This Is MS Multiple Sclerosis Knowledge & Support Community

Robnl wrote:Hi Doc,

spinal veins
Question:


Are these also possible problematic veins and can they be ballooned??

They can be problematic but they are too small and delicate to be treated by angioplasty. I do not think they are a major issue in ccsvi

Do you think it is possible to create models like this for CCSVI purpose / education / study / training / whatever?

http://tinyurl.com/78gwamr

Algis wrote:Do you think it is possible to create models like this for CCSVI purpose / education / study / training / whatever?

http://tinyurl.com/78gwamr

I have used simulation to teach my trainees how to perform a variety of procedures. The device you illustrate seems pretty crude compared to what I have used. there are models that record how many times you poke the wall, and other technical deficiencies. It is all computer based education, guides trainees through graded learning and gives them a report of their progress.

have a look

http://www.mentice.com/default.asp?init ... p?sida=262

Dr. Sclafani,

I have a few questions for you but first I would like to thank you for this epic thread. If only more doctors went the extra mile, perhaps we could get to the bottom of this quicker. So thank you, this is very much appreciated.

Have you observed the patterns of CCSVI that Zamboni et al identified in the seminal CCSVI article? Especially some of the lesser discussed areas like the lumbosacral veins, inferior vena cava, and vertebral veins?

http://jnnp.bmj.com/content/80/4/392.full

How about the agenesia and atresia of the venous lumbar tree associated with the type D pattern?

Thanks!

drsclafani wrote:

Algis wrote:Do you think it is possible to create models like this for CCSVI purpose / education / study / training / whatever?

http://tinyurl.com/78gwamr

I have used simulation to teach my trainees how to perform a variety of procedures. The device you illustrate seems pretty crude compared to what I have used. there are models that record how many times you poke the wall, and other technical deficiencies. It is all computer based education, guides trainees through graded learning and gives them a report of their progress.

have a look

http://www.mentice.com/default.asp?init ... p?sida=262

Indeed; it looks nice. Thank you

Hi Doc,

we talked about blood flow measurement, would the plethysmography collar from Zamboni be a good tool??

A thing i can not understand ; if there is a problem with f.e. the renal vein, would such a device 'notice' a change in the bloodflow??

Robnl wrote:Hi Doc,

we talked about blood flow measurement, would the plethysmography collar from Zamboni be a good tool??

A thing i can not understand ; if there is a problem with f.e. the renal vein, would such a device 'notice' a change in the bloodflow??

Here are some news from Journal of Vascular Surgery:

Assessment of cerebral venous return by a novel plethysmography method
Paolo Zamboni, MD, Erica Menegatti, PhD, Paolo Conforti, MD, Simon Shepherd, PhD, Mirko Tessari, VT, Clive Beggs, PhD
Received 10 November 2011; accepted 26 January 2012. published online 23 April 2012.
Corrected Proof

Abstract Full Text PDF Images References
Background
Magnetic resonance imaging and echo color Doppler (ECD) scan techniques do not accurately assess the cerebral venous return. This generated considerable scientific controversy linked with the diagnosis of a vascular syndrome known as chronic cerebrospinal venous insufficiency (CCSVI) characterized by restricted venous outflow from the brain. The purpose of this study was to assess the cerebral venous return in relation to the change in position by means of a novel cervical plethysmography method.

Methods
This was a single-center, cross-sectional, blinded case-control study conducted at the Vascular Diseases Center, University of Ferrara, Italy. The study involved 40 healthy controls (HCs; 18 women and 22 men) with a mean age of 41.5 ± 14.4 years, and 44 patients with multiple sclerosis (MS; 25 women and 19 men) with a mean age of 41.0 ± 12.1 years. All participants were previously scanned using ECD sonography, and further subset in HC (CCSVI negative at ECD) and CCSVI groups. Subjects blindly underwent cervical plethysmography, tipping them from the upright (90°) to supine position (0°) in a chair. Once the blood volume stabilized, they were returned to the upright position, allowing blood to drain from the neck. We measured venous volume (VV), filling time (FT), filling gradient (FG) required to achieve 90% of VV, residual volume (RV), emptying time (ET), emptying gradient (EG) required to achieve 90% of emptying volume (EV) where EV = VV-RV, also analyzing the considered parameters by receiver operating characteristic (ROC) curves and principal component mathematical analysis.

Results
The rate at which venous blood discharged in the vertical position (EG) was significantly faster in the controls (2.73 mL/second ± 1.63) compared with the patients with CCSVI (1.73 mL/second ± 0.94; P = .001). In addition, respectively, in controls and in patients with CCSVI, the following parameters were highly significantly different: FT 5.81 ± 1.99 seconds vs 4.45 ± 2.16 seconds (P = .003); FG 0.92 ± 0.45 mL/second vs 1.50 ± 0.85 mL/second (P < .001); RV 0.54 ± 1.31 mL vs 1.37 ± 1.34 mL (P = .005); ET 1.84 ± 0.54 seconds vs 2.66 ± 0.95 seconds (P < .001). Mathematical analysis demonstrated a higher variability of the dynamic process of cerebral venous return in CCSVI. Finally, ROC analysis demonstrated a good sensitivity of the proposed test with a percent concordant 83.8, discordant 16.0, tied 0.2 (C = 0.839).

