in total.
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Postby L » Mon Nov 08, 2010 2:47 pm

present continuous, innit?
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Postby Cece » Mon Nov 08, 2010 2:51 pm

Malden wrote:And the question was about "a jugular have an abnormally high flow velocity", not just stenosis part.

It was my question, I am satisfied by the answer.
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To Dr Sclafani

Postby ACE » Mon Nov 08, 2010 3:32 pm

Hi Dr Sclafani, I dont know if you are not receiving my emails, I have sent you many but have received no reply,,,,,, I am due for my 3rd Angoplasty soon and am hanging out for your take on my second Venogram that I sent you a few weeks back, have you received it and have you had time to review it?.....Alexander
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Postby saks » Mon Nov 08, 2010 4:34 pm

Dear Dr Sclafani,
Please feel free to write about/discuss my case on this site. I’ve been tested locally before going to travel to NY to get treated for my CCSVI. Apparently, my upper internal jugular has longish narrowing and my vein is quite small up there. It is feared that I may need something to keep my vein open if angioplasty causes it to collapse.
Please, PLEASE tell me would you advise stents for me or just try to balloon my vein even if it collapses? OR would you suggest I leave it alone for now? OR???

Thanks so much,
Synthia
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Postby Cece » Mon Nov 08, 2010 4:46 pm

saks, was anything found lower down in the jugular that had the upper narrowing?

Dr. Sclafani, you're being discussed over in this other thread:
http://www.thisisms.com/ftopicp-141593.html#141593

Do you remember, seven months ago, answering a question about if you'd ever seen malformations such as these in non-MS patients throughout your career? How obvious are these outflow obstructions in CCSVI, if you weren't looking for them would you go right past them during all catheter venograms in a forty-year career? Do you ever see properly working jugular valves, in your nonCCSVI patients?
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Postby saks » Mon Nov 08, 2010 6:52 pm

No Cece. Why?
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skeptic mentality

Postby drsclafani » Mon Nov 08, 2010 6:58 pm

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Posted: Tue Nov 09, 2010 11:50 am Post subject:
Cece invited me to join this discussion. These posts are very long and of a polemic and philosophical bent. So i dont know how long i will participate but there are some things i said that bear clarification.

Lyon wrote:
I remember the question and appreciated Dr Sclafani's response very much. A couple of things at play here though. One is that, even after I'm convinced it's still going to remain to convince the medical community and I'm pretty sure that Dr Sclafani would be first to admit that his word alone wouldn't convince them and I'm certain he wouldn't want that to hinge on his word alone anyway.





you know, i cant spend a lot of time trying to convince those who have already made up their minds that this is unproven. Neurologists can remain skeptical. it doesnt matter to me at this point. I am happy to educate and dialogue, but i, like many patients, just do not feel i have the time to dick around and prove something I know to those who dont want to accept it. I am an action guy. I see these veins in MS and i am convinced they are abnormal. When i show my vascular colleagues , they are impressed. They readily accept that this is not normal. Why....need i answer? it is our expertise and we know what looks normal.

:
My personal feelings? I documented it at the time (which went over like a fart in church) but is that Dr Sclafani is doubtlessly an expert of what is known of the venous system and its routing.



Perhaps an expert on this forum. but i accept the expertise of many others who have looked at this in many different forms.

:


Considering his many years of ER experience I'd dare put him as a foremost expert, but it's also important to realize that no especially accurate and trustworthy studies of the veins have been done and until recently no one had even been looking for venous stenosis. Accurate venous imaging is recent and as is becoming evident, it could be said that ACCURATE imaging still is beyond us.



i am not sure what this means. There have been studies of the veins and they have noted many things. For example we know that 15% of patients do not have valves in the jugulars. it is inconceivable to me that pathologists looking at veins long enough to note the absence of valves in 15% of patients would not have recognized stiff, inflexible, stenotic valves or stenoses above the valves due to hypoplasia , and not commented on that in papers reviewing the normal anatomy. But if we are asking whether someone should do venography on hundreds of normal subjects to prove that stenoses are atypical of normal, I say we need to see whether we have the time, money and resources to do this.

:
Though he's an expert, Dr Sclafani's experience has often been under time constraint and pressure with the emphasis on keeping the patient alive. Additionally, his frequent canvas of gunshot, knife, explosion, car accident wounds seldom leave untainted viewing of the venous system.

It's only common sense that until recently venous stenosis wasn't an issue and Dr Sclafani wouldn't have been looking for it.



as i said above I WAS looking for abnormalites like narrowing, which is a common imaging finding of trauma.

:
We now have better imaging and ARE looking for stenosis and still it isn't easily noticed. Considering all of the above we are to think he would have happened to notice stenosis and filed it in mind? It's not obvious how or why he would have noticed or kept it in mind and in essence what he would be noticing is the lack of something that he wasn't looking for?


i do not think that venography has improved greatly in the past 10-15 years. it was and remains a quite clear imaging study. I do not think that MRv or CTv are any better. They might on occasion be preferable because they are less invasive, but they are not better at seeing the veins.

Dr Zamboni feels that it's essential for researchers looking for stenosis to be trained in the tricks of the trade by him because it's evidently so hard to notice and Dr Sclafani would have noticed, while not looking for stenosis and most of the time without benefit of our modern, more accurate imaging equipment.

dr z was speaking about ultrasound. This test is a long standing test that is highly operator dependent. The techniques used prior to ccsvi are not applicable. I think we have already discussed that in many areas. It is not that the ultrasound doppler test for ccsvi is particularly difficult to perform. it is just different and people continue to do the ultrasound the way they know, not the way it should be performed FOR THIS ENTITY. It will just take some education before it is as regular a diagnostic test as any other ultrasound it. But for the moment, zamboni is the main teacher.

