New Study casts doubts over vein blockages in people with MS

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

Postby L » Tue Jun 15, 2010 5:14 am

The other side of the coin, Dr Sclafani's point of view:

That ultrasound is quite specific. The Doppler is quite relevant and the images need to be taken in just the right way, otherwise the diagnosis is unclear.

Erica, the PhD who works with paolo, is phenomenal. She is very experienced at finding the veins and making pictures that are clear, unquestioned and sensible.

She starts with the right side of the neck in the lying down position. She does the doppler of the jugular vein in three areas J1 near the clavicle, J2 near the thyroid, and J 3 above the carotid bifurcation. She looks to see the direction of flow in each area. she images transversly. This shows the carotid and the jgular simultaneously. The color is supposed to be red and blue.....one going toward (IJ vein) and one going away (carotid) from the heart. Showing the two vessels together makes it very clear that they go in opposite directions if normal. Patients have sent me many images where the vein is seen in profile, but alone. cant figure out flow direction like that.

ok. after looking at the IJV at the three areas, she looks for the vertebral vein and artery. again, the two vessels are imaged together and the colors should be opposite.

Great, then she has the patient take a big breath which allows the veins to distend. she measures the cross sectional area of the jugular in its largest dimension.

Then she does a transcranial doppler looking for the deep cerebral veins. (this is the part i find the most difficult) She is looking for reversal of flow. that is always abnormal.

Finally puts the Bmode on and looks at the anatomy, looking for webs, stenoses, valves, etc

THEN She does everything again, in the upright position.

THEN, she does everything on the left side in just that order.

This study is quite challenging to learn. My colleage dan zinn finally got it. just by watching a few cases. It is not necessarily the most difficult but it certainly is quite specific and doing it wrong is going to lead to failures

As I was saying, I have reviewed a lot of studies done around the world. For the most part , they suck. when you get half the views, or the wrong manuevers, one is left with the distinct impression that you have no idea what it all means.

So it is clear that we need to create a standard. that standard needs to be specific, reproducible and simple.

by the time i learn this one, paolo may have perfected a US test that is easier to do with similar reliability.
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Postby malden » Tue Jun 15, 2010 5:54 am

cheerleader wrote:... In this study, they measured at the apex of blood flow in two specific locations....Dr. Zamboni measured over the course of the entire IJV. It's like they took the transducer and held it in one spot- the apex of blood flow. That's not what doppler technology is....the transducer wand is supposed to cover the entire vein, not 2 "apical sites." I think this is a very important difference...


Yes that's what doppler technology is:
(Color Doppler Imaging: Principles, Limitations, and Artifacts http://radiology.rsna.org/content/177/1/1.full.pdf

"The frequency of ultrasound changes when it is reflected from red blood cells that are moving relative to the ultrasound beam. If the blood cells are moving toward the source (transducer), the frequency of the reflected sound will be increased, whereas if the cells are moving away from the source, the frequency will decrease.
The Doppler shift frequency is the difference between the frequency of the transmitted ultrasound and the frequency of the reflected ultrasound. This frequency is proportional to the velocity component aligned with the axis of the ultrasound beam."


That's the reason why the Longitudinal Color Doppler image can show both blue and red colors in the same vesel on the opposite sides or in the middle when the helical flow is present. Also, you can't get reasonable blood flow measurements when blood flow is perpendicular to the ultrasound beam.

"Blue indicates flow toward the transducer; red, away from the transducer. High Doppler frequencies are indicated by decreased saturation (pale shade). The highest frequencies in this image (*) correspond to regions where the angle between the ultrasound beam and the blood flow is lowest, whereas lower frequencies correspond to flow that is nearly perpendicular to the beam. Where flow is perpendicular (arrows), a complex mixture of red and blue is observed."

(see Figure 2. in Color Doppler Imaging: Principles, Limitations, and Artifacts)

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Postby cheerleader » Tue Jun 15, 2010 7:48 am

I know what color doppler is. I also have the entire paper in front of me. I should have said, that is not the complete technique employed by Dr. Zamboni's team. Correction.

