DrSclafani dialogues w other doctors re:CCSVI interventions

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

Postby uprightdoc » Fri Jan 14, 2011 5:05 am

phlebologist wrote:
uprightdoc wrote:
drsclafani wrote:
uprightdoc wrote:can we stay on this case please


Basing on these pictures you can say nothing about intracranial sinuses -
.
Moreover, poor visibility of internal jugular vein at the level of skull base most likely does not represent compression by osseous or fibrotic pathology. Rather, it is a result of collapse of the vein secondary to negative transmural pressure. Transmural pressure is the difference between pressure inside the vessel (due to the blood flow forces) and pressure outside (executed by the tissue surrounding blood vessel). Value of transmural pressure is of great importance in a case of the vein, since most of the veins can collapse (thin wall; the exception are veins like inflamed varicose veins, but this is the other story). Since outside pressure remain constant, the vein can collapse when the pressure inside goes down below the value of external pressure. This can be due to gravitational effects (jugular vein in an upright person, saphenous vein with leg elevated, or cubital veins with hand elevated), but also in a case of low flow through the vein (simplified, since in a case of CCSVI perhaps more complex fluid mechanics principles play a role)


I didn't bring up the sigmoid sinus. Dr. Cummings pointed it out.

Likewise, the superior sagittal sinus drops 5-10 mmHg in the upright position. Despite negative intraluminal pressure it stays open due to the strength of the dura mater. (Aging may cause it to collapse slightly due to weakening of the dura). This increase in the venous pressure gradient is critical to brain blood and CSF flow in upright posture. It is also important to the passive production of CSF, brain flotation and support. Humans use emissary veins as well as the hypoglossal and condylar canals to connect the dural sinues of the brain to the VVP for drainage during upright posture.

RA is associated with spondylosis, stenosis, scoliosis and cervical syndromes, especially upper cervical syndromes, which can affect the neural canal and VVP. RA can thus affect the drainage system of the brain as well as CSF flow. In this regard, RA has been associated with NPH.
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Postby drsclafani » Fri Jan 14, 2011 2:04 pm

uprightdoc wrote:
drsclafani wrote:can we stay on this case please


Regarding this case, we were discussing a possible lack of filling of the left sigmoid sinus and occlusion at the skull base. One possible cause is malformation of the sigmoid sinuses and jugular foramen. Malformations of the base of the skull are common in humans. Another possible reason is mechanical compression due to scoliosis resulting in a head tilt, which has not been ruled out. Additionally, this case has a co-morbidity of RA. RA can cause subluxations of the spine and cervical stenosis. It can also lead to an early death when it affects the upper cervical spine. In this particular case misalignment of the spine may be the cause of poor drainage and ischemia.


oh, now i see. I dont usually visualize the dural sinuses on internal jugular venography unless there is major obstruction or i have put the catheter up too high. It would be interesting to know how other physicians position the catheter and inject the contrast media.

Good point about the RA, but this patient didnt have very severe RA, that i noticed
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Postby drsclafani » Fri Jan 14, 2011 2:08 pm

phlebologist wrote:
drsclafani wrote:.

Image

i do not know what to name it.



I wonder if the vein actually has its anatomical name, I don't think it is the facial vein, it might be one of deep cervical veins, but also it might be an originally very small vessel transformed within years of pathologic outflow conditions into a larger conduit (look at its tortuosity), for sure it is a compensatory outflow route from the IJV and maybe also (is it joining intracranial veins?) from the brain - otherwise it will not fill with contrast.
In Italy or France it will be called a vicarious shunt (I'm not sure if American doctors are familiar with this term)


that large conduit with the red arrow goes from the innominate vein directly up to the skull base and opacifies the sigmoid sinus. The original straight one has branches in the face but i dont think its the IJV.

it presented quite a challenge in finding what if anything to dilate.
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Postby DrCumming » Fri Jan 14, 2011 2:32 pm

Sal,

For IJs, I place the catheter at the ostium, and image both during normal respiration and a medium breath hold. I then cross into the IJ and do breath hold imaging at the proximal, mid and distal IJ. I always image the distal IJ and sigmoid sinus.

