What does the forum know about Intracranial ?

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

What does the forum know about Intracranial ?

Postby silverbirch » Thu Feb 03, 2011 5:48 pm

Dear Forum

CeCe explained
Extracranial stenoses are the ones in our jugulars. An intracranial stenosis, which some people here have, would be within the brain or skull; this would include the dural sinuses. Extracranial CCSVI is being treated; intracranial is not unless possibly it is at PI - if anyone has been treated in the dural sinuses at PI, I would love to hear about it, this is not being done to my knowledge


What does the forum know about Intracranial , your thoughts , views , kneoledge hey may be a bit of brain storming on Intracranial !!!
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Postby HappyPoet » Sun Feb 06, 2011 8:55 am

Hi Silverbirch,

I just read that Dr. Arata confirms he is in the IJV, and not some other vessel, such as a collateral vein, by always going into the sinus, so he is not treating the sinuses but rather just using them to confirm he is, indeed, in an IJV.

If my doctor was unsure of what type of blood vessel he or she has entered, then I would rather have no treatment than have an IR or VS enter my brain. Hopefully, Dr. Arata is fully explaining, in layman's terms, exactly what he plans to do and why before the procedure so patients know exactly what will be happening or will not be happening.

Hope this helps!

~Pam
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Postby Cece » Sun Feb 06, 2011 9:10 am

But this fits in with what Dr. Sclafani was discussing, in the doctor's thread, where there was uncertainty over which vein was the left IJV. In a normal person, it may be obvious, but in a pwCCSVI, what a tangle in there. I think Dr. Arata's following the IJV all the way to the sinus to be sure it is the IJV strikes me as a useful technique. That also answers the question of if he is treating the sinuses, which is good to know too, at least there is consensus that this is beyond the reach of our IRs (and possibly in the laps of a neuroIR - if one gets interested in CCSVI, we can share that name here secretly, it'll be like summertime all over again).

A patient here who was just treated by Dr. Sclafani after being treated this summer by another doctor had some uncertainty over whether the jugular was originally treated or if it had been a collateral that had been ballooned, since the second doctor treating had been unable to access the jugular. Ballooning of collaterals instead of the real jugular might be more likely than we know. When an IR can't find the jugular, one technique is to go into a vein alongside where it should be and image there, hoping to catch a glimpse of the correct vein on the side.

HappyPoet, would you say that if an IR enters the sinus, they have entered the brain? I think technically it is still below the brain. The IRs most definitely do not want to enter the veins of the brain.
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Re: What does the forum know about Intracranial ?

Postby concerned » Sun Feb 06, 2011 9:15 am

silverbirch wrote:Dear Forum

CeCe explained
Extracranial stenoses are the ones in our jugulars. An intracranial stenosis, which some people here have, would be within the brain or skull; this would include the dural sinuses. Extracranial CCSVI is being treated; intracranial is not unless possibly it is at PI - if anyone has been treated in the dural sinuses at PI, I would love to hear about it, this is not being done to my knowledge


What does the forum know about Intracranial , your thoughts , views , kneoledge hey may be a bit of brain storming on Intracranial !!!


I linked an article that I thought was relevant but for some reason it's been deleted.
concerned
 

Postby HappyPoet » Sun Feb 06, 2011 10:13 am

Cece wrote:HappyPoet, would you say that if an IR enters the sinus, they have entered the brain? I think technically it is still below the brain. The IRs most definitely do not want to enter the veins of the brain.

Cece, as I understand it, the sinuses, which are carved into the skull, are covered with dura matter which is a protective covering over the brain; hence, the term "dural sinuses." Since the brain is separated from the sinuses by dura matter, some people might consider the sinuses separate from the brain.

The answer to your question depends on one's perspective, I think. IIRC, Dr. Sclafani once said (I can't find the post) that he is not comfortable working near the sinuses and would defer to his neuro colleagues, so maybe my reticence is due to his reticence.

Perhaps someone can ask Dr. Arata for clarification.
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Re: What does the forum know about Intracranial ?

