Every once in a while an dramatic change occurs instantaneously after CCSVI treatment. I dont see dramatic outcomes very often, usually improvements occur over several weeks.
This case illustrated immediate return of stereognosis within minutes of completion of three valvuloplasties.
50 year old man came with numbness in both hands, and in both legs. Typical fatigue, some balance issues were also present.
CCSVI ultrasound met multiple criteria for venography.
during preop testing of his neurological status, I noted that he was numb in both hands. Further testing demonstrated that he had difficulty identifying small objects placed in his hands while his eyes were closed.Further history revealed that he could not button his shirts unless he could see the button because he was unable to recognize by feel the button or the button hole.
This failure to recognize objects by touch is called Astereognosis.
His venogram showed stenoses of the area of the confluens of both Internal jugular veins that was shown by Intravascular ultrasound (IVUS) to be caused by inability of the valves to open properly. the valves had areas of thickening. He also had stenosis of the junction of the ascending azygous vein and the azygous arch. the images are shown below
This RIJ Venogram (#1)has a typical tight stenosis at the valve area. (orange circles). There is also a narrow hypoplastic vein higher up (curved arrow) Image #2 shows no contrast media coming down in the internal jugular vein because the jugular vein is occluded by the catheter in the area of the rectangle. In figure 3, a collateral vein drains the contrast in the skull base veins. Note how narrow the dural sinus is (straight arrow). After angioplasty of the lower segment, the stenosis at the confluens is resolved.
I thought it best to leave the hypoplastic vein alone. I have not been impressed with treatment outcomes when managing hypoplasias. It is not uncommon for this to be ineffective.
The left side also had a valvular stenosis (orange oval) In this case the upper portions of the IJV were of normal caliber and the dural sinus was intact. After 16x4 baloon angioplasty, the vein is now open and properly draining.
This azygous venography is really illustrative of several points. Firstly, the frontal view (#1) looks normal. No stenosis. On the 70 degree view Fig #2,3), the posterior part of the azygous arch is beautifully seen and there is a significant stenosis. IVUS showed that this was caused by a valve that would not open. After balloon dilatation, the vein has a normal contour and improved flow characteristics on venography.
Immediately after the catheter was removed from the left saphenous vein, the patient remarked that he had improved sensation in his finger tips. In the recovery room I retested him for stereognosis. He was able to identify with his eyes closed several objects including coins, a paper clip and a penl.
Astereognosis is the inability to recognize objects by feel, generally by the hands or feet, or by the tongue. although recognition of the objects by sight may be intact. This patient could recognize the buttons on his shirt by vision but not by touch. He had great difficulty, for example, buttoning clothing above the second button because he could not see the button. When he had to rely upon his hands, he could not recognize the button or the button hole.
This case also emphasized the value of IVUS, Not only is it superior to venography in delineating the abnormality causing stenosis, but it gives superior imaging of the effects of angioplasty. In this particular case, the extent of the valvular stenosis within the azygous vein was much longer than venography indicated.
It is always startling to me, when patients have these dramatic and unexpected improvements. I find it difficult to imagine that this improvement could be psychosomatic and related to placebo effect.
