The hypothesis of patho-physiological correlation between chronic cerebrospinal venous insufficiency and multiple sclerosis: rationale of treatment
S Guerzoni and
+ Author Affiliations
Department of Cardiothoracic and Vascular Surgery, Hesperia Hospital, Via Arquà, 80, 41100 Modena, Italy
The possible role of the venous system in the pathogenesis of chronic neurodegenerative diseases has been hypothesized for decades. Quite recently, the description of a venous condition defined as chronic cerebrospinal venous insufficiency (CCSVI) and its strong association with multiple sclerosis (MS) has brought back the attention of the scientific community to the hypothesis of an aetiological or concomitant role of an altered venous function in the occurrence of this pathology. CCSVI is identified by sonographic criteria, thus the indication for its possible treatment is based on ultrasound findings.
We retrospectively examined 167 consecutive patients affected by clinically defined MS and CCSVI, identified by ultrasound assessment by the presence of at least two sonographic criteria. Ultrasonographic diagnosis of CCSVI was then integrated by venography and intravascular ultrasound examination (in 43 patients). Patients were all submitted to endovascular procedure (venoplasty).
In 37% of cases there was no correspondence between the preoperative ultrasound assessment and the venographic findings. In the event of incongruity between venography and sonography, the intravascular ultrasound examination investigation, when performed, confirmed ultrasound findings in 42% of cases and venography results in 58%. At one month in 12% of cases ultrasound assessment showed the persistence of altered flux. In 67% of cases patients reported subjective amelioration, regarding non-specific symptoms.
The pathophysiology of CCSVI is yet to be defined. The superior cava venous system is highly complex in terms of anatomy and possible anomalies, as well as its haemodynamic mechanisms. Further studies are required to define the parameters of diagnosis and treatment of CCSVI.
Once again we hear that two-thirds of patients experience improvements ("subjective amelioration" of "non-specific" symptoms).
It would be good to know what separated the improvment group two-thirds from the no noticeable improvements one-third, and to know if that one-third might still experience a beneficial impact over time.
At one month, it was successful in 88% of patients but in 12% there was still "altered flux" meaning abnormal blood flow was still present.
And the comparison between venogram and sonography and ivus doesn't shed much light on which is best.
In 37% of case there was no correspondance between the preoperative doppler ultrasound and what was found on venogram?! That is a high percentage, and indicates that either the doppler technician needs more training or the doppler itself is a poor instrument for the important task of diagnosing CCSVI.