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 » Tue Jul 30, 2013 9:13 pm

Needled wrote:Dr. S,
Are you still surprised at the types and variety of problems you're finding, 3 1/2 years after performing your first ccsvi procedure?
Cheryle


My, how time flies!

There is nothing that surprises me about CCSVI or MS
at this point I would say something challenging, unexpected, or a new observation occurs about once in five patients

Often it is simply judgements or technique nuances.

For example I continue to have a difficult time treating septum. I end up using very high pressure and this is often unsuccessful.
This week I treated one with a larger balloon but limited the pressures to less than I normally use and and it worked. I will try that again when I see a septum in the future
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Re: DrSclafani answers some questions

Postby drsclafani » Tue Jul 30, 2013 9:15 pm

Cece wrote:Did the patient experiences any changes in MS status (onset or worsening or ?) around the time of the dural sinus thrombosis occurring several years back?


Yes, she developed really severe headaches 8010/10 that lasted a very long time

They subsided but never fully disappeared after anticoagulation therapy
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Re: DrSclafani answers some questions

Postby drsclafani » Tue Jul 30, 2013 9:19 pm

NHE wrote:Dr. Sclafani,
So what steps were taken for treatment and what effects, improvements or otherwise, were reported by the patient?


The case just happened a week ago

I only treated the jugular veins.

Forgive my better judgement, but I do not treat intracranial lesions in the ambulatory center.

I am getting consultations from those who specialize on such cases.
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Re: DrSclafani answers some questions

Postby cheerleader » Wed Jul 31, 2013 2:56 pm

Hi Dr. Sclafani,
Not sure if you saw my earlier post, but I was wondering if this patient was also being checked for benign intracranial hypertension (pseudotumor cerebri). It's most prevalent in overweight or pre-menopausal women on birth control pills, but my slim and trim husband had it. It can create venous sinus stenosis and thrombosis of the dural/transverse sinus. In Jeff's case, it manifested as optic disc swelling, vision loss, headache and objective pulsatile tinnitus. All better since tranverse sinus stenting at Stanford hospital. Shunts can be helpful, so can medication. Sometimes, simply losing weight and stopping BCPs can help. Of course, if she's all better after jugular ballooning, that would be the best!
here's a great study on venous pulsatility and dural incompetence in IHH...has great MRV pics, too. Think you'll enjoy it :)
http://neurosurgery.med.wayne.edu/pdf/n ... y_2012.pdf
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 Cece » Wed Jul 31, 2013 4:17 pm

I googled a patient forum on transverse sinus thrombosis http://www.medhelp.org/posts/Neurology/ ... how/291951 so now I know everything. A little knowledge is a safe thing. Is rheolytic catheter thrombectomy an option when it has been years since the thrombosis formed, or is it too late?
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Re: DrSclafani answers some questions

Postby drsclafani » Thu Aug 01, 2013 6:24 am

Cece wrote:I googled a patient forum on transverse sinus thrombosis http://www.medhelp.org/posts/Neurology/ ... how/291951 so now I know everything. A little knowledge is a safe thing. Is rheolytic catheter thrombectomy an option when it has been years since the thrombosis formed, or is it too late?

I think it is much too late for anything like that. Risk probably higher than likelihood of benefit. However, I am consulting with those more expert in this condition.
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Re: DrSclafani answers some questions

Postby drsclafani » Thu Aug 01, 2013 7:23 am

cheerleader wrote:Hi Dr. Sclafani,
Not sure if you saw my earlier post, but I was wondering if this patient was also being checked for benign intracranial hypertension (pseudotumor cerebri). It's most prevalent in overweight or pre-menopausal women on birth control pills, but my slim and trim husband had it. It can create venous sinus stenosis and thrombosis of the dural/transverse sinus. In Jeff's case, it manifested as optic disc swelling, vision loss, headache and objective pulsatile tinnitus. All better since tranverse sinus stenting at Stanford hospital. Shunts can be helpful, so can medication. Sometimes, simply losing weight and stopping BCPs can help. Of course, if she's all better after jugular ballooning, that would be the best!
here's a great study on venous pulsatility and dural incompetence in IHH...has great MRV pics, too. Think you'll enjoy it :)
http://neurosurgery.med.wayne.edu/pdf/n ... y_2012.pdf
cheer


Thanks for the quote. I was surprised to consider that the stenosis could be caused by the intracranial hypertension. I had thought that the stenosis would be the cause of the intracranial hypertension.

In this case the patient experienced a defining severe and unrelenting headache leading to an MRI that showed "blood clot" in the brain for which she was given heparin and coumadin. That clearly suggests to me dural sinus thrombosis. She ceased birth control pills. Her symptom complaints were not visual signs but rather cognitive issues.

She is about two weeks past the jugular vein angioplasty procedure and states that she is 'clearer" inm thinking and her vision is sharper.

