disability caused by MS associated with number of stenoses

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

disability caused by MS associated with number of stenoses

Postby Cece » Wed Dec 05, 2012 5:16 pm

http://www.ncbi.nlm.nih.gov/pubmed/23202144
Phlebology. 2012 Nov 30. [Epub ahead of print]

Disability caused by multiple sclerosis is associated with the number of extra cranial venous stenoses: possible improvement by venous angioplasty. Results of a prospective study.

Denislic M, Milosevic Z, Zorc M, Ravnik IZ, Mendiz O.

Source
* MC Medicor, d.d., Tbilisijska 81.
Abstract
OBJECTIVE:
Chronic cerebrospinal venous insufficiency (CCSVI) was recently described in patients with multiple sclerosis (MS). The hypothesis of the vascular aetiology provides a new approach in the investigation and treatment of MS.
METHODS:
Our open-label study included 94 MS patients who fulfilled ultrasound sonographic criteria required for CCSVI. The internal jugular and/or azygous veins by a catheter venography were dilated.
RESULTS:
In 34.8% of the patients unilateral, in 65.2% bilateral venous abnormalities and in 2.1% no luminal obstructions were demonstrated. The patient group with the higher disability score had a significantly higher number of venous lesions (P < 0.005). Significant improvement of clinical disability in relapsing-remitting patients was (P < 0.001) achieved. In our study no stents were used. Re-stenosis occurred in 21.7% of the patients.
CONCLUSION:
The number of venous narrowings is higher in more disabled patients. A significant improvement in clinical disability in the relapsing-remitting group was observed.

Prospective research supporting the CCSVI theory.
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Re: disability caused by MS associated with number of stenos

Postby 1eye » Wed Dec 05, 2012 6:08 pm

See? See Cece? I don't guess this one will convince any skeptics. I wonder if there's an argument that the circumstantial evidence is overwhelming? If it looks, smells, sounds, tastes, feels anatine and can fly, it may actually be a duck.
"Try - Just A Little Bit Harder" - Janis Joplin
CCSVI procedure Albany Aug 2010
'MS' is over - if you want it
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Re: disability caused by MS associated with number of stenos

Postby Robnl » Thu Dec 06, 2012 5:14 am

1eye wrote:See? See Cece? I don't guess this one will convince any skeptics. I wonder if there's an argument that the circumstantial evidence is overwhelming? If it looks, smells, sounds, tastes, feels anatine and can fly, it may actually be a duck.


Are you sure 1eye? It will propably only be believed if every doc can look at, feel, smell.....etc and then say; 'hey...it's a duck'
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Re: disability caused by MS associated with number of stenos

Postby Cece » Thu Dec 06, 2012 9:03 am

When MS is the goose laying golden eggs, it is hard to re-envision it as a mere duck!

A nice presentation by the authors of this study. They are from Slovenia and Argentina.
http://solaci.org/es/pdfs/congresosolac ... 1045M8.pdf
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Re: disability caused by MS associated with number of stenos

Postby Cece » Thu Dec 06, 2012 9:29 am

Image

Here's an image from the presentation linked above.

Is (a) normal in appearance? It looks that way to me. Even when a vein looks good at first glance, there can be that characteristic funnel effect that is somewhat hidden. (Flow comes up under the 'wings' of the valve, thus making it look like the vein is normal when really the flow is narrowed to pass between the funnel, which can be seen as an area of darker contrast within the lighter contrast.) But I don't see that here.

Is (b) an intraluminal defect and, specifically, a membrane? The vein itself looks distended. The pink arrow is pointing to a white line. It's in the area where valves are commonly found. I am not sure what is meant by membrane, as this looks to me like a stiff valve. An IVUS image would be of use in determining exactly what the intraluminal defect is, but it's clearly an intraluminal abnormality. Intraluminal meaning within the vein. The vein wall itself is not the stenosis, it's the white line within the vein that is the stenosis. In this image, it's difficult to see contrast effects, but those would have been seen in the real-life moving image. I am curious, for how big that distended vein appears, how much of an opening there actually was at the area of stenosis.

