DrSclafani answers some questions

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

Postby drsclafani » Sat Sep 03, 2011 7:37 am

cheerleader wrote:
drsclafani wrote:
I have been involved with this since 2009 and no one has ever mentioned the emissary veins. No one!


Hi Dr. S..welcome home! Actually, Marie and I were writing about emissary veins on here in relationship to heat intolerence in MS. And Dr. Flanagan was writing about it, too...although we hadn't read him at that time.
Here's me rambling....
Jugular vein stenosis will probably affect all of the "tributary" veins surrounding them--and those include the emissary veins, which control the body's temperature regulation, and the thyroid veins, which control the release of thyroid hormone. I even postulated on another thread that vitamin D may be getting screwed up because the HPA axis (hypothalmic/pituitary/adrenal) pathway was being messed up, do to delayed signaling and slowed flow....but there are no studies on that yet. The neck veins are responsible for CSF, hormones and blood flow from the brain. Lots going on in there--



Marie linked this study on emissary veins from 3/09
http://www.ajnr.org/cgi/content/figsonly/23/9/1500

I remain convinced that it's the overuse of the emissary veins messing up the brain's cooling mechnism in CCSVI.
Here's Dr. Flanagan on this very topic....he explains it quite well.
http://uprightdoctor.wordpress.com/2010 ... n-cooling/
cheer


thanks, excellent

It surprises me that external veins like the condylar emissary vein would flow INTO the head.
since i have begun starting all procedures from the transverse sinuses, i have noted three patterns in patients with ccsvi

1. enormous condylar veins draining into the posterior neck muscles and the vertebral veins
2. completely nonvisualized condylar veins
3. small condylar veins

I have never seen a condylar vein drain into the brain

I can make no correlations yet with heat intolerance since almost all patients have heat intolerance.
I havent made any correlation with spinal lesions. either.

Trying to understand why some patients have very large and others have very small condylar and other emissary veins is perplexing.

perhaps prenatal jugular malformations result in large emissary canals.
perhaps jugular stenoses developing after skull development inhibits enlargement of bony canals. I find it implausible that emissary canals would enlarge much later in life.

Thanks for the links
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Postby David1949 » Sat Sep 03, 2011 9:59 am

Apparently I accidentally posted my question about Daflon 500 in a new thread. Dania was kind enough to repost it here, where I intended it to be in the first place. Thanks Dania.
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Re:

Postby drsclafani » Sun Sep 04, 2011 4:11 pm

Cece wrote:
drsclafani wrote:As I have modified my venogram of the dural sinuses, I have noted very prominent emissary veins and these veins provide large conduits increase flow through the spinal veins. I am unclear if there is an association between this emissary vein and symptoms, though.

(I actually emailed dr zamboni about this today!) Wonder what he thinks, although I dont think that dr galleoti routinely images the dural sinuses.

I wonder too! Might be ok if no azygous blockage but not good if there is azygous blockage because it adds to the flow there. Spinal veins also not meant to carry excess flow?


My thoughts exactly. Those emisssary veins are adding considerable flow through the cervical spinal circulation
Salvatore JA Sclafani MD
Patient contact: ccsviliberation@gmail.com
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Re:

Postby drsclafani » Sun Sep 04, 2011 4:17 pm

David1949 wrote:Apparently I accidentally posted my question about Daflon 500 in a new thread. Dania was kind enough to repost it here, where I intended it to be in the first place. Thanks Dania.



I am too cautious to recommend this in ccsvi at this point.
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Re:

Postby Cece » Mon Sep 05, 2011 10:13 am

drsclafani wrote:I have been involved with this since 2009 and no one has ever mentioned the emissary veins. No one!
drsclafani wrote:since i have begun starting all procedures from the transverse sinuses, i have noted three patterns in patients with ccsvi

Do you know of any other IRs who start procedures in the transverse sinus?
Is there anything else being overlooked that you can think of?

