DrSclafani answers some questions

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Re: DrSclafani answers some questions

Postby mo_en » Sat Jul 27, 2013 3:48 pm

-RIJV seems squeezed right beneath the skull (fig.3,4).
-figs 2,6 are quite the same though the dye comes from different veins. Difficult flow through LIJV?
-fig 5 indicates elongated valve or collarbone compression?
-What is the highlighted part in figs 3,7?
-fig 9: the wire fills all available space inside the LIJV?
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Re: DrSclafani answers some questions

Postby NHE » Sat Jul 27, 2013 9:48 pm

Could the well defined v-shaped line of contrast agent in figure 7 represent a bad valve blocking flow?
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Re: DrSclafani answers some questions

Postby drsclafani » Sun Jul 28, 2013 8:39 am

51-year-old Caucasian female with known multiple sclerosis since 1987. At the current time, she suffers from right foot drop, bilateral weakness and hyperreflexia of her lower extremities, some cerebellar dysfunction, dysphagia, dysarthria, memory impairment and executive processing difficulties, chronic fatigue, and urinary symptoms. She underwent ultrasound on July 18, 2013, which demonstrated findings consistent with venous outflow obstruction of the internal jugular veins.


Image

Take a look at the images and we will discuss them after I get five commentaries.




I am quite thrilled that there was such response so quickly. Thank you all for giving it a try. Hopefully there are some lurking doctors who also enjoy this case.
Let's review each image in sequence.

Image
#1: I began this procedure by catheterizing the right internal jugular vein. It is always my intention to advance the catheter through the jugular foramen into the dural sinuses. My logic is that in order to be sure that there is no impediment to good flow in the internal jugular vein, the contrast has to be injected above it (in the dural sinus). I have shown on TIMS cases of stenoses of the upper jugular vein that went unrecognized during exams done previously by other physicians and myself because the entirety of the IJV was not imaged. Another reason to start in the sinus is to be sure that intracranial stenoses and obstructions do not go unrecognized. I have found that MRV, the most common way to look at the sinuses may miss things and show false stenoses.

In this case the guidewire kept going into some vein near the midline instead of going up and laterally. It just would not follow the usual pathway into the right transverse sinus. So I left the catheter in the sigmoid sinus (Red arrow) and did the venogram. The contrast media flowed downward through a condylar emissary vein (green arrow) but only a small portion of the transverse sinus was opacified (yellow arrow).

Figure 2. A second venogram showed the contrast media flowing toward the midline. No transverse sinus was seen (question mark).a The contrast filling paired structures (green arrows) and a longitudinal structure above them that directed the dye into the left transverse sinus (yellow TS) and ultimately into the left internal jugular vein toward the chest (dashed blue arrow).

In the absence of the right transverse sinus, reflux into the left internal jugular vein from a right IJV venogram was surprising and unexpected. Flow should be in the path of least resistance down the right IJV. The reason was not surprising: a high grade stenosis was seen at the bottom of the image (purple dashed arrow). I think only is the presence of some obstruction on the right sidewould the contrast media flow toward the left

What could be the causes of dural sinus obstruction?
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Re: DrSclafani answers some questions

Postby drsclafani » Sun Jul 28, 2013 8:45 am

mo_en wrote:-RIJV seems squeezed right beneath the skull (fig.3,4).
-figs 2,6 are quite the same though the dye comes from different veins. Difficult flow through LIJV?
-fig 5 indicates elongated valve or collarbone compression?
-What is the highlighted part in figs 3,7?
-fig 9: the wire fills all available space inside the LIJV?



good observation on fig 2/6.
the "collar bone compression" is usually a valvular stenosis. below the collar bone subclavian/brachiocephalic artery can compress the brachiocephalic vein. other compressions are much higher in the neck.

actually the guidewire in figure 8 goes from the left internal jugular vein across the sinuses and down into the right internal jugular vein. That caused me some confusion.
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Re: DrSclafani answers some questions

Postby drsclafani » Sun Jul 28, 2013 8:47 am

NHE wrote:Could the well defined v-shaped line of contrast agent in figure 7 represent a bad valve blocking flow?



not sure what you are describing but not the case. Fig 7 is way above the valves.
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Re: DrSclafani answers some questions

Postby drsclafani » Sun Jul 28, 2013 8:54 am

dlynn wrote:To me it looks like in #s 1,2,3,4&6, blood flow is trying to exit by way of RIJV only. I might be completely wrong
but it looks like there is no flow in the LIJV. The other pics., I won't attempt.
My question earlier, would you consider treating a patient who had four CCSVI procedures?



on the contrary, in figures 1,2,3,4 blood is trying to exit through all kinds of collaterals.