Conclusions
Cerebral venous return characteristics of the patients with CCSVI were markedly different from those of the controls. In addition, our results suggest that cervical plethysmography has great potential as an inexpensive screening device and as a postoperative monitoring tool.

Any interesting cases lately?

This is something I have been wondering about: is it possible to utilize collateral veins as a substitute IJV? There have been some cases of people with congenital deformed, or severely undersized, IJV's which might not respond to having them dilated. Also, some patients have severely scarred IJV which cannot be treated. I realized that each case is different, but let's suppose there are a network of collateral veins running roughly parallel to the IJV.

Would it be possible to enlarge a target collateral vein (and maybe re-routing them to facilitate flow) to function as a IJV?

Donnchadh

I am viewer # 777,777.
There has to be good luck in that.

After several hundred procedures, truly unusual and enigmatic procedures sometimes come along. Despite difficulties in diagnosis, an unusual angiographic appearance of uncertain cause, and a lack of clarity of the pathology, a great outcome comes from limited interventions.
The patient is a 42 year old Canadian who was diagnosed with secondary progressive multiple sclerosis. He had had symptoms of neurological disease for more than twenty years beginning with "flashing lights in his head and grand mal seizures as a young adult. For years no diagnosis was made. The patient was told that it was "nerves", or anxiety. In June 2011 he was finally diagnosed with progressive multiple sclerosis.
Currently he walks with a cane except for loss distances which require a wheelchair, having weakness in his left leg, a foot drop and imbalance that it is worst at night. He suffers from heath intolerance and intense fatigue: he sometimes sleeps for two days. He has numbness and tingling in both torso, hands and feet. He has headaches and electric shocks in his left leg.
On examination, he had difficulties with memory, decision making and word and number recall. Cranial nerves exam revealed positive Rhomberg test and weakness of spinal accessory muscles. He had weakness in left left hip function, and paralysis of his left ankle and foot. He had absent sensation to vibration and light and sharp touch in his left fingers and toes and the dorsum of his left foot. He could not walk without a cane.
Her Doppler examination had three criteria of CCSVI. The valve leaflets of the right and left internal jugular veins were extremely long. Reflux was noted in both jugulars and the deep cerebral veins.
I performed venography last week.

Cece wrote:
In the fourth image on the 'azygous vein' series, is that the renal vein? Is it abnormal?

Robnl wrote:
The 5th image on the 'azygous vein' series, the most right one, which vein is that?? Looks like a ladder to me
(don't recognize the azygous in that image)

The fourth image is the hemiazygous vein entering the azygous vein
The fifth image is a continuation of a robust left ascending lumbar vein into the hemiazygous vein.

AnCap wrote:Dr. Sclafani,

I have a few questions for you but first I would like to thank you for this epic thread. If only more doctors went the extra mile, perhaps we could get to the bottom of this quicker. So thank you, this is very much appreciated.

Have you observed the patterns of CCSVI that Zamboni et al identified in the seminal CCSVI article? Especially some of the lesser discussed areas like the lumbosacral veins, inferior vena cava, and vertebral veins?

http://jnnp.bmj.com/content/80/4/392.full

How about the agenesia and atresia of the venous lumbar tree associated with the type D pattern?

Thanks!

You are quite welcome. This forum and this dialogue have helped me greatly in developing my understanding of ccsvi and my methodolgy of how i treat it.

agenesis and atresia and hypoplasia of the lumbar veins is not limited to type D. these anomalies can be present in any of the patterns i have seen. Sometimes the diagnosis is difficult because anomalies of lumbar venous drainage results in an appearance that mimics he lumbar hypoplasia pattern.

The spinal cord ends at the elevenhof the twelfth vertebra so that these veins drain the area below the spinal cord. When they are abnormal, i am unclear of the consequences of this. Does it mean that there is congestion of the venous system above the lumbar area? That might be significant.

A paper out of China reported upon several patients whose neurological disabilities were improved by angioplasty of stenoses of the ascending lumbar vein. .

Robnl wrote:Hi Doc,

we talked about blood flow measurement, would the plethysmography collar from Zamboni be a good tool??

I think it would be great if it can be validated by others. I would love to have such a test that I could use shortly after a venoplasty. It would help determine whether the venoplasty has accomplished the desired results. However doing standing images would be difficult.

A thing i can not understand ; if there is a problem with f.e. the renal vein, would such a device 'notice' a change in the bloodflow??

I always look at the cerebrospinal venous circuit as a large fluid structure involving many inputs and outputs. I suspect that changes would be recognized but that is conjecture on my part.

Cece wrote:Any interesting cases lately?

yes, i started posting a new case above