DrSclafani answers some questions

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

Postby drsclafani » Sun Jan 02, 2011 3:52 pm

Cece wrote:
drsclafani wrote:what is this? stump the professor day by asking about this stump of a vein?

Nah, it was the other IR who was stumped. You were the one who saw the duplication in hwebb's image! Altogether impressive.


slow down, cece, the proof is in the puddin

helen, can you show us the venogram that was ultimately found to have an abnormality so we can see if I am correct in thinking that a duplication hid the stenosis?
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Postby Cece » Sun Jan 02, 2011 5:33 pm

...edited out: wrong type of duplicated IJV...

I am still impressed, Dr. Sclafani, even if Helen's IJV does not turn out to be a duplication. If it'd been my vein and my doctor, he'd have used IVUS and we'd have known for sure right away. ;)

And I am convinced Helen has an excellent doctor also. He was able to identify the stenosis on the MRV and go back in a second time and fix it. With so many travelling patients, this is better care than nearly anyone gets; for many there would be no second procedure.
Last edited by Cece on Sun Jan 02, 2011 7:40 pm, edited 1 time in total.
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Postby drsclafani » Sun Jan 02, 2011 6:46 pm

Cece wrote:Here's a publication on a duplicated IJV found in a patient without MS. It shows a surgical image of it too.
http://tinyurl.com/2wwc8wl

My original post on this, which sadly got no responses:
http://www.thisisms.com/ftopic-14874-0- ... rasc-.html

It says this:
Duplication of the internal jugular vein is a rare anomaly found during the dissection of the neck. The reported incidence is 4/1000 of unilateral neck dissections

So, since 1/800 people get MS and 1/250 is the reported incidence of a duplicated IJV, perhaps it can occur benignly?
Duplication usually involves the upper third of the vein and extends down to a variable level.1 Very few cases have been reported about low duplication 3, 4. Duplication of the internal jugular vein is usually reported in association with phlebactasia, which is a soft non-pulsatile cervical swelling that increases in size during a valsalva maneuver

Or is what we are seeing in CCSVI the rare low duplications? It would be just like us, to have the rare version.

I am not familiar with phlebactasia. Perhaps this swelling would serve as an outflow obstruction as well.

I am still impressed, Dr. Sclafani, even if Helen's IJV does not turn out to be a duplication. If it'd been my vein and my doctor, he'd have used IVUS and we'd have known for sure right away. ;)

And I am convinced Helen has an excellent doctor also. He was able to identify the stenosis on the MRV and go back in a second time and fix it. With so many travelling patients, this is better care than nearly anyone gets; for many there would be no second procedure.


cece
what i am describing is very different. it is an incomplete duplication of 206 cm of the jugular vein centrally. it shares a common wall with the true jugular vein. and an orifice with the sublcavian/inominate
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Postby Cece » Sun Jan 02, 2011 7:20 pm

terminology strikes again! :)

That does explain why this
fenestration of the common wall?

is a possible solution. There has to be a common wall before you can fenestrate the common wall.
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Postby pairOdime » Sun Jan 02, 2011 7:35 pm

Dr. Sclafani,

Two potential techniques or methods (without stent or surgery) are intriguing.
(1) What technique or instrument might be used to create the opening in the common wall of the vessel? (2) How might the lumen be closed via endovascular procedure?

I know this is all very hypothetical.
Thanks in advance Dr. Sclafani.
It's a paradigm shift
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thanks guys

Postby hwebb » Sun Jan 02, 2011 10:38 pm

I'm buoyed to read the amount of discussion on this problem "possibly duplicate" vein. When I get the most recent venogram images, I will upload for further discussion. The windsock analogy kinda fits with my observations on posture (my symptoms are far worse when i sleep flat, than when i sleep on my left side). Proof will be in the puddin'.

Can you believe that my right side has worse symptoms these days than my left side (which is governed by a hypoplastic jugular...only 0.5cm in width now it's been stretched and the 0.2cm stenosis cleared).

Definitely happy with my doctor. He's conservative, but collaborative and open-minded.

H.
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Postby sara2407 » Mon Jan 03, 2011 3:18 am

Dear Doctor,
I wish you a successful 2011.

I have PPMS since 2003 with Edds 7.0.
25.08.2010. I have the liberation procedure in Sofia, Tokuda Hospital. I had a very small improvements, such as excess energy and I was stable so far.
Ten days ago I felt a tremendous fall, each day worse than the previous one. Galloping.
I called Tokuda hospital and they told me to come to control and if there was restenosis, repeat the procedure.

Does it make sense to go to the control and repeat the process of liberation?
This life makes no sense, but I am very afraid of the future.
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Postby Algis » Mon Jan 03, 2011 4:23 am

Dear Sara:

re-stenosis do happen often as far as I am aware; and tho we do not think it is 'normal' it seems to be in the actual state of the development.