Postby Cece » Tue Feb 21, 2012 9:48 am

*this is an old thread bumped up to add new info on intracranial sinuses*

http://www.isnvd.org/files/ISNVD%20Abstract%20Book.pdf
from the 2012 ISNVD consensus document:
9. Should we assess stenoses of intracranial sinuses

Catheterization, mechanical and chemical thrombolysis, angioplasty and stenting of intracranial
venous sinuses are performed by neurointerventionalists for venous thrombosis, pseudotumor cerebri
associated with venous stenosis and a few other uncommon disorders. However, the magnitude of
possible complications is significantly higher than the same interventions in extracranial veins. The
most dreaded complication is perforation of the jugular bulb or sinus or wire perforation of a cortical
or cerebellar vein with devastating and usually fatal intracerebral hemorrhage. In addition, the
anatomical features of extracranial veins, such as plasticity, compliance and deformability are simply
not there for these venous channels encased partly in bone and partly in rigid leafs of dura permeated
by delicate and unpredictable draining veins. Therefore, the questions regarding management of
intracranial sinuses are:

- Should we perform venography of these veins routinely, or only in very selected cases, since
most of the doctors will not manage a lesion in this location even if detected, while the risk of
diagnostic venography in this particular area cannot be neglected.
- Should we perform therapeutic procedures in this territory, or rather should we wait until an
evidence of clinical benefit from the treatments for CCSVI performed in other venous
territories will be more obvious.
- Pre-procedural evaluation of intracranial vein routinely consists of MR venography. It is wellknown
that there is a lot of artifacts associated with this imaging test, for example very often
left transverse sinus does not show at MRV, while actually it is perfectly patent; what is the
best way to evaluate these veins before and after endovascular treatment?
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Re: What does the forum know about Intracranial ?

Postby Donnchadh » Fri Feb 24, 2012 10:15 am

I find it interesting that Dr. Arata does go up to the sinus veins. The neuro-surgeon, Dr. Farhat, who did my C5-C6 disk procedure, has no problems going there also. When I started this journey, I didn't know that I had serious problems at the sigmoid sinus and that most Interventional radiologists are reluctant to venture there.

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Re: What does the forum know about Intracranial ?

Postby HappyPoet » Fri Feb 24, 2012 11:24 am

Interesting... my L-TS was reported as absent on MRV. A huge R-IJV collateral was present which I attributed to the absent L-TS forcing more blood to the right side of my brain. If my L-TS is actually patent, though, I wonder what could be the cause of the huge R-IJV collateral (had no L-IJV collaterals).

Cece, do you think the answer could possibly be due to my misaligned C1 (Atlas vertebra) having indented the L-IJV??? Both IJVs had >95% valvular blockage. Saw DrS for my procedure immediately after an Atlas adjustment by my AO chiro--now I wonder if that adjustment could help explain why there was no "indent" found on venography of my L-IJV, assuming a misalignment forward 14 degrees would be enough to show such stenosis on venography (I don't know).

Thanks so much, Cece, for all your postings! Much appreciated! :-D
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Re: What does the forum know about Intracranial ?

Postby Cece » Fri Feb 24, 2012 3:25 pm

HappyPoet, I don't know. I tend to trust Dr. Sclafani's judgment on what he saw when he saw you. I don't know either if the recent alignment might've been enough so that no indent or narrowing was seen. If there was an indent there, it would not be something an IR should treat. That way lies occluded upper jugular stents....

The right side is typically the side that takes more flow, so maybe that it why had a large collateral? The left surely had collaterals, just smaller ones? What makes you think that the absent transverse sinus was a misdiagnosis and you really have one? It's very good if this is true!

I didn't get everything posted, believe it or not. I skipped over many of the abstracts, including any of the sideways ones, and covered a lot of the perfusion day but not as much of the iron day. I'm also planning to do a post of what was not covered at ISNVD....
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Re: What does the forum know about Intracranial ?

Postby HappyPoet » Fri Feb 24, 2012 5:08 pm

Cece wrote:The right side is typically the side that takes more flow, so maybe that it why had a large collateral? Thanks, I didn't know this info! The left surely had collaterals, just smaller ones? Maybe? But no left-sided collaterals were noted. What makes you think that the absent transverse sinus was a misdiagnosis and you really have one? Sorry for the confusion. I just wondered if my absent L-TS finding is because of what you posted; the words "very often" caught my attention:
- Pre-procedural evaluation of intracranial vein routinely consists of MR venography. It is wellknown
that there is a lot of artifacts associated with this imaging test, for example very often
left transverse sinus does not show at MRV, while actually it is perfectly patent

I didn't get everything posted, believe it or not. I skipped over many of the abstracts, including any of the sideways ones, and covered a lot of the perfusion day but not as much of the iron day. I'm also planning to do a post of what was not covered at ISNVD.... Well blow me down, as Popeye would say. There are actually topics on CCSVI that were not covered at ISNVD??? Looking forward to finding out what wasn't covered and why not. Thanks again! :)
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Re: What does the forum know about Intracranial ?