She is vacationing in France now and I will revisit her case when she returns.
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Re: DrSclafani answers some questions

Postby SLOV8213 » Thu Aug 01, 2013 9:50 am

Hi Dr Sclafani,

Would you agree that certain MS patients may have delicate veins? I have undergone three CCSVI procedures, spoken with IR's and patients who have made the same statements.

Regards, Stephen Lovatt.
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Re: DrSclafani answers some questions

Postby drsclafani » Thu Aug 01, 2013 1:26 pm

SLOV8213 wrote:Hi Dr Sclafani,

Would you agree that certain MS patients may have delicate veins? I have undergone three CCSVI procedures, spoken with IR's and patients who have made the same statements.

Regards, Stephen Lovatt.


Dear Stephen
I would agree that ALL patients (and healthy controls) have delicate veins. That is why all angioplasties should be done delicately.
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Re: DrSclafani answers some questions

Postby SLOV8213 » Thu Aug 01, 2013 3:56 pm

Hi Dr Sclafani,
Thank you for taking the time to answer my question regarding some MS patients having delicate veins. I have now been asked if I have any evidence of this? I have read many studies that talk of venous abnormalities along with picture presentations from ECTRIMS 2011. Can you think of any specific reference.
Regards, Stephen.
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Re: DrSclafani answers some questions

Postby drsclafani » Thu Aug 01, 2013 6:29 pm

SLOV8213 wrote:Hi Dr Sclafani,
Thank you for taking the time to answer my question regarding some MS patients having delicate veins. I have now been asked if I have any evidence of this? I have read many studies that talk of venous abnormalities along with picture presentations from ECTRIMS 2011. Can you think of any specific reference.
Regards, Stephen.

Stephen, I am unsure about what you need specific information. Veins are thin walled highly stretchable structures which at times have slow flow. So while they can stretch, they can also tear and thrombose. Delicate treatment takes this into consideration.

So, would you mind being very direct about what issue you desire clarification, and i will do my best to be direct in my answer.
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Re: DrSclafani answers some questions

Postby SLOV8213 » Thu Aug 01, 2013 6:51 pm

Hi Dr,
I posted my opinion "see below" about TVAM treatment. Now I'm asked for evidence of MS patients having fragile veins.
Regards, Stephen.


Where is the clinical evidence that this is a method that will work? Why aren't they creating their own by filing for an IRB through a recognized institution that allows them to follow their patients? Let's face facts, without evidence, it's not real, and although it's a patient's right to choose such a treatment, there needs to be evidence produced as a result of those therapeutic interventions. Also its dangerous to perform venoplasty on a vein that is not occluded to Stretch it.. Worse than that, we know that all veins are not the same. In some MS patients the veins are quite delicate and subject to iatrogenic injury. It is probably just as dangerous to perform a venoplasty on those veins that are thinner-walled and subject to more damage as a result of catheterisation and balloon expansion, without a follow-up strategy that mitigates or eliminates over expression of thrombin/fibrin and tearing.
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Re: DrSclafani answers some questions

Postby drsclafani » Thu Aug 01, 2013 7:35 pm

SLOV8213 wrote:Hi Dr,
I posted my opinion "see below" about TVAM treatment. Now I'm asked for evidence of MS patients having fragile veins.
Regards, Stephen.


Where is the clinical evidence that this is a method that will work? Why aren't they creating their own by filing for an IRB through a recognized institution that allows them to follow their patients? Let's face facts, without evidence, it's not real, and although it's a patient's right to choose such a treatment, there needs to be evidence produced as a result of those therapeutic interventions. Also its dangerous to perform venoplasty on a vein that is not occluded to Stretch it.. Worse than that, we know that all veins are not the same. In some MS patients the veins are quite delicate and subject to iatrogenic injury. It is probably just as dangerous to perform a venoplasty on those veins that are thinner-walled and subject to more damage as a result of catheterisation and balloon expansion, without a follow-up strategy that mitigates or eliminates over expression of thrombin/fibrin and tearing.

Steph3n,
What does TVAM mean? I will respond tomorrow. But I never said fragile, I said they were delicate.
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Re: DrSclafani answers some questions

Postby SLOV8213 » Thu Aug 01, 2013 9:23 pm

Sorry, delicate.

Transvascular Autonomic Modulation (TVAM)

Regards, Stephen.
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Re: DrSclafani answers some questions

Postby Cece » Fri Aug 02, 2013 11:55 am

SLOV8213 wrote:Sorry, delicate.

Transvascular Autonomic Modulation (TVAM)

Regards, Stephen.
TVAM is a term that Dr. Arata has coined for his practice of performing angioplasty on normal-appearing veins under the assumption that this stimulates nearby nerves and improving autonomic nervous dysfunction via the nerve stimulation. Stephen, you sound like you are opposed to this or at least have a reasonable expectation that evidence be provided?
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