DrSclafani answers some questions

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

Imaging is the Key

Postby JohnJoseph » Sat Jan 15, 2011 11:33 am

I see that good imaging is clearly the Key preposition for any successful angioplasty treatment.
I re-post a question regarding an alternative phlebography imaging technique (possibly a kind of shortcut/speed-up?):
JohnJoseph wrote:Dear Dr S,
...
What is your take on this imaging technique of the azygous I've heard of recently - the so called "occlusion phlebography", with the following setup:
Catheter is fed into the upper part of the azygous and then the vein is closed near its confluence with SVC by means of a compliant baloon inflation, so that blood flow towards heart is temporarily disabled. Then with only a single dye injection, the whole azygous system becomes visible at once (assuming the dye can flow backwards into all veins - would this apply only for a healthy azygous system?). The idea here is to possibly replace multiple step-wise dye injections typically done while moving the catheter tip upwards from the very bottom. Would you find such type of images interesting, at least to get a first global picture of the azygous system? Do you see any issues with such an approach?(Unfortunatelly, I do not have any images to show here)
...
All the best for 2011!

JJ
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Postby mavis » Sat Jan 15, 2011 4:58 pm

Dr. Sclafani this might be a stupid question but, if you have reflux in the jugular that also has a clot, is it plausible that the reflux can cause the clot to move back to the brain and cause a stroke?

Thanks for the answer.
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Re: Liberation treatment

Postby drsclafani » Sun Jan 16, 2011 12:23 am

sara2407 wrote:Dear Dr. Sclafani,

I agreed check-in Tokuda Hospital.
Please give me one of your opinions.
I had a stenosis of both jugular veins of 80-90% and 30% of the azygos. Angioplasty was performed only on the jugular veins.
Would the result of liberation treatment was better to have intervention on azygos vein?

if there is stenosis of the azygous vein, it should be treated. the outcomes of innterventions are not yet established in terms of what constitutes a significant stenosis
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Re: Imaging is the Key

Postby drsclafani » Sun Jan 16, 2011 12:27 am

JohnJoseph wrote:I see that good imaging is clearly the Key preposition for any successful angioplasty treatment.
I re-post a question regarding an alternative phlebography imaging technique (possibly a kind of shortcut/speed-up?):
JohnJoseph wrote:Dear Dr S,
...
What is your take on this imaging technique of the azygous I've heard of recently - the so called "occlusion phlebography", with the following setup:
Catheter is fed into the upper part of the azygous and then the vein is closed near its confluence with SVC by means of a compliant baloon inflation, so that blood flow towards heart is temporarily disabled. Then with only a single dye injection, the whole azygous system becomes visible at once (assuming the dye can flow backwards into all veins - would this apply only for a healthy azygous system?). The idea here is to possibly replace multiple step-wise dye injections typically done while moving the catheter tip upwards from the very bottom. Would you find such type of images interesting, at least to get a first global picture of the azygous system? Do you see any issues with such an approach?(Unfortunatelly, I do not have any images to show here)
...
All the best for 2011!

JJ


i think that occlusion venography can be very misleading with occlusion, one cannot tell whether there is abberant deranged hemodynamics. one cannot tell if there is sluggish flow, reflux or other problemsl
i havent read about this technique or seen any imaging. however my gut tells me that this would not be necessary or helpful in most cases
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Postby drsclafani » Sun Jan 16, 2011 12:28 am

mavis wrote:Dr. Sclafani this might be a stupid question but, if you have reflux in the jugular that also has a clot, is it plausible that the reflux can cause the clot to move back to the brain and cause a stroke?

Thanks for the answer.


mavis
that is highly unlikely.
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Postby scorpion » Mon Jan 17, 2011 5:13 pm

Dr. Scalfani there has been a lot of posts on here indirectly accusing the medical community of letting people die by not performing the liberation procedure on people with "end stage MS"(I know that term is vague). Can you give your opinion on this and also talk about what liabilty a doctor could face by making the decsion, at this point in time, to perform this surgery on those who are seriously ill.
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Postby AlmostClever » Mon Jan 17, 2011 6:28 pm

Hi Dr. Sclafani,

What options are there in treating a jugular vein the has stenosed directly below a stent placed high up? Have you seen this yet?