Here is the case I talked about above. Patient done south of the border. Distal IJ was not imaged. Proximal IJ was treated. Here is the pre balloon imaging....

http://picasaweb.google.com/lh/photo/Jr ... directlink

Here we see near complete occlusion of the distal IJ on our angio.


http://picasaweb.google.com/lh/photo/j4 ... directlink


Treated with conventional and then cutting balloon. Nice angio result.



http://picasaweb.google.com/lh/photo/MC ... directlink

No wonder there was no improvement after their first treatment.


Sorry for the links, I cannot figure out how to embed the images. Must be above my pay grade :)
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Postby drsclafani » Fri Jan 14, 2011 10:53 pm

DrCumming wrote:Sal,

For IJs, I place the catheter at the ostium, and image both during normal respiration and a medium breath hold. I then cross into the IJ and do breath hold imaging at the proximal, mid and distal IJ. I always image the distal IJ and sigmoid sinus.

Here is the case I talked about above. Patient done south of the border. Distal IJ was not imaged. Proximal IJ was treated. Here is the pre balloon imaging....

http://picasaweb.google.com/lh/photo/Jr ... directlink

Here we see near complete occlusion of the distal IJ on our angio.


http://picasaweb.google.com/lh/photo/j4 ... directlink


Treated with conventional and then cutting balloon. Nice angio result.



http://picasaweb.google.com/lh/photo/MC ... directlink

No wonder there was no improvement after their first treatment.


Sorry for the links, I cannot figure out how to embed the images. Must be above my pay grade :)


type in [img]then%20the%20url[/img]

ask any of the patients :wink:
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Postby drsclafani » Fri Jan 14, 2011 10:59 pm

DrCumming wrote:Sal,

For IJs, I place the catheter at the ostium, and image both during normal respiration and a medium breath hold. I then cross into the IJ and do breath hold imaging at the proximal, mid and distal IJ. I always image the distal IJ and sigmoid sinus.

Here is the case I talked about above. Patient done south of the border. Distal IJ was not imaged. Proximal IJ was treated. Here is the pre balloon imaging....

http://picasaweb.google.com/lh/photo/Jr ... directlink

Here we see near complete occlusion of the distal IJ on our angio.


http://picasaweb.google.com/lh/photo/j4 ... directlink


Treated with conventional and then cutting balloon. Nice angio result.



http://picasaweb.google.com/lh/photo/MC ... directlink

No wonder there was no improvement after their first treatment.


Sorry for the links, I cannot figure out how to embed the images. Must be above my pay grade :)


i thhink it is important to image during expiration. this wil distend the jugular veins and reduce risk of false positive angiogram becasue expiration increases the thoracic pump and draws sblood into the IJV .
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Re: CASE STUDY #1

Postby uprightdoc » Sat Jan 15, 2011 7:21 am

drsclafani wrote:The patient is a 33 year old female with short term memory deficiencies, cognitive dysfunction, fatigue, headaches, and imbalance. She has numbness in both hands and the soles of both feet and temperature intolerance. Weakness is predominantly in the lower extremities. She has moderate spasticity, which is worse in the morning. She has co-morbidities of rheumatoid arthritis and multiple sclerosis.


What are the patient's rheumatological complaints. Does she have any x-rays of the spine? Did anyone examine her spine? If so what did they find?
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Re: CASE STUDY #1

Postby drsclafani » Sat Jan 15, 2011 3:27 pm

uprightdoc wrote:
drsclafani wrote:The patient is a 33 year old female with short term memory deficiencies, cognitive dysfunction, fatigue, headaches, and imbalance. She has numbness in both hands and the soles of both feet and temperature intolerance. Weakness is predominantly in the lower extremities. She has moderate spasticity, which is worse in the morning. She has co-morbidities of rheumatoid arthritis and multiple sclerosis.


What are the patient's rheumatological complaints. Does she have any x-rays of the spine? Did anyone examine her spine? If so what did they find?


i did not elicit any specific complaints related to the RA.
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Postby uprightdoc » Sun Jan 16, 2011 8:13 am

Blood is shunted and rerouted through emissary veins, the occipital marginal sinus, the pterygoid sinus connections and the jugular routes according to head and neck movements as well as respiration. It is similarly shunted in chronic head tilts. Plumbers use 1/4 in/ft. The drainage system is about 3 in across. A head tilt of about 1/16" will cause fluid shifts to different drainage routes.

