Migraine patients exhibit CCSVI-like venous outflow

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Migraine patients exhibit CCSVI-like venous outflow

Postby Cece » Fri Jan 06, 2012 10:25 am

http://www.ncbi.nlm.nih.gov/pubmed/22194216
Mult Scler. 2011 Dec 22. [Epub ahead of print]

Non-specific alterations of craniocervical venous drainage in multiple sclerosis revealed by cardiac-gated phase-contrast MRI.

Ertl-Wagner B, Koerte I, Kuempfel T, Blaschek A, Laubender RP, Schick M, Steffinger D, Kaufmann D, Heinen F, Reiser M, Alperin N, Hohlfeld R.

Source

Institute of Clinical Radiology, University of Munich - Grosshadern Campus, Ludwig-Maximilians-University Munich, Germany.

Abstract

Objective: There is an on-going controversy about venous drainage abnormalities in multiple sclerosis (MS). We applied cardiac-gated phase-contrast and venographic magnetic resonance (MR) techniques to compare venous drainage patterns in patients with MS, healthy controls, and subjects with migraine.

Methods: A total of 27 patients with MS (21 female, age 12-59 years, mean disease duration 8.4 ± 8.5 years) and 27 age- and gender-matched healthy controls (21 female, age 12-60 years) were investigated with velocity-encoded cine-phase contrast MR sequences and a 2D time-of-flight MR venography of the cervicocranial region on a 3-T MRI. The data were compared with 26 patients with chronic migraine headaches (19 female, age 17-62 years), previously investigated with the same protocol. The degree of primary and secondary venous outflow in relation to the total cerebral blood flow (tCBF) was compared both quantitatively and qualitatively. Statistical analyses were performed using linear regression models.

Results: Secondary venous outflow was significantly increased in patients with MS compared with healthy controls, both qualitatively (p < 0.001) and quantitatively (p < 0.013). The observed changes were independent of age and disease duration. Very similar alterations of venous drainage were detectable with the same approach in patients with migraine, without significant differences between MS and migraine patients (p = 0.65).

Conclusion: Our MRI-based study suggests that patients with MS have alterations of cerebral venous drainage similar to subjects with chronic migraine. These non-disease-specific changes seem to a secondary phenomenon rather than being of primary pathogenic importance.

I wonder what's going on with the migraine patients? If they have similiar drainage patterns as pwMS, do they have CCSVI as well?
Were there significant differences between the migraine patients and the healthy controls? It's not said.
There are cerebral blood flow irregularities in migraine, but I'm not familiar enough to know what they are.
I am not sure that this meaningfully shows that these alterations of venous drainage are a non-disease-specific change. It is only testing against one other disease, and one in which blood flow is known to be irregular. I am not convinced that MRI is the best imaging tool for flow. Dr. Zamboni tested against a number of neurological diseases and found CCSVI only in MS patients. Dr. Zivadinov found a higher percentage of CCSVI in other neurological diseases than in health controls, but not as high as in MS.

It is always interesting to see negative results published in neurology journals, and positive in vascular journals. Two different worlds, hearing two different things.
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Re: Migraine patients exhibit CCSVI-like venous outflow

Postby CuriousRobot » Fri Jan 06, 2012 10:27 am

Great research but not great news.
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Re: Migraine patients exhibit CCSVI-like venous outflow

Postby questor » Fri Jan 06, 2012 10:37 am

http://www.ncbi.nlm.nih.gov/pubmed/22194216 wrote:Results: Secondary venous outflow was significantly increased in patients with MS compared with healthy controls, both qualitatively (p < 0.001) and quantitatively (p < 0.013). The observed changes were independent of age and disease duration. Very similar alterations of venous drainage were detectable with the same approach in patients with migraine, without significant differences between MS and migraine patients (p = 0.65).

One wonders what secondary venous outflow is. Would this be blood flow through collateral veins instead of the primary outflow routes?

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Re: Migraine patients exhibit CCSVI-like venous outflow

Postby Cece » Fri Jan 06, 2012 12:31 pm

I wondered what that meant too. MRIs are the best noninvasive way to detect collaterals in CCSVI, so it makes sense that might be what they measured.