Life does have a sense; cheer up; we all in this together :)
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Postby drsclafani » Mon Jan 03, 2011 8:29 pm

Cece wrote:terminology strikes again! :)

That does explain why this
fenestration of the common wall?

is a possible solution. There has to be a common wall before you can fenestrate the common wall.


you can join my residency program
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Postby drsclafani » Mon Jan 03, 2011 8:32 pm

pairOdime wrote:Dr. Sclafani,

Two potential techniques or methods (without stent or surgery) are intriguing.
(1) What technique or instrument might be used to create the opening in the common wall of the vessel? (2) How might the lumen be closed via endovascular procedure?

I know this is all very hypothetical.
Thanks in advance Dr. Sclafani.

We might have to invent the instruments
we can poke a needle through the common wall....that is not likely to be a durable technique. We can develop a scalpel that travels on a guidewire.

closing the duplicaiton is possible but we wsould have to invent it

in good time
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Re: thanks guys

Postby drsclafani » Mon Jan 03, 2011 8:33 pm

hwebb wrote:Can you believe that my right side has worse symptoms these days than my left side (which is governed by a hypoplastic jugular...only 0.5cm in width now it's been stretched and the 0.2cm stenosis cleared).
H.


helen
I am not surprised. i do not think there is any correlation between side of stenosis and side of brain damage
s
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Postby drsclafani » Mon Jan 03, 2011 8:37 pm

sara2407 wrote:Dear Doctor,
I wish you a successful 2011.

I have PPMS since 2003 with Edds 7.0.
25.08.2010. I have the liberation procedure in Sofia, Tokuda Hospital. I had a very small improvements, such as excess energy and I was stable so far.
Ten days ago I felt a tremendous fall, each day worse than the previous one. Galloping.
I called Tokuda hospital and they told me to come to control and if there was restenosis, repeat the procedure.

Does it make sense to go to the control and repeat the process of liberation?
This life makes no sense, but I am very afraid of the future.


if you had improvements for four months, then you should go back and have another look. All the doctors are getting better at this day by day. The doctors in Tokuda work very hard to make good results. When you have long period of PPMS, the damage is great, the likelihood of miracles is low, but slowing the beast may be worth it to you.
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AXYGOS findings

Postby drsclafani » Mon Jan 03, 2011 8:54 pm

ok class....

Today we review an azygos vein. This vein, which drains the spinal cord via intercostal veins and lumbar veins, enters the superior vena cava at the top, the renal vein in the middle and the ascending lumbar veins at the bottom.

The findings of malformations are
1. valvular problems of fixation, stiffness and fusion
2. Webs & septations running through the ascending component of the vein
3. twists and kinks

Let's have a look at this:

Image
1. on the left contrast media is injected at the tip of the catheter (red arrow). One notes that there is no dye flowing up toward the superior vena cava.
2. on the second image one sees that there is dye above the area of blockage (red arrows). This is flowing past the obstruction through a large feeding branch. (orange curved arrow)
3. On the third image the narrowed segment is quite obvious. For those readers who are not obvious and have real moral character, the red arrow points to the pointed narrowing.
4. Finally, the last image on the right SHOWS NO NARROWING. What could be the explanation?

Tomorrow we will continue this harrowing adventure.

This is Dr Whiplash, i am out to lunch.
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Re: AXYGOS findings

Postby CCSVIhusband » Mon Jan 03, 2011 9:10 pm

drsclafani wrote:ok class....

Today we review an azygos vein. This vein, which drains the spinal cord via intercostal veins and lumbar veins, enters the superior vena cava at the top, the renal vein in the middle and the ascending lumbar veins at the bottom.

The findings of malformations are
1. valvular problems of fixation, stiffness and fusion
2. Webs & septations running through the ascending component of the vein
3. twists and kinks

Let's have a look at this:

Image
1. on the left contrast media is injected at the tip of the catheter (red arrow). One notes that there is no dye flowing up toward the superior vena cava.
2. on the second image one sees that there is dye above the area of blockage (red arrows). This is flowing past the obstruction through a large feeding branch. (orange curved arrow)
3. On the third image the narrowed segment is quite obvious. For those readers who are not obvious and have real moral character, the red arrow points to the pointed narrowing.
4. Finally, the last image on the right SHOWS NO NARROWING. What could be the explanation?

Tomorrow we will continue this harrowing adventure.

This is Dr Whiplash, i am out to lunch.



I know, I know!!! I know the answer (so do you want me to answer? - I defer to the expert in this case, you of course Dr. Sclafani) ... I don't want to devalue that education and expertise you've been so kind to bring to this forum by using incorrect terminology.

I just hope you work hard and put some collective brain power together with some of these great doctor colleagues of yours (perhaps your friend who treated it the first time) ... and find a good, permanent "fix" ...

It was a pleasure sir. A true honor.
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Postby Cece » Mon Jan 03, 2011 9:22 pm

drsclafani wrote:you can join my residency program

That was nice, thank you.

CCSVIhusband, I think he is interested in generating discussion, so if you can weigh in, I would not hesitate to do so. Or are you familiar with this particular azygous?

Why do the middle two images have diagonal lines across them, while the first and last don't?
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