The German team measured at two apex (high) points of flow in the jugulars and employed valsalva manuever to test for reflux. Dr. Zamboni has repeatedly stated that in his protocol, the entire jugular vein must be scanned under normal breathing conditions. They were using internal jugular vein valve insufficiency as a marker for venous reflux. That is not CCSVI....that is IJVVI. Different thing. Dr. Sclafani's thread, linked above, explains the specifics.

The German team also wrote about the transcranial doppler portion saying--

The blood flow direction in veins connecting cortical with deep veins may vary considerably (in line with the physiological inter-individual variation of the cerebral venous anatomy).
Criteria to identify these veins using Doppler ultrasound do not exist, and hence no reference values regarding blood flow direction and BFV can be given.


Sounds like they are saying that since there is no criteria, there's no problem. Dr. Zamboni created a specific criteria. It's too bad they claim to use it, and don't.
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Postby fogdweller » Tue Jun 15, 2010 11:28 am

This test is like taking a pulse, and saying since it was not different between the two groups, that disproves CCSVI.

The imagaing/diagnostic regime is very rigourous and specific, and it is pretty clear that without the right technique applied, the results are pretty worthless. See the "Ask Dr. Sclafini" thread, pages 126 and 127. The conclusion here is that the non-vascular doctors did not successfully perform diagnostic testing and had only worthless, non-usable results, not that the CCSVI theory was wrong.

The only thing that will convince me that the theory is wrong (and I do have an open mind in that regard) is if the rigourous diagnostic/imaging protocol is followed on healthy and MS patients and no consistent difference is found.
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Postby MrSuccess » Tue Jun 15, 2010 11:59 am

fog - healthy people do not have blocked veins or arteries. Sooner or later there will be consequences resulting from this condition .

Such as ...... MS.



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Postby fogdweller » Tue Jun 15, 2010 12:46 pm

MrSuccess wrote:fog - healthy people do not have blocked veins or arteries. Sooner or later there will be consequences resulting from this condition .

Such as ...... MS.



Mr. Success


Well, people with blocked veins and arteries may be quite healthy otherwise, and a few blocked veins or arteries may not be a big deal. The human body is wonderfully redundant, and can get along quite well without being perfect. Also, the neuros are saying that veins they imaged were not really blocked. They claim to have looked at flow, and the flow was qute normal and adequate. That being the case, the fact that the veins might have been tortuous and convoluted was no big deal.

I think they are wrong, and have a fairly strong belief that CCSVI is real and probably the cause of MS. All I am saying is that I keep an open mind.
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Postby MrSuccess » Tue Jun 15, 2010 1:29 pm

Fog - how is it possible that Neuro's have looked at the veins.

How would they accomplish this feat .... without being vascular experts ?

Refreshingly .... every vascular doctor that I have been following admits to not knowing anything involving the Neuro's domain ....the brain .. and the related diseases there of ....

In addition to being superb surgeons .... they are respectful ...and honest.

What they are saying is .... the brain is your territory of expertise ... but the veins exiting the brain ... is our area of expertise .... and we see blockage as abnormal ...and can solve the problem.

It's that simple.




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Postby foreignlesion » Tue Jun 15, 2010 1:35 pm

Mr. Success,

Many neuros are vascular experts. Strokes and aneurysms, both primararily vascular in nature, both fall under the domain of neuro sciences.

What they aren't experts in is angioplasty and stenting.

This is the area we need the expertise of the vascular surgeons.

But we do and always will need the neuros.

However....after blockages have been found...not allowing intervention IS truely unconcionable.
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Postby MrSuccess » Tue Jun 15, 2010 2:53 pm

foreignlesion- neuro's are vascular experts ? How so ? Do they perform operations in an operating theatre ? Or just recount what they have read in a textbook ? :wink: Your and my definition of vascular experts differ.

I want to make clear this ......

I respect those practising Neurology . Especially Dr. Salvi .......... who is Dr. Zamboni's teammate. And many others. Dr. Salvi is A # 1 . :!:

I am not on an anti-neuro rant .