A year ago, the neurologist research seemed to be addressing the question of whether CCSVI existed or not. Now, the conclusions seem to be that CCSVI exists, and they're trying to decide what it means. This research showed that abnormal venous outflow exists in MS patients, at a significant difference than in healthy controls! That is good news, and supports the theory of CCSVI. The question of migraine patients would need to be sorted out. We haven't seen any doppler study research on outflow obstructions in migraine patients, nor autopsy results, nor catheter venogram research, all of which we have in CCSVI in MS. So for now it does not carry a lot of weight, and it could mean different things.
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Re: Migraine patients exhibit CCSVI-like venous outflow

Postby Lyon » Fri Jan 06, 2012 12:39 pm

Interesting but not the least surprising that you admit you don't totally understand the research yet you finish with the assertion that
Cece wrote:It is always interesting to see negative results published in neurology journals, and positive in vascular journals. Two different worlds, hearing two different things.
I don't think anyone has ever done a better job of exemplifying that objectivity was long ago lost to the hopes and dreams for ccsvi.
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Re: Migraine patients exhibit CCSVI-like venous outflow

Postby Cece » Fri Jan 06, 2012 12:49 pm

Lyon wrote:Interesting but not the least surprising that you admit you don't totally understand the research yet you finish with the assertion that
Cece wrote:It is always interesting to see negative results published in neurology journals, and positive in vascular journals. Two different worlds, hearing two different things.
I don't think anyone has ever done a better job of exemplifying that objectivity was long ago lost to the hopes and dreams for ccsvi.

It's a pattern though, isn't it? I am sure there are exceptions. Doepp comes to mind, assuming that his negative findings were published in a vascular journal. Dr. Robert Fox of Cleveland Clinic is definitely a neurologist, and his recent work on autopsy findings of CCSVI in MS patients was presented at ECTRIMS; I don't think it's published yet but would expect that to land in a neurologist journal. So those would be exceptions.
Objectivity in science means that scientific measurement can be tested independent from the individual scientist (the subject) who proposes them.

http://simple.wikipedia.org/wiki/Objectivity_(science)

This paper demonstrated such objectivity: outflow venous flow abnormality was found in MS patients, as Dr. Zamboni had proposed.
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Re: Migraine patients exhibit CCSVI-like venous outflow

Postby Lyon » Fri Jan 06, 2012 1:49 pm

Cece wrote: It's a pattern though, isn't it? I am sure there are exceptions. Doepp comes to mind, assuming that his negative findings were published in a vascular journal. Dr. Robert Fox of Cleveland Clinic is definitely a neurologist, and his recent work on autopsy findings of CCSVI in MS patients was presented at ECTRIMS; I don't think it's published yet but would expect that to land in a neurologist journal. So those would be exceptions.

Admitting a pattern would require agreeing that what you consider "negative" really signifies negativity on the part of researchers towards the theory of ccsvi and I don't agree with that. Just because researchers publish work that isn't glowing about ccsvi doesn't make it negative, it just makes it science.
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Re: Migraine patients exhibit CCSVI-like venous outflow

Postby cheerleader » Fri Jan 06, 2012 2:18 pm

I don't find this research to be anything but interesting. Migraine is associated with vascular spasm, ischemia and hypoperfusion creating white matter lesions.

As a migrainer with aura and complicated migraine who has had an MRI, I learned about this.

Migraine is another neurologic problem associated with periventricular abnormalities. In a study by Soges and colleagues periventricular hyperintensities were found in 41 per cent of patients with classic or common migraine and in 57 per cent of patients with complicated migraine. The white matter lesions resemble deep white matter ischemia or vasculitis more than multiple sclerosis, and the classic pattern of headaches usually identifies these patients.

http://spinwarp.ucsd.edu/neuroweb/Text/br-840.htm

Perhaps slowed venous drainage is impacting migrainers. But this is NOT the same as CCSVI in MS---which has the component of reflux of blood in the deep cerebral veins. Without the transcranial test, this study proves nothing about Dr. Zamboni's discovery of CCSVI....but gives us another interesting connection to neurovascular disorders and hypoperfusion. If anything, I see it as more "positive" evidence of venous drainage impacting the brain.

The one odd thing about this study is the assertion that the collateral flow in CCSVI and migrainers "seem to be secondary" rather than "primary pathogenic importance." How can they so readily say that? If someone had carotid artery blockage and suffered a TIA, the arterial blockage would be called primary and would be treated.
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Re: Migraine patients exhibit CCSVI-like venous outflow

Postby Ellegaard » Fri Jan 06, 2012 3:02 pm

Just because ccsvi shows in Patients with Migraine does not make ccsvi a all good condition??? That we should not give any attention or treatment...