I would consider treating any patient regardless of the number of times they had been treated previously depending upon a number of issues

1. what was the response to prior treatments? Which symptoms improved? how long did improvements last?
2. what was the anatomical problem leading to treatment?
3. Did the prior venograms completely visualize all structures that are part of my standard diagnostic venography and was IVUS used.
4. did the therapeutic procedure meet my standard of care?
5. Current status of the patient's disease

i am sure there are other considerations that would also come into play as i understood patient's condition.
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Re: DrSclafani answers some questions

Postby drsclafani » Sun Jul 28, 2013 8:59 am

NZer1 wrote:In image 4&9 is that the end of the catheter that looks like a wire? To me that seems very high up and 'risky'?

The more I look at this series the more I am confused about the possibility of serious reverse flow, I am not sure of the sequences and it is leading me to assume things.

And we made the magic 5 post mark quite quickly! ;)



I always advance the guidewire into the dural sinuses so it may be high, but I havent had any negative sequellae to doing this. Patients experience some usually mild pain as the guidewire and catheter pass through the jugular foramen that is managed with some intravenous analgesia.
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Re: DrSclafani answers some questions

Postby drsclafani » Sun Jul 28, 2013 9:00 am

Cece wrote:I'm struck by the images in #5: on the left image there appears to be a valve with the flow above and below it, but in the next image it's hidden by the flow.

In #9, is the catheter deep into the sinuses, and it would be expected that the contrast would go equally out both sides of the sinus but it is concentrated instead in the right sinus? But in image #7 the left sinus looks good. In #8 everything lights up even up around the eyes? Is flow being diverted from the sinuses into the facial veins? Is the catheter misplaced? I am not sure what we are being shown in #8.

Ok now I look back at #2 and I think we are being shown that the contrast being injected into the right jugular is going up into the sinuses and then, because of a blockage between the left and right sinus, the contrast is going up even higher through alternate routes to get to the left sinus and then down the left jugular. Yikes.


we will get to your observations soon enough
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Re: DrSclafani answers some questions

Postby drsclafani » Sun Jul 28, 2013 9:01 am

NHE wrote:
Robnl wrote:
NHE wrote:1 & 2: It looks like flow in the RIJV is blocked and is being diverted through the LIJV.


I thought left jug is blocked, right = left on the image, right?


In image 2, the catheter appears to be in the RIJV. However, flow seems to be backing up and going down the LIJV. In contrast, in image 6, the catheter is in the the LIJV and most of the flow appears to be going down the RIJV which suggests a blockage in the LIJV as well. Hopefully, Dr. Sclafani will clarify this situation.


all in good time. This is pretty complicated. Took me a while to figure it out. I had not seen anything like this before
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Re: DrSclafani answers some questions

Postby drsclafani » Sun Jul 28, 2013 9:02 am

vesta wrote:I'm not qualified to comment, but it looks like the flow on the right in image 6 is seriously blocked?


yes, isnt it
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Re: DrSclafani answers some questions

Postby drsclafani » Sun Jul 28, 2013 9:04 am

Robnl wrote:
NHE wrote:1 & 2: It looks like flow in the RIJV is blocked and is being diverted through the LIJV.


I thought left jug is blocked, right = left on the image, right?


we shall see that both IJV are obstructed
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Re: DrSclafani answers some questions

Postby 1eye » Sun Jul 28, 2013 8:39 pm

The left seems to have a candy-cane twist and the dye seems to pool lower down. Looks like a septum or something is holding it in? The right seems non-existent, and if no dye is getting past the jugulars at all, maybe there just aren't enough others and collateral veins, to handle what should be the jugulars' flow in prone position?

Also, I had another question. Do you examine or what the flow looks like in both upright and prone? Not to treat spinal veins, but just as a double-check before treatment??
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Re: DrSclafani answers some questions

Postby NZer1 » Sun Jul 28, 2013 10:03 pm

I'm guessing here but the way the flow reverses and the region around the brain stem/foramen magnum I am suspicious of a Chiari Malformation.

I also get the impression there are 'twists' or internal plaques in veins because of the way that the blood is pooling in places. Really hard to see what is happening in a still one dimension image?
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Re: DrSclafani answers some questions

Postby Cece » Sun Jul 28, 2013 10:43 pm

drsclafani wrote:What could be the causes of dural sinus obstruction?
It could be a clot, and if it's a removable clot, all the better. Or there could be agenesis (of the right tranverse sinus) or an over-sized arachnoid granulation.

People with CCSVI could be at increased risk for sinus thrombosis due to flow being slowed because of jugular obstructions; it certainly seems to follow.
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Re: DrSclafani answers some questions

Postby pelopidas » Sun Jul 28, 2013 11:15 pm

Cece wrote:
drsclafani wrote:What could be the causes of dural sinus obstruction?
It could be a clot, and if it's a removable clot, all the better. Or there could be agenesis (of the right tranverse sinus) or an over-sized arachnoid granulation.

People with CCSVI could be at increased risk for sinus thrombosis due to flow being slowed because of jugular obstructions; it certainly seems to follow.

..and some kind of tumor
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