Is (c) a circumferential abnormality? I believe this means an actual stenotic vein wall at the area marked with a pink circle. Does anyone know what is being shown by the pink arrow? Is there a lightening of contrast there? The blue arrow is clearly intended to show that the contrast is escaping down a collateral vein. Because the pink circled stenosis is in the area of the valves, I am inclined to disagree with the diagnosis that this is a vein wall stenosis because it could be yet another valvular stenosis. Either way it does appear to be a stenosis. In normal IJVS, there can be some natural narrowing before the IJV juncture with the innominate vein, but the presence of the collateral and the apparent high percentage of narrowing makes this seem like a stenosis that qualifies to be treated with ballooning.
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Re: disability caused by MS associated with number of stenos

Postby Cece » Thu Dec 06, 2012 9:42 am

Image
One more. This is clearly a hypoplasia. The vein is long and skinny. The IR chose to balloon. We need a proper study of these hypoplasias to see if it ever a good idea to balloon or in what circumstances it is. My understanding, which admittedly is not firsthand, is that the outcome is poor when hypoplasias are treated. Perhaps the balloons being used are too large for the size of the very small vein. Perhaps the need for treatment across a long length of vein results in more vein injury. Perhaps they are just diseased veins that aren't going to respond well. Perhaps there is not enough flow through the vein after treatment for it to heal well.

Although the vein in its original state was not taking much flow, it was taking some flow, and that needs to be weighed against the very real risk that the hypoplastic vein will clot off if treated.

I am not a doctor, but these are questions that I believe the doctors are considering. No easy answers. I also think as a patient, if our ultrasound shows a hypoplastic vein (and remembering that ultrasounds are not 100% accurate), at that time it would be useful to have a discussion of how the doctor will treat or not treat that hypoplasia. The choice is not standardized, the doctors each make it for themselves.
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Re: disability caused by MS associated with number of stenos

Postby Cece » Thu Dec 06, 2012 9:59 am

Oh, the good images just keep on coming. Further down in the linked pdf, there's an image labelled, "Stenosis of the right IJV." It's a severe stenosis and a cutting balloon was used. The final image is labelled, "Improved flow after dilatation." I can't tell if it is a good outcome image or not. There is still narrowing.

The two balloons technique is shown in the next image,which is equivalent more or less to the use of a high pressure balloon. With two balloons, both are inflated within the vein at the same time.

"Stenosis of the left IJV with collateral" : the contrast looks blotchy in the final image, I don't know why? The vein looks wider. There is still some evidence of the collateral opening.

"Deformity of the azygous vein": final image looks good as far as I can tell! A big difference.

"Impressions of the removed inflated balloon": What the heck!! Our stenoses are so resistant to ballooning that they leave impressions on the removed balloon? Is this common or only in cases of extreme stenoses? Could the presence of impressions on the removed inflated balloon predict a greater likelihood of restenosis?

"PTA of the right IJV (female patient, 43 years, duration 1 year, course PP)": the outcome image doesn't look as good to me, I wonder if this was underdilated? But then the next image shows a before MRI of the spinal cord in this patient, with two MS lesions, and a post image several months later, with no lesions!!

"Extracranial venous obstructions": In only 2% of patients, they had normal extracranial veins. 98% had abnormal. If only one IJV was abnormal, 75% of the time it was the left IJV. Interesting. Azygous involvement was seen in 50%.

Improvement of disability greater than 1 EDSS was seen in 45% of patients. That is very good. Relapses in 13%. DMDs could be a confounder as 64% were on DMDs, 36% were not.

I wonder what the visual analogue scale is. Results look good. And what is micturation disturbance! OAB-V8??

Safety profile looks very good. No deaths, no major bleeding events. One ruptured balloon.

Their vision for the future of MS is first-line treatment with DMDS plus angioplasty.
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