Thanks!

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If you can't explain it simply, you don't understand it well enough. - Al Einstein
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Postby AlmostClever » Mon Jan 17, 2011 6:42 pm

sry - duplicate
If you can't explain it simply, you don't understand it well enough. - Al Einstein
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Postby drsclafani » Mon Jan 17, 2011 9:17 pm

johnny21 wrote:Hello Dr Sclafani,

I had one relapse 3 years ago (one lesion in the spinal cord, one in brain; no new relapses so far). The lesion affected the strenght in my legs. I got cortisone but my legs still feel a bit weak. Since that i searched for possibilities to stop possible progression.
CCSVI seems to be this possibility.
I have a question that you might be able to answer to,
how big is the chance that the lesion in the spine can heal, that the damages in my legs disappear or improve? in general, is it possible that damages in the spine heal after a treatment or the progression stops for sure?
i hope you can answer my questions, thank you very much!

johnny


Lesions on MRI have regressed, weakness and spasticity have resolved. Much of this depends upon extent of damage and type of MS
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Postby drsclafani » Mon Jan 17, 2011 9:22 pm

javabean wrote:Hello Dr Sclafani,
I had my procedure one month ago in Albany. I didn't feel any improvements right awaybut after about three days I had some great stuff happen. Twice I walked 25 minutes, another day I walke 15 minutes while holding my baby, and then around one mile. Since then my improvements have disappeared and I feel even a little worse -- maybe a post pregnancy flare? (It's only been two months). I know placebo can be one answer as to why I had such good results, but I think know my body well enough to say it was real. Do you think I could have restenosis after less than two weeks? I plan to have an ultrasound in a month, so I hope to get some clarity, but wanted your opinion on restenosis.
BTW, both jugulars were almost completely closed and my azygous needed treatment as well.
Thank you and sorry for the long-winded message.


Improvements are common within one month, but some worsening and then slower recovery is shown in dr zamboni's graph on responses. I think we need to look at these responses in a slow methodical way.

We are still trying to understand who gets better, how long it takes, what techniques lead to te best recovery. This is not a clear issue. Compounded by placebo effects and the waxing and waning natural history of MS, establishing a clear picture is not present yet.

Restenosis can occur quickly from elastic recoil but thrombosis can also occur, either as a silent event or as one with deterioration of symptoms

The physicians doing this treatment are using very variable techniques and as such this is another "confoudning variable"
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Postby drsclafani » Mon Jan 17, 2011 9:28 pm

silverbirch wrote:Dr

DX RRMS 2010 no DMD – CCSVI LIJ stenosis of the mid third – ballooned
At my 6mt follow up no stenosis – in the upper third of the right internal jugular vein there is extrinsic indentation from the adjacent common artery bifurcation ???. Flows are within limits.

My neck on the right side does give me pain to include the right of brain stem in addition to this I have a large mottled red rash (under my ear) that is sore/hot the rash this first appeared following my attack were I was first DX stroke…. (Weeks later) Then DX MS . Previous medical problems history of migraines… odd feeling in throat bottom lip tremor

Carotid sinus does this fit in line with CCSVI ?? And should I have this further investigated

carotid sinus? i dont know what that is. The narrowing by the carotid BULB is often indicative of a valve problem but you say the flow looked normal. I am concerned that only one vein was abnormal and thus treated. We expect two or more vessels to be abnormal with ccsvi. that is what happens most of the time.

however if you are feeling well, i would sit tight. The pain in the neck for six months seems unusually long. Did you get stents?

The rash? very curious. Do you have a purple neck?
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Postby drsclafani » Mon Jan 17, 2011 9:29 pm

nellie wrote:Dr.
My physical therapy/fitness center has acquired a WBV (whole body vibration) machine & have encouraged me to try it. I had ccsvi treatment 2 months ago. Is this a machine something I should utilize or would it be a negative to me having had angio recently? Also, in general has WBV proved helpful for ms? Thanks.


i am not an expert in all phases of MS. I am focusing on ccsvi. its what plumbers do
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Postby drsclafani » Mon Jan 17, 2011 9:33 pm

L wrote:A long time ago you kindly took the time to answer this question of mine:

drsclafani wrote:
L wrote:Hello Dr Sclafani

I have another question. Quite a while ago, when I was 23 or so, I had a defibrillator implanted. I didn't want it but my family persuaded me. Anyhow, I got my first symptoms of MS, shortly after the operation. I have always suspected that one led to the other. I had it explanted when it was clear that it wasn't in fact necessary. Years later it became apparent that anaemia was leading to irregular heart rhythms, but anyway.

