cerebral sinuses and white matter demyelination

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

cerebral sinuses and white matter demyelination

Postby Cece » Mon Dec 27, 2010 10:14 pm

J Neurol. 1981;225(1):1-8.

Direct drainage of extracranial arteries into the superior sagittal sinus associated with dementia.
Friede RL, Schubiger O.

Abstract
A 62 year-old-man suffered from progressive dementia for the last 5 years of his life. Angiography disclosed draining of multiple extracranial, galeal arteries directly into the superior sagittal sinus with retrograde filling of cerebral veins. At necropsy there was arterialization of the walls of the sinus and a multichannelled lumen in its middle third. The sinus was not distended, the dura normal, and no angioma was found. The leptomeninges and the cerebral white matter contained excessively distended veins, some with thickened fibrotic walls. Many arteries in the arterial white matter were mineralized. There were widespread patches of incomplete demyelination about these abnormal vessels. The lesion was classified as a developmental anomaly with direct shunting of extracranial arteries into the superior sagittal sinus.

http://www.ncbi.nlm.nih.gov/pubmed/6164751

I searched to see if I could find any link between abnormalities of the dural sinuses and unidentified white matter lesions. (Yeah, got nothing on that.)

But this one is a case study, it sounds similar to an AVM. It's a developmental anomaly but didn't cause his progressive dementia until after the first 57 years of his life. Also relevant because the condition caused retrograde flow through the cerebral veins and white matter demyelination.
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just curious

Postby leetz » Tue Dec 28, 2010 3:05 pm

Anyone elso on the board have chronic sinus problems?
GOD BLESS.... CCSVI treatment Dr. Siskin great doc....symptom's improved for about 3 week's (gait, balance, spasticity) now back to square 1...
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Postby Cece » Tue Dec 28, 2010 3:20 pm

I do, actually, on one side only. :)

But this is about the dural sinuses, straight sinus, transverse sinus, occipital sinus...these are all names for various deep cranial veins.

According to Dr. Sclafani, they have great variability, we don't know what's pathological. But in CCSVI, we have reports of missing sinus veins or obstructions. They aren't currently being treated, because they're up too high, the risk/benefit ratio is unknown.

On a totally anecdotal level, if anyone here who has a known sinus vein abnormality wants to answer, can you tell me if you have white matter lesions near or upstream from that sinus vein?
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Postby Cece » Thu Dec 30, 2010 7:13 pm

Venous Sinuses
In the early embryo, venous drainage of the brian proceeds in a centrifugal pattern from deep to superficial surface channels, much like the adult arrangement of the spinal cord. However at some point dural sinus channels form and take over the function of venous drainage. For some reason, surface veins cannot support this function in the adult, as evidenced by gradual venous and subsequent brain failure in cases of Sturge-Weber syndrome

http://neuroangio.org/VenousSinuses.aspx

Really, even among our venous guys, we're back to "for some reason" as an explanation?

Why can surface drains not support the drainage as an adult?

Sagittal Sinus Thrombosis -- collaterals. All of the above anatomic knowledge can become very useful in evaluation of venous thrombosis. Numerous collateral pathways develop in this setting attempting to compensate for the loss.

Ok, new question for anyone with hypoplasia of the sinus veins or obstructions of same, do you see distinctive collaterals up there?

I had one person respond to my question in the previous post, much gratitude. :)
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Postby HappyPoet » Fri Dec 31, 2010 7:55 am

Cece wrote:I do, actually, on one side only. :)

But this is about the dural sinuses, straight sinus, transverse sinus, occipital sinus...these are all names for various deep cranial veins.

According to Dr. Sclafani, they have great variability, we don't know what's pathological. But in CCSVI, we have reports of missing sinus veins or obstructions. They aren't currently being treated, because they're up too high, the risk/benefit ratio is unknown.

On a totally anecdotal level, if anyone here who has a known sinus vein abnormality wants to answer, can you tell me if you have white matter lesions near or upstream from that sinus vein?

If I may...

The dural sinuses (sagittal, straight/transverse, occipital, sigmoid, etc.) are actually carved into the underside/inside of the skull (outside the brain, between the layers of dura matter that cover the brain), and they are fixed in nature, just like built-in cement drainage pipes are fixed, rather than being flexible like true veins. The sinuses are part of the vascular system, but they are not veins. The "deep cranial veins" drain into the sinuses which drain into the IJVs.

These sinuses are not the frontal sinuses associated with a traditional sinus infection that drains through the nasal passages and down the throat, but they are similar in that they are all built-in spaces/cavities; hence, they share the same medical term of sinus.