What comes to mind is that IRs are such do-ers, that if a vein is too small to be treated, it is unimportant. Lumbar veins, vertebral veins, emissary veins.... But you need to know these veins in order to know CCSVI. It reminds me too of the ISET presentation on MS and that IRs treating CCSVI need to understand MS, even if it is not directly applicable to the 'do-ing' of what you do (balloons etc.) You can't see connections if you don't look at the full picture.

1. enormous condylar veins draining into the posterior neck muscles and the vertebral veins
2. completely nonvisualized condylar veins
3. small condylar veins

I have never seen a condylar vein drain into the brain

I can make no correlations yet with heat intolerance since almost all patients have heat intolerance.
I havent made any correlation with spinal lesions. either.

Trying to understand why some patients have very large and others have very small condylar and other emissary veins is perplexing.

But typically it is either very large or very small or nonvisualized? Is there a known 'normal' size in between and you are not seeing normal?

We are endlessly interesting patients.
perhaps prenatal jugular malformations result in large emissary canals.
perhaps jugular stenoses developing after skull development inhibits enlargement of bony canals. I find it implausible that emissary canals would enlarge much later in life.

Thanks for the links

I can look this up too but when is the window for skull development and when these bony canals could theoretically enlarge? Largest growth up to age 2 and smaller growth from then on until adolescence?

Is there any difference in size of emissary veins in warm climates vs cold climates? If they are pivotal in heat management, are they typically larger in warm climates.

If enlargened emissary veins add to the flow through the cervical spinal circulation, this would impair the drainage through the small veins that directly drain the cervical spine. Or would the veins just grow bigger, particularly if this is all present prenatally, and be able to compensate for this.
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Re: DrSclafani answers some questions

Postby dania » Mon Sep 05, 2011 1:20 pm

mtf
Post subject: Drug Eluting Balloons in Liberation Treatment by Doctor Rafa
Unread postPosted: Tue Sep 06, 2011 6:09 am
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Dear Dr. Scafani,

What do you think about drug eluting balloons?
Thanks for answer
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Re: DrSclafani answers some questions

Postby mtf » Tue Sep 06, 2011 7:31 am

Apparently I posted my mail in a new one. Sorry Dr. Sclafani, for that but the Thisisms site has changed the look and was lost.
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Re: DrSclafani answers some questions

Postby pelopidas » Tue Sep 06, 2011 12:16 pm

dania wrote:mtf
Post subject: Drug Eluting Balloons in Liberation Treatment by Doctor Rafa
Unread postPosted: Tue Sep 06, 2011 6:09 am
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Dear Dr. Scafani,

What do you think about drug eluting balloons?
Thanks for answer



hi
it must be drug eluting stents
getafix
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Re: DrSclafani answers some questions

Postby dania » Tue Sep 06, 2011 12:29 pm

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Re: DrSclafani answers some questions

Postby Cece » Wed Sep 07, 2011 5:27 pm

pelopidas wrote:
hi
it must be drug eluting stents

Welcome to TiMS and to Dr. Sclafani's thread.
I had the same thought too in a former conversation when I assumed we were talking about drug-eluting stents, when indeed it was drug-eluting balloons. If I recall correctly the drug is intended to reduce intimal hyperplasia? Or is that a different one? If Dr. Sclafani is accurately sizing through IVUS and treating the bad valve but not the healthy vein, he might not be seeing intimal hyperplasia in his patients, so no need then for a drug-eluting balloon to reduce this.

psssst Dr. Sclafani....any interesting cases to share? I know of one, late last week, in which you were successful in a long procedure where success might not have been expected. Congrats and well done. :)
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Re: DrSclafani answers some questions

Postby msfire » Wed Sep 07, 2011 6:41 pm

Hi Dr. S
Finally got my account to continue hearing of your great work. May I say as with all your followers, you do some amazing work. As I once wrote on a piece of paper. "You are a Saint"
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Re: DrSclafani answers some questions

