DrSclafani answers some questions

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

Re: DrSclafani answers some questions

Postby drsclafani » Sat Dec 15, 2012 3:09 pm

Robnl wrote:Hi Doc

What are your thoughts about vagues nerve compression and Dr. Arata;s findings???

Regards,

Robert


I find this highly speculative and unlikely. It does not make sense to me. Dysautonomia has been discussed on this tread for about two years. It is nothing new. I find other possible explanations for improvements in autonomic function to be more palatable and rationale. So many patients have asked me about this. I am wondering why it resonates with patients.

DrS
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Re: DrSclafani answers some questions

Postby drsclafani » Sat Dec 15, 2012 3:17 pm

dania wrote:Taking medication to prevent clotting is not a guarantee one will not produce clots. I did and was taking 10mg of Coumadin My INR was 2.6 and clotted in the vein that was stented. I did not have clots in the other 2 veins and they developed scarring and died as well.

Agreed. As i said, it is vital that vigilance be high and that both anticoagulation such as coumadin AND platelet inhibition by aspirin, clopridogrel or plavix accompany the anticoagulation. Even that is no guarantee. But if a patient id not vigorously scrutinized for early detection of thrombus formation, then loss of a vein can be expected if thrombus develops.

As I said, Dania, hypercoagulable states, low flow states and other problems can lead to thrombosis. I have noted that some patients have a small junction between the internal jugular vein and the dural sinus, or phasic stenosis at the C1-2 area or from muscle compression of the IJV in the J2 Segment. . angioplasty of the IJV valve in such situations is at risk for thrombosis.

In your case where multiple veins have occluded, I would suspect a hypercoagulable state.

sorry for your poor outcome. I can imagine that you might be very angry about it.

once the vein occlusion becomes organized, it is just a fibrous band with no flow.
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Re: DrSclafani answers some questions

Postby Cece » Sat Dec 15, 2012 4:36 pm

You mentioned 1.5% of your patients had clotting. That's a very low number. Back in the beginning, we knew that clotting was a problem but we had no idea what the percentage was. I think knowing a percentage (1.5%, in your experience with your techniques) is progress.

Very nice series of images. This is not something you've shown us before, to my knowledge. Clotting caught early and retreated, with apparent success.

What would be your best guess as to when the clotting occurred in this patient? On the day of intense fatigue? If there was still liquid clot, is that evidence that it was very recently formed?
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Re: DrSclafani answers some questions

Postby drsclafani » Sat Dec 15, 2012 4:58 pm

Cece wrote:You mentioned 1.5% of your patients had clotting. That's a very low number. Back in the beginning, we knew that clotting was a problem but we had no idea what the percentage was. I think knowing a percentage (1.5%, in your experience with your techniques) is progress.

Very nice series of images. This is not something you've shown us before, to my knowledge. Clotting caught early and retreated, with apparent success.

What would be your best guess as to when the clotting occurred in this patient? On the day of intense fatigue? If there was still liquid clot, is that evidence that it was very recently formed?


the surveillance ultrasound i am using is a simple compression ultrasound.I am not looking for a zamboni protocol ultrasound. a color doppler is used to see flowf. compression is used to determine the presence of thrombus. A normal jugular vein collapses the vessel diameter when compressed. But when there iws thrombus in it, compression does not collapse


this imaging study can be done almost anywhere
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Re: DrSclafani answers some questions

Postby Robnl » Sun Dec 16, 2012 12:40 am

Hi Doc,

With the images you posted you speak about 'liquid clotting'....hmmm...what is it? :o

Rgds,

Robert
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Re: DrSclafani answers some questions

Postby drsclafani » Mon Dec 17, 2012 10:45 pm

Robnl wrote:Hi Doc,

With the images you posted you speak about 'liquid clotting'....hmmm...what is it? :o

Rgds,

Robert

hi robert

it was a poor and confusing term.

when thrombus forms, it is possible for the body to dissolve it with natural fibrinolytic substances that dissolve the clot. in the images i showed, #4 has area of dense contrast media in the middle. this likely represented an area where some thrombus had dissolvedd. The area below was really thick and hard, most likely thrombus filled with a clump platelets. it is white and like scar. very difficult to traverse.

liquified thrombus would have been better term

Drs
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Re: DrSclafani answers some questions

Postby drsclafani » Mon Dec 17, 2012 11:19 pm

My m.s. symptoms did flare up the (late) day after the procedure, overwhelming fatigue, imbalance, etc., and didn't subside yet.
Is this normal, what are your thoughts? Next procedure is Jan.12th,


It is late. I just read this email and it is so important i wanted to share it. I have written about this particular scenario in the past. this is the second such patient and it bears discussing because it quite clearly has some implications.

The patient has MS and came to me after she had undergone a few procedures by others with some improvements. She was not asking me to treat her CCSVI but rather to treat her pelvic congestion symptoms. Rectal pain, pelvic floor fatigue, varicose veins in the thighs, childhood fatigue were among her symptoms. She had an MRI that showed extensive venous congestion in the pelvis, a dilated ovarian vein and nutcracker phenomenon.