Having said that, though, there is the "dural sphenoid sinus" which, if I understand somewhat correctly, shares the same bone wall as the frontal sinus directly behind the nose (or something like that). I am completely missing the dural sphenoid sinus which means blood must back up (reflux) back into the veins of my brain to try to find another dural sinus down to the IJVs. I believe this is partly why my liberation wasn't successful.

No, unfortunately, I can't tell if I have inflammation, demyelination, axonal loss, atrophy or iron deposits near or upstream from my malformed/missing dural sinuses in either white matter or gray matter areas because none of my previous brain MRI reports specified this info, BUT my next one will, that's for certain!!

I don't know if I have collateral veins in my brain. Is the Transcranial Doppler US a test that can show these? Would such collaterals show up in an MRI? Anyone know?
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Postby Cece » Fri Dec 31, 2010 1:51 pm

HappyPoet, thank you for that explanation.

I think we'd have to take the image of the sinuses and overlay it with the image of the white matter lesions and then be neurologists or neurovascular specialists and run a statistical analysis on a bunch of these in pwMS to see if there is a statastically significant correlation in white matter lesion location to these sinus abnormalities. Advantage is that this could be done retrospectively through the already existing images.

Another approach is to do regional fMRI testing to see if the areas of the brain drained by the abnormal sinus have abnormalities in oxygen utilization and speed of perfusion. This could be tested in both people with MS with sinus abnormalities and people with sinus abnormalities without MS. And normals for comparison of course. I would like to see that one! Might as well throw in a fourth group, of people with MS but without sinus abnormalities, to cover all bases. This would help answer the question of whether these sinus abnormalities are pathological and warrant treating in people with MS. Now where is my funding.... :cry:

A third approach, if reflux can be measured, is to see if the sinus abnormalities are creating statistically significant amounts of reflux. Disadvantage to this approach is that reflux is not yet proven to be pathological in and of itself. It is curious, though, because the thrombosis research does discuss reflux and describes it as pathognomic. I have yet to google that word.

I love research design, I once was accepted into a PhD program in clinical psychology at a lesser university but turned it down before starting, after the campus tour/interview and the realization of how much of an undertaking it would be. I had the passion but lacked the stamina.

Collaterals show up when they do the catheter venogram when investigating the sinuses for thrombosis (this is what all the venous sinus research is about, thrombosis is rare but particularly damaging). I imagine that when they're doing that cath venogram, they're up higher in the brain than our docs are when they're doing ccsvi cath venograms.
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Postby bluesky63 » Sat Jan 01, 2011 12:33 pm

How would an arachnoid granulation in the transverse and/or dural sinuses affect drainage? I've seen people here describe that finding.
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Postby Cece » Sat Jan 01, 2011 1:01 pm

That still makes me think of spiders. :)

American Journal of Neuroradiology, Vol 16, Issue 4 901-904, Copyright © 1995 by American Society of Neuroradiology


--------------------------------------------------------------------------------

ARTICLES


MR of giant arachnoid granulation, a normal variant presenting as a mass within the dural venous sinus
AC Mamourian and J Towfighi
Department of Radiology, Dartmouth-Hitchcock Medical Center, Lebanon, NH 03756, USA.

We report three cases of masses within the cerebral dural venous sinuses shown with either MR or angiography. The dural venous sinuses of 10 patients without known venous disease were examined at autopsy. In two patients, three giant arachnoid granulations were identified. On the basis of the literature and our limited autopsy series, we suggest that these lesions identified at imaging are giant arachnoid granulations, normal variants of no known clinical significance.

But until recently, our messed-up jugulars might've been considered "normal variants of no known clinical significance."
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Postby HappyPoet » Sat Jan 01, 2011 1:03 pm

Cece wrote:Collaterals show up when they do the catheter venogram when investigating the sinuses for thrombosis (this is what all the venous sinus research is about, thrombosis is rare but particularly damaging). I imagine that when they're doing that cath venogram, they're up higher in the brain than our docs are when they're doing ccsvi cath venograms.

Cece, you never cease to amaze me. I was hoping the answer wasn't going to be a catheter venogram because...

I've heard cranial venography is very painful. Veins have no pain receptors, correct? Brain tissue has no pain receptors, correct? Yet, pain has been reported. A member of TIMS had this test and reported pain -- this gentleman's missing jugular vein was the first such reported case, and his other jugular vein was severely pinched by a malformed, extra-long cervical vertebral bone.