In addition to trauma, which can cause misalignments, I believe there is an association between scoliosis and kyphosis in MS. Some of these cases can be corrected with much less invasive specific upper cervial correction and obviate the need for further intervention. Other cases are associated with permanent scoliosis, hypoplasia or atresia of drainage outlets that can permanently impair drainage. Eliminating musculoskeletal problems as best as possible may help determine the best location and method for more invasive vascular intervention. It may be that ballooning the side with minimal flow, possibly due to hypoplasia or other isssues, will result in minimal results. It may be better to improve the drainage capacity of the side with better flow.

Angioplasty and stents work similar to the superior sagittal sinus. They improve cerebral perfusion pressure and blood and CSF flow because they stay open despite extraluminal pressure. More severe musculoskeletal problems, such as scoliosis and kyphosis that increase extraluminal pressure may need more durable intervention such as stents.
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Postby RN » Mon Jan 17, 2011 10:17 am

If the complex questions surrounding CCSVI are to be answered, we must all embrace every thoughtful contribution to the discussion. Dr. Flanagan's thesis is worthy of respect and further investigation. I have read his book and find it intriguing, brilliant in its application to MS, Parkinson's and Alzheimer's and potentially applicable to many of us with symptoms of brain fog in particular. I am, in fact, excited about the remarkable changes upper cervical treatment has brought about for me. After several months of treatment I am experiencing the improvement I had hoped to get with angioplasty, but did not despite opening significant occlusion in both IJV's.

We have applauded Dr. Zamboni and others for "thinking outside the box." Yet, as I follow the mixed results of venous angioplasty in actual patient experience, it is clear there is more to the picture than previously hoped. We must not allow ourselves to get boxed in again by any one solution in front of us at the moment. I applaud Dr. Flanagan for offering us the opportunity to expand our vision and exploration into the total picture of fluid dynamics of the brain. The drainage system for cerebrospinal fluid may be a critical component of the CCSVI picture for some of us. I am learning that it is for me.

Let us keep the door open for all disciplines to make a contribution. Well informed neurologists, IR's, physicists, chiropractors, PCP's, RN's and the Joan Beal's of the world can all help solve medical mysteries if they thoughtfully consider each other’s work. No individual or medical discipline will do it alone. Despite some comments on TIMS to the contrary, every statement made by Dr. Flanagan in his discussions of CCSVI is relevant in the context of head and neck structure and CFS drainage. I am grateful that he has entered the picture to help all of us continue to "think outside the box."
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Postby uprightdoc » Mon Jan 17, 2011 12:41 pm

Interestingly, a patient just contacted me regarding assymetry of the superior sagittal sinus connections to the transverse sinuses. The right side is more direct and larger. It also has 5x the flow. Repeat procedures performed in Poland to open the LIJV have failed to significantly improve flow in his case. In cases such as this one, it might be better to increase the siphoning action and flow through the right IJV than to try to improve flow through the weaker left side.
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Postby drsclafani » Mon Jan 17, 2011 9:33 pm

uprightdoc wrote:Blood is shunted and rerouted through emissary veins, the occipital marginal sinus, the pterygoid sinus connections and the jugular routes according to head and neck movements as well as respiration. It is similarly shunted in chronic head tilts. Plumbers use 1/4 in/ft. The drainage system is about 3 in across. A head tilt of about 1/16" will cause fluid shifts to different drainage routes.

In addition to trauma, which can cause misalignments, I believe there is an association between scoliosis and kyphosis in MS. Some of these cases can be corrected with much less invasive specific upper cervial correction and obviate the need for further intervention. Other cases are associated with permanent scoliosis, hypoplasia or atresia of drainage outlets that can permanently impair drainage. Eliminating musculoskeletal problems as best as possible may help determine the best location and method for more invasive vascular intervention. It may be that ballooning the side with minimal flow, possibly due to hypoplasia or other isssues, will result in minimal results. It may be better to improve the drainage capacity of the side with better flow.

Angioplasty and stents work similar to the superior sagittal sinus. They improve cerebral perfusion pressure and blood and CSF flow because they stay open despite extraluminal pressure. More severe musculoskeletal problems, such as scoliosis and kyphosis that increase extraluminal pressure may need more durable intervention such as stents.


dr flanagan, we should stay within our expertise. i try, if i dont slap me hard

stents are not more durable in veins. stents in these veins should be avoided. the track record is not great by most operators. thrombosis is not uncommon, placing stents high near the skull base is associated with cranial nerve injuries as well.
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Postby drsclafani » Mon Jan 17, 2011 9:37 pm

RN wrote:If the complex questions surrounding CCSVI are to be answered, we must all embrace every thoughtful contribution to the discussion. Dr. Flanagan's thesis is worthy of respect and further investigation. I have read his book and find it intriguing, brilliant in its application to MS, Parkinson's and Alzheimer's and potentially applicable to many of us with symptoms of brain fog in particular. I am, in fact, excited about the remarkable changes upper cervical treatment has brought about for me. After several months of treatment I am experiencing the improvement I had hoped to get with angioplasty, but did not despite opening significant occlusion in both IJV's.