My point is simple . It is not in the realm of Neurologists to treat vascular problems . By treat ... I mean repair / correct vascular problems via surgical procedures. Such as CCSVI .

I say the evidence is so strong that the time has come to let other medical specialists [ vascular doctors ] try to remedy MS ... and possibly other neurological illness'.

As has been done already .... in small numbers. With mixed results.



Stay calm .... and carry on ..........




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Postby cheerleader » Tue Jun 15, 2010 2:55 pm

These were vascular specialists performing the ultrasounds. Ursula was tested at Charite, and she posted on here and said they were vascular docs.

I really wanted to keep this discussion away from attacking the doctors, and simply looking at what might have been different in their protocol. What I found was that they employed valsalva manuever and looked at internal jugular vein valve insufficiency as a measure of venous reflux and Dr. Zamboni utilized normal breathing. They also measured 2 points, and Dr. Zamboni's protocol looks at the entire jugular. Their TCD machine was different, and they admitted that interpretations of TCS scans are variable. That's all I could find in the German paper...but I'm sure that Dr. Zamboni's team will answer the study, if he is given the opportunity to reply in the Annals of Neurology.
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Postby smokey » Tue Jun 15, 2010 3:13 pm

L wrote:
smokey wrote:Some questions and comments about this study:

Were any interventional radiologists or vascular surgeons consulted or supervising the procedures. Who interpreted the results?

There are obvious problems with this study if interventional radiologists or vascular specialists were not consulted. Neurologists would have clearly been working outside their areas of expertise, which raises ethical issues. That is not to say neurologists should not be involved in CCSVI studies. Surely the best outcome would be if all specialisations worked together. Now that would be a novel approach!

Methods are given in detail for the purpose of reproducibility. Zamboni’s study design was criticised. This study can and should also be criticised for not following research protocols.

One interpretation of these results is that they show extreme lack of expertise in the area of CCSVI identification.


In (a partial) answer to your question, a quote from Ursula, from the thread that cheerleader linked to above.

hi yannis,

rumors, rumors, rumors.('Embarassed')
everyone has something to say about the charite trial but nobody took part.

i took part and the sonography wasn´t made by a beginner but by the leader of the sonographic institute of the charite.
and they are not at all sceptic about the ccsvi issue but interested.

they scanned my veins for at least 30 minutes with no abnormal result. i also asked dr. schreiber about the other people in the trial and he mentioned that they couldn´t find anything special so far.

let´s talk again in a couple of years then it will turn out if the stents and all that are really so effective.

ursula

p.s.: i also took part at the egcg trial and can say that i have been relapse free since i am on egcg.



I stand corrected Ursula. Method/protocol appears to be the key. It will be interesting to read published replies to this study.
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Postby patientx » Tue Jun 15, 2010 3:28 pm

MrSuccess wrote:Or just recount what they have read in a textbook?


Actually, in this case it looks like they wrote the textbook:
link

The authors of this study might know a little about neuro-vascular imaging and vascular issues:

http://www3.interscience.wiley.com/jour ... 2/abstract
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Postby 1eye » Tue Jun 15, 2010 3:47 pm

Good afternoon.

I spent quite a few hours yesterday and today, attending first the Parliamentary Take Note debate, which you really gotta see. Dr. Zamboni and Dr. Simka were there at the Parliamentary committee meeting this afternoon. It really seems to me that the dam is about to burst or the clouds or the seed pod or something.

They are both on record on TV. All you really need from either one is to see the last single statment Dr. Zamboni made, and to know that everyone there who counted was listening very closely and took every word he said very seriously. The star of last night was Dr. Kirsty Duncan who in spite of what the Member from Barrie (Dr. MacDonald's riding) said, was really the main force behind convening the Committee. She and a few other very committed Liberal Members spoke very eloquently and passionately. The debate was on for four or more hours. Rebecca and Andrew of MSLiberation had convened us (about 20-30 MS people) and we were up in the (peanut) gallery where you're not allowed to clap or boo.