When I had it explanted they removed most of the lead but lost a stainless steel wire in me in the process. It was implanted via the subclavian vein. I've only just realised that this vein can be associated with CCSVI. I'm thinking ahead lots here, and I understand that a definite answer won't be possible with just this little information, but would you imagine if it turns out that my subclavian vein is occluded, this stainless steel wire lost in it will make my treatment more difficult/impossible?

I just had to ask.. I became more pessimistic as my MS progressed and now I'm imagining the (untreatable) worst.

Thanks so much.

if your subclavian vein is occluded, it might also involve your inominate vein. the junction of the IJV and the SCV form the inominate vein. Thus occlusion of the inominate vein may make it impossible to treat any IJV obstructions on that side
Moreover, someone told me a story about how they had radiation to the chest that resulted in stenosis of the subclavian vein. that in turn appears to have resulted in MS. could you be a second patient?


At the time I was worried about the possibility of being untreatable - it turns out that it was quite possible to balloon both jugulars. But only now I'm turning back to what you said about your being aware of another patient for who occlusion of the subclavian vein may have been a trigger for MS and, when I got my treatment in Alexandria, I completely forgot to mention my subclavian vein. Not very clever of me.

If the subclavian vein is occluded do you expect that it will be difficult to treat, given that there is a discarded length of stainless steel wire there? Could I send you my Dicom venogram images so that perhaps you could tell me if it is occluded or not, if possible? I'd be very grateful.


L, if your subclavian vein is occluded. then all the blood from your arm has to return to the heart using collateral veins. Those collateral veins might need to go up into your spine, chest, brain to get across the obstruction. Thus they MIGHT result in greater blood flow through vessel pathways that, in you, are obstructed, possibly worsening cerebral venous outflow.

you can send me your images, but send a copy and hope for the best. Now that I am treating, the time to review cases is getting much more difficult
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Re: continuing our wind sock discussion

Postby drsclafani » Mon Jan 17, 2011 9:36 pm

hwebb wrote:Dr S,

a little while ago I posted my MRV - which indicated a problem low in my right jugular. You

asked to look at the venogram, and found what could potentially be a "wind sock" type

structure in my lower right jugular. Anyway, I had another venogram just before our

discussion - and now have the images. First...here is a before/after shot of my train wreck

left jugular which now looks quite nice:

[img][img]http://farm6.static.flickr.com/5164/5353475537_9ea1edc0d5.jpg[/img]
left_jug_before_after by anatomical, on Flickr[/img]

And here is a before/after shot of my right lower jugular:

[img][img]http://farm6.static.flickr.com/5169/5354090182_1485ab7016.jpg[/img]
lower_right_jug_before_after by anatomical, on Flickr[/img]

It should be noted that a modest stenosis was found in the upper third of the right vein, and the right valve appeared thickened. A delay in draining was observed. The upper area, and valve were ballooned. I can provide more images if need be. I suspect I didn't select the best image last time during our "wind sock" discussion.

I feel the latest angio treatment had a huge effect on my symptoms (my right arm no longer goes dead in any postural position)...though still have some modest odd sensations in the right side of my face, and tightness on the right side of my head.

Helen


Helen, it is always difficult to look at a couple of frames and make a diagnosis, especially regarding the jugular base duplication. I think that the duplication causing the windsock can be overcome, but restenosis is perhaps more common.

Good luck, things look pretty nice to me
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Re: Liberation treatment

Postby drsclafani » Mon Jan 17, 2011 9:39 pm

sara2407 wrote:Dear Dr. Sclafani,

I agreed check-in Tokuda Hospital.
Please give me one of your opinions.
I had a stenosis of both jugular veins of 80-90% and 30% of the azygos. Angioplasty was performed only on the jugular veins.
Would the result of liberation treatment was better to have intervention on azygos vein?


i dont want to criticize a colleague without seeing images of the work. a 30% stenosis is something i would consider dilating
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