I chose to treat her problems in a staged fashion, initially treating the incompetent ovarian vein by coil embolization and sotradechol foam sclerotheraphy. There were two branches of the ovarian vein that connected with a very large internal iliac vein in the pelvis.
We planned her second treatment, to stent the renal vein, for january 12th.

As you can see in her report to me tonite, her ccsvi symptoms dramatically worsed after closing off the ovarian vein flow. Like the prior patient I reported here last year, symptoms worsed after closing the refluxing ovarian vein. Unlike the other patient, she does have MS and CCSVI independent of the sequellae of the nutcracker and pelvic congestion.

why should this happen? I think it is quite simply explained by the anatomy and physiology.

There are three veins that are the major collaterals when the left renal vein has compressive occlusion of the outflow of the left renal venous circulation, namely the ovarian vein, the hemiazygo-renal trunk and the ascending lumbar vein. In this patients case, closing of the ovarian vein flow basically shunted the high flow renal venous output into the hemiazygous vein and perhaps the ascending lumbar vein. these two veins are direct contributions to the cerebrospinal venous circulation. As the renal vein flow is comparable to the cerebral venous flow, this is a tremendous increase in circulation and I believe it is causing venous congestion and possible reflux

I have asked the patient to come in for treatment as soon as possible.

I think these cases are important because they represent direct evidence of cerebrospinal venous insufficiency.

DrS

It takes a long time to make those images, sometimes hours. being it so close to the holidays, i cannot spare the time to make pictures but can share the case.
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Re: DrSclafani answers some questions

Postby NZer1 » Mon Dec 17, 2012 11:32 pm

Thank you for telling us about this Dr S.

I have a question that has come up on Dr F's thread about disc bulges and their effect on the Vascular system. It is becoming quite common to hear of the co-incidence of trauma, injury and Spine Alignment in PwMS, me included.

I am wondering if there has been any indications that you have seen where the disc bulges are associated with vein stenosis.

For me personally I am of the belief that the jugs are involved with CCSVI, but, there is more to learn about the veins used when Upright in the incidence of MS and other de-generative diseases. We are Upright for so much more of our time and we are active and creating opportunity for things like reflux to occur whether because of body position and vein compression or from malformation issues etc.
I guess you hear this often enough, the question is, has your imaging shown issues like we are starting to see from the use of Upright MRI.

Regards,
Nigel

Edited.
I am thinking that the flow in the VV's is impacted by these issues ;)
Last edited by NZer1 on Tue Dec 18, 2012 10:43 am, edited 1 time in total.
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Re: DrSclafani answers some questions

Postby Cece » Tue Dec 18, 2012 9:50 am

drsclafani wrote:I chose to treat her problems in a staged fashion, initially treating the incompetent ovarian vein by coil embolization and sotradechol foam sclerotheraphy. There were two branches of the ovarian vein that connected with a very large internal iliac vein in the pelvis.
We planned her second treatment, to stent the renal vein, for january 12th.

In the future, would you stage this the other way, with the renal vein treated first? Or perhaps everything done at once?
There are three veins that are the major collaterals when the left renal vein has compressive occlusion of the outflow of the left renal venous circulation, namely the ovarian vein, the hemiazygo-renal trunk and the ascending lumbar vein. In this patients case, closing of the ovarian vein flow basically shunted the high flow renal venous output into the hemiazygous vein and perhaps the ascending lumbar vein. these two veins are direct contributions to the cerebrospinal venous circulation. As the renal vein flow is comparable to the cerebral venous flow, this is a tremendous increase in circulation and I believe it is causing venous congestion and possible reflux

I hope you are able to publish and influence others in this. It is logical. As you said, direct evidence.
It takes a long time to make those images, sometimes hours. being it so close to the holidays, i cannot spare the time to make pictures but can share the case.

A reasonable compromise. Happy holidays.
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Re: DrSclafani answers some questions

Postby mo_en » Tue Dec 18, 2012 11:38 am

Hi Dr S, everybody.
Regarding the earlier thrombosis case, would a neck collar make any difference? Could it eliminate the phasic stenoses that are due to neck movements? At least for the first week after the procedure?
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Re: DrSclafani answers some questions

Postby drsclafani » Tue Dec 18, 2012 8:20 pm

NZer1 wrote:Thank you for telling us about this Dr S.

I have a question that has come up on Dr F's thread about disc bulges and their effect on the Vascular system. It is becoming quite common to hear of the co-incidence of trauma, injury and Spine Alignment in PwMS, me included.

I am wondering if there has been any indications that you have seen where the disc bulges are associated with vein stenosis.

For me personally I am of the belief that the jugs are involved with CCSVI, but, there is more to learn about the veins used when Upright in the incidence of MS and other de-generative diseases. We are Upright for so much more of our time and we are active and creating opportunity for things like reflux to occur whether because of body position and vein compression or from malformation issues etc.
I guess you hear this often enough, the question is, has your imaging shown issues like we are starting to see from the use of Upright MRI.