Postby Cece » Fri Feb 24, 2012 5:25 pm

I didn't read very carefully, because I didn't catch that about the left sinus very often not showing on MRV even though it's there.
I should be more specific though that, rather than the right jugular takes more flow, it's that the right jugular tends to be bigger than the left jugular (and hence, could accomodate more flow). I don't understand why the right jugular tends to be bigger but it has something to do with which side the heart is on. And there is great variability and there can be assymetry either way. But one of the talks at ISNVD was on right vs left jugulars. I think left jugulars are more likely to have ccsvi, and more likely to have complications.
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Re:

Postby drsclafani » Fri Feb 24, 2012 11:50 pm

HappyPoet wrote:Hi Silverbirch,

I just read that Dr. Arata confirms he is in the IJV, and not some other vessel, such as a collateral vein, by always going into the sinus, so he is not treating the sinuses but rather just using them to confirm he is, indeed, in an IJV.

If my doctor was unsure of what type of blood vessel he or she has entered, then I would rather have no treatment than have an IR or VS enter my brain. Hopefully, Dr. Arata is fully explaining, in layman's terms, exactly what he plans to do and why before the procedure so patients know exactly what will be happening or will not be happening.

Hope this helps!

~Pam



Pam, i cannot speak for dr arata but for myself. I advance the catheter into the dural sinuses for several reasons

1. dural sinuses are rarely stenosed
2. I think that evaluation of the posterior circulation through the emissary veins is important and helpful in understanding the flow dynamics
3. there is often a large vein coming from the jugular vein that drains the phyarynx, aptly called the pharyngeal vein. It runs parallel to the internal jugular vein and can be mistaken for the jugular vein
4. failure to see the entry of the blood from the brain veins into the neck veins can cause one to mis diagnose or fail to see stenoses of the upper jugular vein
5. there are docs who do not even image the entire jugular vein

dont think harshly of those who do it.
Salvatore JA Sclafani MD
Patient contact: ccsviliberation@gmail.com
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Re: Re:

Postby HappyPoet » Sat Feb 25, 2012 7:23 am

drsclafani wrote:
HappyPoet wrote:Hi Silverbirch,

I just read that Dr. Arata confirms he is in the IJV, and not some other vessel, such as a collateral vein, by always going into the sinus, so he is not treating the sinuses but rather just using them to confirm he is, indeed, in an IJV.

If my doctor was unsure of what type of blood vessel he or she has entered, then I would rather have no treatment than have an IR or VS enter my brain. Hopefully, Dr. Arata is fully explaining, in layman's terms, exactly what he plans to do and why before the procedure so patients know exactly what will be happening or will not be happening.

Hope this helps!

~Pam

Pam, i cannot speak for dr arata but for myself. I advance the catheter into the dural sinuses for several reasons

1. dural sinuses are rarely stenosed
2. I think that evaluation of the posterior circulation through the emissary veins is important and helpful in understanding the flow dynamics
3. there is often a large vein coming from the jugular vein that drains the phyarynx, aptly called the pharyngeal vein. It runs parallel to the internal jugular vein and can be mistaken for the jugular vein
4. failure to see the entry of the blood from the brain veins into the neck veins can cause one to mis diagnose or fail to see stenoses of the upper jugular vein
5. there are docs who do not even image the entire jugular vein

dont think harshly of those who do it.

Hi Dr. Sclafani and welcome back!

Thank you for this post. Cece resurrected this old thread to update it with ISVND info. My post you quoted from is over a year old, and during the past year, you posted much and taught us lots in your thread about the dural sinuses. Thank you for posting your thoughts here because new readers might not be aware of all your previous posts.

Although I may have missed some of the finer points, after your last case about the dural sinuses, I became a true believer that there are times when the IR knows best regarding them. Plus (I love to plug this!), you saved my life when you saved my femoral vein and have given me 12 months of symptom improvements with no sight nor sign of restenosis, so Dr. Sclafani, if I do need you again, you and your IVUS are allowed to go anywhere in my body you want to go! :)
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