This Is MS Multiple Sclerosis Community: Knowledge & Support

[Cece]

www.plosone.org/article/info:doi/10.137 ... ne.0025012

Quantitative Colour Doppler Sonography Evaluation of Cerebral Venous Outflow: A Comparative Study between Patients with Multiple Sclerosis and Controls

Lucia Monti1*, Elisabetta Menci1, Monica Ulivelli2, Alfonso Cerase1, Sabina Bartalini2, Pietro Piu2, Nicola Marotti1, Sara Leonini1, Paolo Galluzzi1, Daniele G. Romano1, Alfredo E. Casasco3, Carlo Venturi1

1 Unit of Neuroimaging and Neurointervention, Department of Neurological and Sensorial Sciences, Azienda Ospedaliera Universitaria Senese, Santa Maria alle Scotte General Hospital, Siena, Italy, 2 Department of Neurosciences, University of Siena, Siena, Italy, 3 Unit of Endovascular and Percutaneous Therapy, Clinica Nuestra Señora del Rosario, Madrid, Spain

Background

Internal Jugular Veins (IJVs) are the principle outflow pathway for intracranial blood in clinostatism condition. In the seated position, IJVs collapse, while Vertebral Veins (VVs) increase the venous outflow and partially compensate the venous drainage. Spinal Epidural Veins are an additional drainage pathway in the seated position. Colour- Doppler-Sonography (CDS) examination is able to demonstrate IJVs and VVs outflow in different postural and respiratory conditions. The purpose of this study was to evaluate CDS quantification of the cerebral venous outflow (CVF) in healthy subjects and patients with multiple sclerosis (MS).

Methodology/Principal Findings

In a group of 27 healthy adults (13 females and 14 males; mean age 37.8±11.2 years), and 52 patients with MS (32 females and 20 males; mean age 42.6±12.1 years), CVF has been measured in clinostatism and in the seated position as the sum of the flow in IJVs and VVs. The difference between CVF in clinostatism and CVF in the seated position (ΔCVF) has been correlated with patients' status (healthy or MS), and a number of clinical variables in MS patients. Statistical analysis was performed by Fisher's exact test, non-parametric Mann-Whitney U test, ANOVA Kruskal-Wallis test, and correntropy coefficient.

The value of ΔCVF was negative in 59.6% of patients with MS and positive in 96.3% of healthy subjects. Negative ΔCVF values were significantly associated with MS (p<0.0001). There was no significant correlation with clinical variables.

Conclusions/Significance

Negative ΔCVF has a hemodynamic significance, since it reflects an increased venous return in the seated position. This seems to be a pathologic condition. In MS patients, a vascular dysregulation resulting from involvement of the autonomous nervous system may be supposed. ΔCVF value should be included in the quantitative CDS evaluation of the cerebral venous drainage, in order to identify cerebral venous return abnormalities.

The entire article is available. It is from a research team in Spain, not affiliated with Dr. Zamboni or using his protocols, but they found CCSVI in the MS patients.

[MarkW]

Sounds like a method to show CCSVI procedure has worked. Measure pwMS in reduced gravity machine (clinostatism), if ΔCVF is negative then do CCSVI procedure. Then re-measure ΔCVF should be positive. Measure results over time.
Nice find Cece, maybe one our Spanish friends will follow up.
MarkW

[David1949]

Measure pwMS in reduced gravity machine (clinostatism)

I didn't find a definition of clinostatism in online sources. May I ask where you found that definition? Also how does one achieve reduced gravity ?

[MarkW]

Hello David,
I used a well known source of mis-information (Wikipedia) in combination with a Spanish-English dictionary to make a guess. I trust the paper gives details of the machine used, when someone checks. I understand a clinostat for plants but never seen one for people. Lying down reduces the effect of gravity on human circulation so probably not too complex a device.
MarkW

[1eye]

If you take clinostatism, as I did, to mean lying down, this is a verification by several statistical methods, of Dr. Zamboni's results, using colour Doppler.

[fernando]

As far as I can tell clinostatism is a fancy way to say "lying down", at least in spanish and italian (clinostatismo in both languages).

In Italian they say "posizione del corpo orizzontale ma leggermente inclinata verso un'estremità", which (I do not trust myself translating between two non native languages, but anyway) could mean "body in horizontal position but slightly tilted towards some extremity".

http://it.wiktionary.org/wiki/clinostatismo

[Cece]

In a group of 27 healthy adults (13 females and 14 males; mean age 37.8±11.2 years), and 52 patients with MS (32 females and 20 males; mean age 42.6±12.1 years), CVF has been measured in clinostatism and in the seated position as the sum of the flow in IJVs and VVs. The difference between CVF in clinostatism and CVF in the seated position (ΔCVF) has been correlated with patients' status (healthy or MS), and a number of clinical variables in MS patients. Statistical analysis was performed by Fisher's exact test, non-parametric Mann-Whitney U test, ANOVA Kruskal-Wallis test, and correntropy coefficient.

The value of ΔCVF was negative in 59.6% of patients with MS and positive in 96.3% of healthy subjects. Negative ΔCVF values were significantly associated with MS (p<0.0001). There was no significant correlation with clinical variables.

This is a nice sample size at 52 pwMS and 27 controls. We've seen smaller groups than this. They also measured combined flow in the jugulars and the verts. I don't know if any other study has included the verts.

I can't take credit for finding this study, I lifted it off of CCSVI in MS facebook page earlier today.

I agree with the agreed-upon meaning of clinostatism.

[fernando]

Profile of Alfredo Casasco
http://www.cxvascular.com/nn-profiles/neuro-news---profiles/alfredo-casasco

What are the honours that you have received that you look back on with pride?

