This Is MS Multiple Sclerosis Community: Knowledge & Support

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.

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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“Assessment of ‘CCSVI’ criteria: A specific effort was undertaken to search for the presence of one or more of the following criteria by which ‘CCSVI’ has been defined:
(i) a reflux >0.88 sec in the IJV and/or the VV, (ii) reflux in the deep cerebral veins (DCV), (iii) B-mode evidence of proximal IJV stenosis, defined as local
reduction of CSA ≥ 50% in a recumbent position (0°), (iv) flow not Doppler detectable in both IJVs and/or both VVs (v) a missing IJV diameter decrease in the sitting position, so called “reverted postural control” of the main cerebral venous outflow pathways.”

“Blood volume flow in the IJVs was assessed as apical as possible in the upper region of the neck close to the mandibular angle. Vertebral vein (VV) flow was assessed either between intervertebral segments C4/C5 or C5/C6. Measurements were obtained at an identical site in supine and upright body position. Ultrasound assessments were performed in an identical fashion in patients and controls.”

“Where the IJV was completely flat no CSA and therefore no BVF measurements could be obtained.”

“The Doppler-sonographic observation of bi-directional flow in parts of the IJVs [by Zamboni’s team] may be caused by a pulsation artifact from the nearby carotid artery and hence be misinterpreted as a venous reflux, particularly if blood flow measurements were not assessed along the entire IJV.”

“Regional narrowing of the IJV and VV was assessed by insonating their entire accessible length using the sagittal plane of the B-mode imaging. A local CSA reduction of ≥ 50%, following the suggestion by Zamboni et al. was considered a stenosis.

“Depending on different ultrasonographic indices e.g. the pulse repetition frequency, blood flow may not be detectable using the duplex technique, especially when the BFV is low. The BFV is often low in the VVs and also decreases with age leading to a lower detection rate in the elderly. With respect to the IJVs, a wide vessel lumen and/or a state of exsiccation (leading to low central venous pressure) may reduce the BFV immensely and render detection of the vessel in the duplex mode impossible.”

I wonder if any of these guys actually went to Italy and looked in person at what Dr. Zamboni's team is doing?

I think if they did this, they would have mentioned.

from the paper
Where the IJV was completely flat no CSA and therefore no BVF measurements could be obtained. In case of marked
respiratory variation of CSA and flow velocity measurements within subjects they were asked to briefly hold their breath after a normal exhalation, and measurements were obtained during these episodes of apnoe. Page 7 of 39


This seemed really odd to me...why would the IJV be completely flat, and no BVF measurements could be obtained? And then why did they ask the subjects to hold their breath and take blood flow during breath holding? This is where the protocol differs from Dr. Zamboni's. Dr. Z specifices that there should be no breath holding, which I assume affects the blood flow. But I do not know how, nor am I going to get a sonographer's
degree anytime soon.

But this paper talks about how breath holding changes jugular venous pressure:

"To determine the mean jugular venous pressure, the examiner should observe the nadir of the venous column on inspiration and then the crest of this column on expiration. Next, the midpoint of the excursion of the venous pulse during normal respiratory cycles is estimated visually. Exaggerated breathing or breath holding distorts the normal mean venous pressure and should be avoided."

http://www.ncbi.nlm.nih.gov/bookshelf/b ... &part=A622

Anyhoo...all I know is Zamboni made a big deal in Bologna about no breath holding, no valsalva, his method was different. I really hope his reply is published, because it's vitally important that if his technique is so revolutionary, he needs to make sure techs understand that before publishing papers saying they have "followed his criteria."

this was helpful to me.

the reason dr zamboni wants the study done in inspiration is to activate the thoracic pump and increase blood flow through the jugular veins. it is the overwhelming of the outflow volume that leads to the reflux in ccsvi.

Quote:
Examinations performed by untrained personnel failed to correlate with the results obtained by trained personnel.

The full article is available (again thanks to Sotiris).