Regards,
Nigel

Edited.
I am thinking that the flow in the VV's is impacted by these issues ;)


NIGEL
With IVUS we get a marvelous phasic view of the jugular veins. I am not seeing compression very often except at the midline in front of the C1-2 space. I have found that this compression is phasic, that with flexion of the neck, flow is improved, same with rotation. I am not convinced that these phasic narrowings need to be treated. afterall, flow in the inferior vena cava is phasic, same with many other veins. It is a very difficult proposition to prove that treatment of a phasic phenomenon will improve clinical symptoms.

i havent seen many abnormal vertebral veins. i dont get the sense that this is a major problem.
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Re: DrSclafani answers some questions

Postby drsclafani » Tue Dec 18, 2012 8:21 pm

mo_en wrote:Hi Dr S, everybody.
Regarding the earlier thrombosis case, would a neck collar make any difference? Could it eliminate the phasic stenoses that are due to neck movements? At least for the first week after the procedure?

Mo-en, this patient did not have phasic narrowings of significance. depending on the patient a neck collar might make things worse. many times phasic narrowings expand just by turning the head.

DrS
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Re: DrSclafani answers some questions

Postby drsclafani » Tue Dec 18, 2012 8:28 pm

Cece wrote:
drsclafani wrote:I chose to treat her problems in a staged fashion, initially treating the incompetent ovarian vein by coil embolization and sotradechol foam sclerotheraphy. There were two branches of the ovarian vein that connected with a very large internal iliac vein in the pelvis.
We planned her second treatment, to stent the renal vein, for january 12th.

In the future, would you stage this the other way, with the renal vein treated first? Or perhaps everything done at once?


NO. stenting the renal vein makes it more difficult to treat the ovarian vein congestion because the stent may cover over the orifice of the ovarian vein.

it would be a consideration to treat both entities at the same time. However sometimes a second treatment of the ovarian vein may be warranted. so i like to treat the ovarian vein incompetency by embolization and sclerotherapy. then i bring the patient back for a second look at the ovarian vein embolization, re-treat if necessary. and then treat the nutcracker syndrome which is probably the cause of the problem to begin with. If this scenario of worsening neuro symptoms keeps occurring, then i will have to revise my strategies.

Patient is coming back early.
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Re: DrSclafani answers some questions

Postby EJC » Wed Dec 19, 2012 2:49 am

Dr S.

I follow this thread, despite not understand a reasonably large amount if it, I do try.

The fact you're here and spend the time discussing this subject in such detail with your patients and anyone else wanting to ask questions is simply outstanding, like you haven't got enough on your plate already. What I'm trying to find though is an overview of your thoughts. Not particularly just medical detail, but how you feel about where you are with CCSVI and where CCSVI is with MS patients.

Do you feel you understand CCSVI more than ever or as you've delved deeper into the subject are you still raising more questions than answers?

When you see a new patient do you feel a CCSVI procedure stands a good chance of helping them?

My wife had CCSVI treatment in Scotland in Dec 2010 and had very promising results (particularly eyesight improvements) which gradually regressed over the next 9-12 months. In Dec 2011 she had jaw realignment work in London which I'm documenting on this forum, with fantastic results.

Each treatment/procedure had a direct effect on different symptoms.

CCSVI returned warmth to my wifes hands and feet, reduced cog fog and provided an instant and substantial improvement in eyesight. Much of this regressed.

Jaw realignment eradicated debilitating neuralgia in her left arm, hand leg and foot. It also has reduced substantially the amount of fatigue she suffered from a daily "battery" life of awake hours of 6-7 hours to a near normal 12-14 hours. Rather than any sign of these regressing they are continuing to improve as time passes, to a degree that phyio and physical rehabilitation has begun to get her back on her feet and more mobile (EDSS reached 6.5 but now starting to improve).

As a layman I look at these results and see two treatments offering relief of two clear sets of symptoms. These are the questions that run through my mind.

1. Was my wife under treated for CCSVI (quite rightly at the time) as we were in the early stages of the development of the treatment two years ago?

2. Have we actually found two things my wife needed treating for but gone about it in the wrong order?

3. Is there any connection at all between skeletal misalignment/TMJ disorders and CCSVI? Or have we simply discovered my wife has two separate ailments providing symptoms currently known to medicine as MS?

4. Once treatment for My wifes TMJ problem are complete would she benefit from a further CCSVI procedure based on the initial improvements of the first procedure?

I'm not actually sure I even expect an answer, I'm typing this more to share my thoughts rather than look for something definitive. But I would really like to know where you feel you are at the moment with CCSVI, globally. In laymans terms.

TIA.
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Re: DrSclafani answers some questions

Postby Luvsadonut » Wed Dec 19, 2012 3:43 am

EJC,
As Im unsure which treatment to go for first (had a positive CCSVI scan at Glasgow 2 years ago and an appointment with Dr Amir tomorrow) I follow your threads as much as possible, therefore even without an answer from Dr S, I appreciate your thoughts. That said I too would love to hear Dr Sclafanis thoughts on the connection/possibility of CCSVI/TMJ/MS.

Darren
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