I cherish the memories of my nomination as associated professor at the University of Paris, and the prize of the National Academy of Medicine of France for my work about “Endovascular treatment of intracranial aneurysms.”

What are your current research interests?

I am presently dedicated to the endovascular treatment of spinal vascular malformations, and to the combined treatment (surgery-laser-embolization) of superficial vascular malformations. I am also collaborating on the development of stent diversifiers of intracerebral flow.

What do you hope to achieve in your term as president of ESMINT?

I would like to bring together a group that is as large as possible comprising interventional neuroradiologists, neurosurgeons and neurologists from all nationalities. I would like to create an open space for real debate, without social, political or idiomatic obstacles. So we are working and hoping to achieve a high level of scientific discussion in a relaxed and friendly environment which allows young people to express themselves without any complexes, and for older people to speak with wisdom and humility.

What are three key questions in interventional neuroradiology which you would like to see answered?

Which future substance and technique will be able to achieve a 100% embolization in arteriovenous malformations? Is it possible to develop anti-angiogenic factors to reduce or heal vascular malformations? How long would it take for stroke units to be able to treat ischaemic stroke within the first four hours routinely?

What are the new techniques/technologies that you are watching closely?

The use of stent diversifiers of flow in the treatment of intracranial giant aneurysms, techniques for the treatment of acute ischaemia intra-arterially and embolization techniques of spinal vascular malformations.

He sounds very open minded.

[samovar]

...In the seated position, IJVs collapse, while Vertebral Veins (VVs) increase the venous outflow and partially compensate the venous drainage. Spinal Epidural Veins are an additional drainage pathway in the seated position... excerpt from Cece's message.
That is the reason why the doctor (Dr. Albayram from Istanbul Cerrahpasa University hospital) who performed two liberation procedures on me), told me to sleep in a sitting position. I didn't take it seriously until last spring when I had two consecutive nights of not being able to walk at all on waking up at night. (then and current EDSS score : 6)
For six months now I've been sleeping in a semi - upright position. Sorry if this has been brought about, but I do recommend sleeping in a sitting position especially to those who have walking difficulties getting worse like me. I should have told that earlier, Cece's message reminded me of it.

[1eye]

Thanks. I'll try it. The ultrasound guy in Montreal must have had something when he said "Don't lie down." But I am concerned (no not that again!) that I will wear out my non-jugular drainage routes that way. Doesn't this end up being unique to the individual, based on Dr. Haacke's wide variations in pathology/deformity? I still think what I may really want is like my brother's shunt, but for blood: a plastic pipe that is open all the time, and has a check valve. I expect he has done OK without that bit of endothelium. Maybe with some kind of modern plastic it can be made somewhat oxygen-permeable.

What about that idea of ballooning so as to plaster the outer layer of the vein to the inside wall of a tube covered with adhesive on the inside. The surgery might be messy but you wouldn't have to hurt the endothelium so much. Dentists use some mighty adhesives, but it would have to last a couple of decades, at least. Any volunteers?

[samovar]

hope it works for you too, 1eye. i think the doctor who gave this advice to me, gives the same advice (to sleep in seated position with the upper body making an angle of at least 45 degrees with the bed) to all his patients after ccsvi angioplasty. he also showed me how heavily branched my collateral (vertebral) veins have become to compansate for the poor flow in the jugulars. he says that is the case for most of the ms patients. he is a neuro-radiologist, so i think he has seen enough evidence.
so, your non-jugular drainage routes may already be overloaded:( still, it might be a good idea to discuss this with a doctor who knows about ccsvi and its possible (to me it is certain) relation to ms.
i think more doctors, researchers must lurk in these forums to get some ideas.

[CureIous]

" In MS patients, a vascular dysregulation resulting from involvement of the autonomous nervous system may be supposed. ΔCVF value should be included in the quantitative CDS evaluation of the cerebral venous drainage, in order to identify cerebral venous return abnormalities."

Sounds to me like the neurologic dept which conducted this study is concluding that ccsvi falls under their purview, that it is a "dysregulation of nerve signals" caused of course by MS. Betcha your local neuro will have THIS study handy next time you mention having an IR fixing your veins lol

[frodo]

Sounds like a method to show CCSVI procedure has worked. Measure pwMS in reduced gravity machine (clinostatism), if ΔCVF is negative then do CCSVI procedure.

Sorry for being picky but CCSVI is not a procedure. It is a condition that includes five meassurements, ΔCVF among them. To avoid mistakes the proper name for the procedure should be "angioplasty".

[MarkW]

Hello Frodo,
CCSVI is a syndrome (see Zamboni & Galeotti paper - chronic-cerebrospinal-venous-insufficiency-ccsvi-f40/topic17538-15.html). I called the balloon venoplasty procedure to treat the symptoms of CCSVI syndrome, the 'CCSVI procedure'. CCSVI syndrome is described in the paper and the treatment is referred to as PTA. I diagree with calling the procedure simply 'angioplasty' as this is a very broad term which usually refers to treatment of arteries. If we must be precise, then the 'procedure to diagnose and treat CCSVI syndrome' is better than 'CCSVI procedure' but the longer term is quite a mouthful.
MarkW

PS CCSVI is a syndrome not a condition. An important difference in the argument with neuros.

[MarkW]

CureIous wrote:
Sounds to me like the neurologic dept which conducted this study is concluding that ccsvi falls under their purview, that it is a "dysregulation of nerve signals" caused of course by MS. Betcha your local neuro will have THIS study handy next time you mention having an IR fixing your veins lol.

If faced with this situation CureIous. I would tell any neuro that I prefer an IR to fix my veins rather than a neuro.............
The paper supports the treatment of CCSVI syndrome by an expert. Even the most arrogant neuro would not argue they are experts in fixing CCSVI syndrome, would they ??

MarkW