:
Despite a long career, under those conditions it's unimaginable that he would have noticed stenosis, one way or the other.



It is true that i was looking at carotid arteriograms and their venous phase images during emergency situations. but rest assured that all of these angiograms were reviewed after the heat of the battle had cooled. Also these angiograms were done for injury. As such a trauma radiologist looks at all possibilities, including occlusions of the jugular veins. I was exploring at that time whether or not damaged veins needed to be ligated. Turns out that they do not unless the wound allows the blood to drain onto the floor. so, my dear friend, Lyon, I was very much focused on the veins. Not looking for obstructions but looking for occlusions. I can say that there were certainly cases of occlusion of veins. This was always associated with significant hematoma in the neck that would compress the veins

Many of the procedures were performed to EXCLUDE injury and provide a reason NOT to surgically explore the neck. In these situations, where there were no hematomas, the veins were large, uniform in caliber, did not have extensive collateral veins, the xray dye did not hold up at the base of the neck. There were no stenoses.


Does that mean that there are not going to be obstructions that do not result in MS? Absolutely not. Indeed we know of several situations where obstructions of the veins do not lead to MS.....Patients with renal failure who get catheters in these veins, occlude or stenose these veins without developing ms, patients with radical neck dissections that results in ligation of these veins, do not develop ms.

however they do develop mental confusion, lethargy, headaches, ataxia, etc.

but in answer to your assumption that in the heat of battle things get missed, i would say generally no. When life and death are in the balance, my mojo gets going and i think i become hyperaware, not distrated or sloppy. its the nature of the game.
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Postby drsclafani » Mon Nov 08, 2010 7:55 pm

saks wrote:Dear Dr Sclafani,
Please feel free to write about/discuss my case on this site. I’ve been tested locally before going to travel to NY to get treated for my CCSVI. Apparently, my upper internal jugular has longish narrowing and my vein is quite small up there. It is feared that I may need something to keep my vein open if angioplasty causes it to collapse.
Please, PLEASE tell me would you advise stents for me or just try to balloon my vein even if it collapses? OR would you suggest I leave it alone for now? OR???

Thanks so much,
Synthia


synthia
if i read your note correctly, you had testing done locally before traveling to new york for treatment.

When i evaluate such situations, i need to look at the imaging myself, as well as understand your disability and your speed of deterioration, among other factors.

So it is difficult for me to answer you with what i know
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Postby drsclafani » Mon Nov 08, 2010 7:57 pm

saks wrote:No Cece. Why?


let me steal cece's thunder for a change

because it is unusual to have upper narrowings without something being wrong in the lower jugular near the valves
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Re: To Dr Sclafani

Postby drsclafani » Mon Nov 08, 2010 7:58 pm

ACE wrote:Hi Dr Sclafani, I dont know if you are not receiving my emails, I have sent you many but have received no reply,,,,,, I am due for my 3rd Angoplasty soon and am hanging out for your take on my second Venogram that I sent you a few weeks back, have you received it and have you had time to review it?.....Alexander


i received two emails today and answered one of them pm shortly thereafter
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Postby drsclafani » Mon Nov 08, 2010 8:00 pm

Malden wrote:Sry... I let it drop...


thanks malden,

i appreciate your skepticism, it makes me think.

so nice of you to visit btw
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Postby drsclafani » Mon Nov 08, 2010 8:13 pm

eyesclosed wrote:Dr Sclafani,

Thank you so much for the time you spend here!

I went to Barrie Vascular Imaging and I was wondering if you could help me interpret my result.

Findings:

Right and Left (both have exactly the same result)

“The cerebral venous outflow appears patent with no evidence of venous thrombosis. Venous insufficiency was evident with reflux in the internal jugular vein at 0 and 90 degrees. The cross sectional area of the internal jugular vein at 90 degrees is larger than the cross sectional area at 0 degrees resulting in negative delta .”

I know I met the criteria for CCSVi (2\5). However, I am not sure why I have reflux in my internal jugular veins if my veins are open. Essentially, could you please explain this part of the result “the cross sectional area of the internal jugular vein at 90 degrees is larger than the cross sectional area at 0 degree resulting in negative delta (positive result)?”



IN A NORMAL PERSON, IF YOU SUBTRACT THE CROSS SECTIONAL AREA OF THE JUGULAR VEIN IN THE UPRIGHT POSITION (SUPPOSED TO BE SMALLER) FROM THE JUGULAR VEIN CROSS SECTIONAL AREA LYING DOWN (SUPPOSED TO BE LARGER) YOU GET A DELTA THAT IS LARGER THAN ZERO.

IN CCSVI, THE THE JUGULAR VEIN DOES NOT DISTEND WHEN LYING DOWN BECAUSE THERE IS NO INCREASE IN FLOW THROUGH IT, BECAUSE OF OBSTRUCTIONS. THEREFORE WE OFTEN GET A SMALLER DELTA
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Postby drsclafani » Mon Nov 08, 2010 8:15 pm

Drury wrote:Dr. Sclafani,

My daughter had a call to schedule a Doppler with Dr. Mandatto at Siskin's office. She had an MRV in August and was told there was no stenosis but that they were not able to see the Azygos properly. Also said she may have reflux but not sure what could be done about it and he basically would have left it at that had we not asked about the Doppler, etc.

Would you suggest she go ahead and have the Doppler? She is on your waiting list and we live in hopes............?

Drury


i always want my patients to have a doppler before treatment. I think doppler is the way to provide surveillance to patients regarding restenosis.
so i need one before and after treatment.
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