Ccsvi in Migraine makes perfect sense.

Agree that this is a proff, that poor brain drainage is not a good thing.
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Re: Migraine patients exhibit CCSVI-like venous outflow

Postby 1eye » Fri Jan 06, 2012 6:05 pm

I have the impression that primary and secondary are referring to the right/left diameter difference in the jugulars. But it could also be the internal jugulars versus the ones used when upright, or versus "the other vein routes". If it is regular veins versus collateral veins the migraine sufferers would have to have significant drainage problems to resemble CCSVI. It seems this paper contradicts Dr. Haacke's finding about low flow rates. Without reading the paper I can't tell why. I can guess that it is not averaged over many heartbeats, and represents instantaneous values found in single MRV slices. Because of the business of flogging the deceased, I am not going to purchase yet another paper that says there is nothing specific to "MS" in CCSVI.

It sounds to me like yet another answer looking for a question.
Last edited by 1eye on Fri Jan 06, 2012 7:14 pm, edited 1 time in total.
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Re: Migraine patients exhibit CCSVI-like venous outflow

Postby Cece » Fri Jan 06, 2012 6:13 pm

http://onlinelibrary.wiley.com/doi/10.1 ... 024.x/full

Migraine Aggravation Caused by Cephalic Venous Congestion

Florian Doepp MD, Stephan J. Schreiber MD, Jens P. Dreier MD, Karl M. Einhäupl MD, José M. Valdueza MD

Background.—Cerebral venous distension is thought by some to serve as a source of migraine pain. Previous investigators have tried to modify pain intensity by induction of additional venous congestion via compression of both internal jugular veins (Queckenstedt's maneuver). The magnitude of blood flow within the internal jugular veins depends markedly on body position, and inconsistencies in positioning may have influenced their results.

Objective.—To investigate the effect of Queckenstedt's maneuver, performed both in the upright and in the supine body position, in migraineurs during an acute attack.

Methods.—Twenty-five patients (18 women, 7 men; mean age ± SD, 35.4 ± 13.3 years) with International Headache Society-defined migraine without aura were evaluated. Queckenstedt's maneuver was performed in both body positions during an acute migraine attack, involving constant application of manual pressure to both internal jugular veins for 30 seconds. Headache intensity was rated before, during, and after Queckenstedt's maneuver on a scale extending from 1 (mild) to 10 (intolerable).

Results.—Seventeen patients (68%) reported an increase of headache intensity in the supine position during Queckenstedt's maneuver. In the sitting position, pain increase was observed only in 6 patients (24%). The magnitude of pain increase was significantly greater in the supine position compared to the upright position (P = .02).

Conclusions.—Our results support a role for cerebral venous congestion in the generation of migraine pain and suggest body position may influence the clinical expression of that process.

Hey, that's Dr. Doepp again!
Researchers deliberately cut off jugular flow to patients during their migraines, and the migraines intensified. The effect was greater if they were lying down (and hence relying more on their jugulars) than when sitting up.

Venous outflow may be involved in migraine patients. That might not mean outflow obstructions. But it could.
Time to get Cheer tested for CCSVI! And don't be signing up for any studies as a healthy control!! :)

Similiar findings in a study with a sham group:
http://onlinelibrary.wiley.com/doi/10.1 ... 781.x/full

And nonfindings in a RCT:
http://jnnp.bmj.com/content/65/2/260.abstract
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Re: Migraine patients exhibit CCSVI-like venous outflow

Postby Cece » Fri Jan 06, 2012 7:02 pm

http://onlinelibrary.wiley.com/doi/10.1 ... x/abstract
Migraine-Like Visual Phenomena Associated With Cerebral Venous Thrombosis

Daniel Seth Newman M.D., Steven R. Levine M.D., Valerie L. Curtis M.D., K.M.A. Welch M.D.
Article first published online: 21 JUN 2005

Two adults presented with new-onset migrainous-type visual disturbances and had angiographically demonstrated filling defects near the torcular Herophili. Neither patient had a visual field deficit nor cerebral computed tomography evidence of an occipital infarction. The association of migraine-like visual phenomena with cerebral venous thrombosis may provide insight into the pathogenesis of migraine.
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Re: Migraine patients exhibit CCSVI-like venous outflow

Postby Cece » Fri Jan 06, 2012 7:13 pm

http://www.sciencedirect.com/science/ar ... 3678922870
MIGRAINE: A VASOMOTOR INSTABILITY OF THE MENINGEAL CIRCULATION☆

J.N. Blaua,

National Hospitals for Nervous Diseases, Queen Square, London WC1, United Kingdon,

and Maida Vale, London W9, United Kingdon

Available online 26 September 2003.