We did anyway, till the police guy quietly shushed us. I want to see the rest on video, because I got too tired around 9:30 last night. At first, while the Prime Minister was still there, it was a bit like the question period following the previous meeting of the Committee, where Mr. Harper and the Health Minister just mouthed the usual generalities, mentioned the MS Society, but said more of the same nothing. After the PM left, Ms. Duncan and her fellow Liberals really got on a roll, and I thought she would bring out her secret weapon, the woman from Barrie.

Magically, the Conservatives had a change of heart. The Member from Barrie started grandstanding, talking directly to constituents on the TV. I heard later that a lot of what he had said was direct thunder-stealing because he and everyone else there had been inundated with email yesterday about her plight. I hope she got the procedure.

But mostly what I heard was a lot of finger-pointing and blame deflection. According to the BLOC it is a provincial matter which Health Canada rightly was ignoring. The Conservatives agreed about that, but after The Change, turned it into finger-pointing at the Provincial Liberals (who are in power at that level), saying if people had been shut down, why don't you ask them? I had never been a Political Football before, and it was quite a volatile feeling.

So anyway I left with the feeling that Ms. Kirsty Duncan and the Liberal gang had done a tremendously good job, and had swayed the hearts of everyone there. But I left with the usual doubts last night, in spite of the feeling that I had really witnessed Democracy in action, in that big place with so few people left in it. Some kind of history was undeniably happening.

By today, maybe the Member from Barrie had seen his performance on TV or something, but he seemed a lot more reachable and sincere. I think the poor woman from the MS Society was brave, but the house was stacked. She could not get anyone to agree that 'you can't have it, because more research is needed' was going to cut it anymore. The guy from the department that really controls the money for research was saying 'send in your box-tops and your Research Plan, we have 16 Million available.' He knocked that down to the 10 M we have all heard about. It seemed a lot of the people that counted were really treating Dr. Zamboni like the expert he is. They were all agreeing, with the patients, that there should be a Big Trial, but one in which there is a Treatment Arm, available to anyone whether they have MS or not. I think Dr. Kirsty and all the tele-doctors had finally won that point.

I think the most likely person to run that study was the vascular surgeon from Sunnybrook hospital in Toronto, and he got quite a few rounds of applause, and cut through a lot of the usual BS.

I left last night proud to be a Liberal again, in spite of Ignatieff' support for the minimum-sentencing bill that sends marijuana-users to prison. I was proud to say I knew Dr. Duncan.

Today I was happy to have been there and proud to be a CANADIAN.
Last edited by 1eye on Tue Jun 15, 2010 4:21 pm, edited 3 times in total.
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Postby belsadie » Tue Jun 15, 2010 4:00 pm

An acquaintance of mine is seen by Dr.Peter Calabrese down at Hopkins and left me a message that Hopkins is pulling out of the ultrasound screening they had planned on initiating, due to the fact that Zamboni's work has not been able to be duplicated and this whole CCSVI thing is probably a wrong way to go. Plus the MS Society is not sanctioning the idea. Interesting! SAD, too
This is a man who heads the MS clinic down at Hopkins. I would have thought that he'd be anxious to do his own studies before he dismissed the hypothesis. He is pushing the Tysabri treatment, which my friend is on and doing really well. When we first began talking about CCSVI and she told me how well she was doing, I told her,"If it ain't broke, don't fix it."
Since she was his patient, she asked to be included in the ultrasound study. That's when he told her the above. Oh, well. More people to have to eat their words.........
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Postby CureIous » Tue Jun 15, 2010 4:02 pm

I'm amazed at how one statement, study, or conjecture is summarily blasted to smithereens when it supports CCSVI, but one dinky ultrasound test, the most difficult to replicate correctly, and they write "case closed" all over it and make authoritative pronouncements. Funny how that never ever works the other way around.

"Seeing what you want/expect to see" goes both ways here.

Just can't deal with the dogmatism involved, the doctors deserve all the lambaste coming their way, for "conduct unbecoming a professional" with the methods they use and the conclusions they headline the paper with.
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