We have applauded Dr. Zamboni and others for "thinking outside the box." Yet, as I follow the mixed results of venous angioplasty in actual patient experience, it is clear there is more to the picture than previously hoped. We must not allow ourselves to get boxed in again by any one solution in front of us at the moment. I applaud Dr. Flanagan for offering us the opportunity to expand our vision and exploration into the total picture of fluid dynamics of the brain. The drainage system for cerebrospinal fluid may be a critical component of the CCSVI picture for some of us. I am learning that it is for me.

Let us keep the door open for all disciplines to make a contribution. Well informed neurologists, IR's, physicists, chiropractors, PCP's, RN's and the Joan Beal's of the world can all help solve medical mysteries if they thoughtfully consider each other’s work. No individual or medical discipline will do it alone. Despite some comments on TIMS to the contrary, every statement made by Dr. Flanagan in his discussions of CCSVI is relevant in the context of head and neck structure and CFS drainage. I am grateful that he has entered the picture to help all of us continue to "think outside the box."


i brought up this case to get some feedback and opinions about a particular case, not have a broad discussion of general concepts.

might i ask if you are a doctor? This thread is supposed to be a dialogue between doctors about case studies. I created a thread for patients to discuss what is discussed on this thread. Can we keep it there. We are already having difficulty in getting doctors to participate.
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Postby drsclafani » Mon Jan 17, 2011 9:40 pm

uprightdoc wrote:Interestingly, a patient just contacted me regarding assymetry of the superior sagittal sinus connections to the transverse sinuses. The right side is more direct and larger. It also has 5x the flow. Repeat procedures performed in Poland to open the LIJV have failed to significantly improve flow in his case. In cases such as this one, it might be better to increase the siphoning action and flow through the right IJV than to try to improve flow through the weaker left side.

URD
are you speaking about the case that i posted?
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Postby drsclafani » Mon Jan 17, 2011 9:43 pm

RN wrote:If the complex questions surrounding CCSVI are to be answered, we must all embrace every thoughtful contribution to the discussion. Dr. Flanagan's thesis is worthy of respect and further investigation. I have read his book and find it intriguing, brilliant in its application to MS, Parkinson's and Alzheimer's and potentially applicable to many of us with symptoms of brain fog in particular. I am, in fact, excited about the remarkable changes upper cervical treatment has brought about for me. After several months of treatment I am experiencing the improvement I had hoped to get with angioplasty, but did not despite opening significant occlusion in both IJV's.

We have applauded Dr. Zamboni and others for "thinking outside the box." Yet, as I follow the mixed results of venous angioplasty in actual patient experience, it is clear there is more to the picture than previously hoped. We must not allow ourselves to get boxed in again by any one solution in front of us at the moment. I applaud Dr. Flanagan for offering us the opportunity to expand our vision and exploration into the total picture of fluid dynamics of the brain. The drainage system for cerebrospinal fluid may be a critical component of the CCSVI picture for some of us. I am learning that it is for me.

Let us keep the door open for all disciplines to make a contribution. Well informed neurologists, IR's, physicists, chiropractors, PCP's, RN's and the Joan Beal's of the world can all help solve medical mysteries if they thoughtfully consider each other’s work. No individual or medical discipline will do it alone. Despite some comments on TIMS to the contrary, every statement made by Dr. Flanagan in his discussions of CCSVI is relevant in the context of head and neck structure and CFS drainage. I am grateful that he has entered the picture to help all of us continue to "think outside the box."


i brought up this case to get some feedback and opinions about a particular case, not have a broad discussion of general concepts.

might i ask if you are a doctor? This thread is supposed to be a dialogue between doctors about case studies. I created a thread for patients to discuss what is discussed on this thread. Can we keep it there. We are already having difficulty in getting doctors to participate.
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