His shocking image was one of the first such pictures to be shown on Dr. Haacke's website well over a year ago; I could be wrong, but I think cheer was the person who put this gentleman in touch with Dr. Haacke.

I posted in two of his threads, and I remember thanking him for enduring his painful cranial venography which would help further research on CCSVI. Oh, how I wish I could remember his user name here, and I also can't remember the findings of his cranial venography, if any.

My mind is so clouded that I don't know how to begin the search for those two threads. I never saw another thread or post from him again, and I so hope he's doing well.
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Postby Cece » Sat Jan 01, 2011 1:49 pm

I'll try to find that thread, it would seem relevant. I remember that particular image!

I don't know how well the thrombosis research will inform us, it is again the distinction between the acute (a sudden thrombosis) and the chronic (a congenitally-malformed venous sinus).
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Postby Blaze » Sun Jan 02, 2011 8:47 am

My MRV indicated a possible earlier thrombosis or a congential hypoplasia in my right sigmoid and dural sinuses.

I'm not sure about white lesions upstream from those sinuses. Here is what MRI of my brain showed: "The images of the brain show multiple small focal high signal lesions in the periventricular and deep white matter of both cerebral hemispheres. There is involvement of perventricular white matter and also juxtacortical white matter in both parietal lobes. Juxtacortical lesions are also seen in the right temporal lode and there is involvement of the right body of the corpus callosum. There is relative sparing of the brain stem and no foci or diffusion restriction are identified."

I have no idea what all of that means in terms of location in the brain. I had the impression from my neurolgoist that those were standard MS findings. Dr. Cece or others, can you shed any light on it?

My understanding of my Doppler is that my right jugular is completely blocked and my left is partially blocked with reflux. There are other details in the Doppler report.

It is because of the issues in the dural sinuses that I have decided not to seek treatment outside of Canada.
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Postby Blaze » Sun Jan 02, 2011 8:49 am

My MRV indicated a possible earlier thrombosis or a congential hypoplasia in my right transverse and sigmoid sinuses.

I'm not sure about white lesions upstream from those sinuses. Here is what MRI of my brain showed: "The images of the brain show multiple small focal high signal lesions in the periventricular and deep white matter of both cerebral hemispheres. There is involvement of perventricular white matter and also juxtacortical white matter in both parietal lobes. Juxtacortical lesions are also seen in the right temporal lode and there is involvement of the right body of the corpus callosum. There is relative sparing of the brain stem and no foci or diffusion restriction are identified."

I have no idea what all of that means in terms of location in the brain. I had the impression from my neurolgoist that those were standard MS findings. Dr. Cece or others, can you shed any light on it?

My understanding of my Doppler is that my right jugular is completely blocked and my left is partially blocked with reflux. There are other details in the Doppler report.

It is because of the issues in the dural sinuses that I have decided not to seek treatment outside of Canada.
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Postby Cece » Sun Jan 02, 2011 11:19 am

Blaze, yes, that might lend support to my hypothesis that the location of the abnormal sinus might be able to be shown to correlate with the location of the lesions. You've described an abnormal sinus on the right and this
Juxtacortical lesions are also seen in the right temporal lode and there is involvement of the right body of the corpus callosum.
which is exclusively on the right. This might be entirely random, we don't know. But my theory is that if we did a large study of pwMS we'd find a lot of reports just like yours. The jugular obstructions slow down the overall flow, the abnormal venous sinus further slows the regional flow where it's located. Our poor brains.

Do we have many reports of how people with venous sinus abnormalities have fared after the treatment of their jugulars and azygous? My expectation is that the increased blood flow from clearing what obstructions can be cleared would indeed help. CCSVI is cumulative; a normal person can have one obstruction, a pwMS will have two or more; so even if not all can be cleared, it's quite possible that some of the cumulative impact would be lowered by getting it down to just one obstruction. But I am not a doctor, I wish I were, some of this gets so technical without a background in it. I know when Dr. Sclafani has come across patients with venous sinus abnormalities, he still treats the jugular and azygous issues in the same patients, while leaving the venous sinuses alone. Blaze, if you are waiting for treatment to be available in Canada, what a wait that will be.
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Postby Blaze » Sun Jan 02, 2011 11:47 am

One thing confusing about this for me is that I understand the right side of the brain controls the left side of the body and the left side the right side of the body.

Yet, the problems in my sinuses are on the right side. My right jugular vein is more significantly blocked than the left. There are other issues identified on the right side of my brain.

Yet, my greatest weakness has always been on the right side of my body. Does that make sense if the left side if the brain controls the right side of my body?
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