Postby pklittle » Wed Sep 07, 2011 8:00 pm

I hate to break it to y'all, but Dr. Sclafani is on a well deserved two week vacation. :-D
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Re: DrSclafani answers some questions

Postby Cece » Wed Sep 07, 2011 8:05 pm

What?
When rain floods out your vacation, it is a clear sign that you are needed back at work and at TiMS.... :smile:

Can I try to usurp his thread in his absence? :-D
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Re:

Postby cheerleader » Wed Sep 07, 2011 8:48 pm

drsclafani wrote:thanks, excellent
It surprises me that external veins like the condylar emissary vein would flow INTO the head.
since i have begun starting all procedures from the transverse sinuses, i have noted three patterns in patients with ccsvi
1. enormous condylar veins draining into the posterior neck muscles and the vertebral veins
2. completely nonvisualized condylar veins
3. small condylar veins
I have never seen a condylar vein drain into the brain

Trying to understand why some patients have very large and others have very small condylar and other emissary veins is perplexing.
perhaps prenatal jugular malformations result in large emissary canals.
perhaps jugular stenoses developing after skull development inhibits enlargement of bony canals. I find it implausible that emissary canals would enlarge much later in life.

Thanks for the links


Found some interesting research on condylar differences in 50 normals, as shown on CT scan. It seems that in normals, there is asymetry or ageneis in the condylar veins, but not these giant veins like you're seeing in pwMS, and the occipital bone showed differences which affected the veins...
In all cases, the anterior condylar veins connected the anterior condylar confluence to the marginal sinus; however, a number of cases with asymmetry and agenesis in the posterior and lateral condylar veins were seen. The posterior condylar vein connected the suboccipital cavernous sinus to the sigmoid sinus or anterior condylar confluence. The posterior condylar canal in the occipital bone showed some differences, which were accompanied by variations in the posterior condylar veins. In conclusion, there are some anatomical variations in the venous structures of the craniocervical junction; knowledge of these differences is important for the diagnosis and treatment of skull base diseases. Contrast-enhanced CT using a multidetector scanner is useful for evaluating venous structures in the craniocervical junction.

http://bjr.birjournals.org/cgi/content/ ... 83/994/831

Dr. Z found that the condylar system became one of the main collateral pathways activated in CCSVI. In fact, that's exactly what my hubby had. No jugulars, but big, squirrely condylars. Once he had jugular veins open and flowing, the condylars disappeared. Since his blockage was high, into transverse sinus, maybe that's why the condylars became developed? Maybe it has to do with the location of stenotic lesion and availability of collateral drainage at that location....the old freeway detour analogy?
The main collateral pathways activated in the course of CCSVI are the condylar venous system, the pterygoid plexus and the thyroid veins.2,6 Additionally, the suboccipital cavernous sinus and the hemiazygous-lumbar venous anastomosis with the left renal vein may also become prominent substitute circles. Collateral circulation prevents brain oedema and intracranial hypertension,2,4 and ensures a correct but slower, and thus insufficient, venous drainage.12,14

http://phleb.rsmjournals.com/content/25/6/269.full
anyway, just read that you may still be on vacation...in which case, nevermind, and we'll all catch up with you later....
cheer
Husband dx RRMS 3/07
dx dual jugular vein stenosis (CCSVI) 4/09
http://ccsviinms.blogspot.com
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Re: DrSclafani answers some questions

Postby CD » Wed Sep 07, 2011 8:49 pm

I think you were on vacation too Cece. 8) Both Dr. S and you were part of the absentees on here. Then some people who frequent this board must have seen the new board and thought, "I must be on the wrong forum." 8O

I think this whole forum, ThisIsMS, is up to 2011 standards now. Thank you to all the computer gurus/ admins and mods, et al for all your hard work bringing everything back to its place again. I'm sure there are still some gremlin bugs in here, but we appreciate the "New Look and Features."

Cece, I hope you enjoyed your vacation, and Dr S is taking a well deserved rest. :-D
CD
Where there is a will, there is a way. "HOPE"

CCSVI Procedure December 2010
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