Abstract

The current view that the migraine aura arises from spasm of the major cerebral arteries and the ensuing headache from extracranial arterial vasodilatation is examined and refuted. It is proposed that the headache is due to stimulation of nociceptive nerve-endings in the walls of meningeal vessels (arterioles, venules, and particularly the dural venous sinuses); and that the aura arises from calibre changes in meningeal vessels that penetrate the outer cortex, resulting in localised inhibition or excitation. It is suggested that there are two types of migraine patients— vasodilators and vasoconstrictors.

Dural sinuses it is! Maybe. And the dural sinuses drain into the internal jugulars. If "secondary" means collaterals in the research that starts off this thread, it could be that the dural sinuses are preferentially draining into collateral veins such as the emissary veins and verts and vertebral plexus. These routes are smaller and might result in slower drainage.

Unlike the veins, the dural sinuses have pain receptors. Very sensitive.
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Re: Migraine patients exhibit CCSVI-like venous outflow

Postby Cece » Fri Jan 06, 2012 7:25 pm

http://www.sciencedirect.com/science/ar ... 2909014719
Decreased Jugular Venous Distensibility in Migraine

Chih-Ping Chung∗, ‡, A-Ching Chao†, Hung-Yi Hsu§, ‡, Shing-Jong Lin‡, Han-Hwa Hu∗, ‡, ,

Received 31 March 2009; revised 16 July 2009; Accepted 5 August 2009. Available online 8 November 2009.

Abstract

It has been demonstrated that internal jugular vein (IJV) compression aggravates headache intensity in patients of migraine. We hypothesized that patients with migraine may have veins that are less distensible; consequently, these veins are more likely to develop and transmit venous hypertension caused by the increased venous blood volume during IJV compression. We used ultrasonography to measure the extent of venodilatation and distensibility of IJV in response to increased transmural pressure, which was produced by a Valsalva maneuver. The extent of venodilatation were compared between 23 migraine patients (5 men, 18 women; mean age: 40.22 ± 12.71 years, range: 27–7 years) and 23 age- and gender-matched normal individuals (5 men, 18 women; mean age: 40.23 ± 12.04 years, range: 27–7 years). In the result, the venodilatation of IJV in response to each level of Valsalva pressure in patients with migraine was significantly less than that in normal individuals. Our results suggest that patients with migraine have less compliant IJVs, which makes them susceptible to cerebral venous hypertension. Further studies are needed to elucidate the clinical implications of decreased venous distensibility in migraine patients.

Patients with migraine have less compliant IJVs. Leading to cerebral venous hypertension. Brilliant.

This fits with the research leading off this thread. A lot of migraine research looks at changes during the migraine. But the research starting off this thread, as well as this, is looking at the jugular outflow anomaly as a condition that is present all the time, not just during the migraine.

This refutes the conclusion of research leading off this thread that the presence of secondary outflow patterns in migraine patients suggests the lack of primary pathogenic importance of CCSVI in MS. Migraine patients are also known to develop hyperintense white matter abnormalities. If I had the physics skills of Dr. Tucker, I'd run the equations with an overall reduction in IJV elasticity and see how the resulting pressure on the blood brain barrier would be similar and how it'd be different from our situation in CCSVI with our outflow obstructions at the base of the jugulars but, presumably, normal elasticity throughout.
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Re: Migraine patients exhibit CCSVI-like venous outflow

Postby cheerleader » Fri Jan 06, 2012 7:47 pm

CECE!! :!:
Great job pulling the research together! And that last abstract is from our Taiwanese friends, Drs. Chung, Hsu and Hu--who have been looking at jugular veins for the past 10 years, as related to IJVVI and transient ischemic attacks and LA in the elderly.

Dr. Hu is speaking at the ISNVD conference on venous outflow in neurological disease...wonder if migraine will be in that presentation?

What's kind of funny is that after I told Dr. Hubbard I was a migrainer with aura, he said I couldn't be tested as a normal...guess I know why, now.
Also, since I've been following the endothelial health program with Jeff....no migraines in three years. Interesting!
(oh man. between my migraines and Jeff's MS...I'd better make sure our son keeps moving, taking D and eating well. He's got a loaded venous deck, so to speak.)
thanks for all the info, Cece!
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