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ANNALS of Neurology
http://onlinelibrary.wiley.com/doi/10.1 ... 1/abstract

http://www.ncbi.nlm.nih.gov/pubmed/21674590

LETTER TO THE EDITOR
Chronic Cerebrospinal Venous Insufficiency and
Susceptibility to Multiple Sclerosis
Avruscio Giampiero, MD

I read carefully the article published in the January 2011 issue
of Annals of Neurology by Baracchini and colleagues on the
prevalence of chronic cerebrospinal venous insufficiency
(CCSVI) measured with echo color Doppler sonography in
patients with high suspicion of initial multiple sclerosis (MS).1
These authors give us 2 very important data that appear underestimated
in their report, but are of extreme importance in the
scientific debate in progress. In Table 4, they show positive
CCSVI Doppler screening in 2% of controls matched for age
and gender versus 16% of patients with possible MS. This
means that:
• The prevalence of CCSVI in healthy people is 2%, confirming
Zamboni’s data,2 with rates far removed from the 22%
recently reported by Zivadinov et al.3
• The risk of having possible MS is dramatically increased by
the presence of CCSVI by >9-fold (odds ratio, 9.3; 95%
confidence interval, 1.1–78; p ¼ 0.0180).
In contrast to the conclusions of the authors, careful analysis
of their results indicates that CCSVI may be among the
factors contributing to the development of MS symptoms at
onset.

Potential Conflicts of Interest
Nothing to report.

Department of Vascular Medicine, Sant’Antonio Hospital,
Padua, Italy

REFERENCES
1. Baracchini C, Perini P, Calabrese M, et al. No evidence of chronic cerebrospinal venous insufficiency at multiple sclerosis onset. Ann Neurol 2011;69:90–99.
2. Zamboni P, Galeotti R, Menegatti E, et al. Chronic cerebrospinal venous insufficiency in patients with multiple sclerosis. J Neurol Neurosurg Psychiatry 2009;80:392–399.
3. Zivadinov R, Marr K, Cutter G, et al. Prevalence, sensitivity and specificity of chronic cerebrospinal venous insufficiency in multiple sclerosis. Neurology (WNL.0b013e318212a901; published ahead of print April 13, 2011).

DOI: 10.1002/ana.22451 VC 2011 American Neurological Association 1

Excellent analysis.

gigi26970 wrote:ANNALS of Neurology
http://onlinelibrary.wiley.com/doi/10.1 ... 1/abstract

http://www.ncbi.nlm.nih.gov/pubmed/21674590

LETTER TO THE EDITOR
Chronic Cerebrospinal Venous Insufficiency and
Susceptibility to Multiple Sclerosis
Avruscio Giampiero, MD

I read carefully the article published in the January 2011 issue
of Annals of Neurology by Baracchini and colleagues on the
prevalence of chronic cerebrospinal venous insufficiency
(CCSVI) measured with echo color Doppler sonography in
patients with high suspicion of initial multiple sclerosis (MS).1
These authors give us 2 very important data that appear underestimated
in their report, but are of extreme importance in the
scientific debate in progress. In Table 4, they show positive
CCSVI Doppler screening in 2% of controls matched for age
and gender versus 16% of patients with possible MS. This
means that:
• The prevalence of CCSVI in healthy people is 2%, confirming
Zamboni’s data,2 with rates far removed from the 22%
recently reported by Zivadinov et al.3
• The risk of having possible MS is dramatically increased by
the presence of CCSVI by >9-fold (odds ratio, 9.3; 95%
confidence interval, 1.1–78; p ¼ 0.0180).
In contrast to the conclusions of the authors, careful analysis
of their results indicates that CCSVI may be among the
factors contributing to the development of MS symptoms at
onset.

Potential Conflicts of Interest
Nothing to report.

Department of Vascular Medicine, Sant’Antonio Hospital,
Padua, Italy

REFERENCES
1. Baracchini C, Perini P, Calabrese M, et al. No evidence of chronic cerebrospinal venous insufficiency at multiple sclerosis onset. Ann Neurol 2011;69:90–99.
2. Zamboni P, Galeotti R, Menegatti E, et al. Chronic cerebrospinal venous insufficiency in patients with multiple sclerosis. J Neurol Neurosurg Psychiatry 2009;80:392–399.
3. Zivadinov R, Marr K, Cutter G, et al. Prevalence, sensitivity and specificity of chronic cerebrospinal venous insufficiency in multiple sclerosis. Neurology (WNL.0b013e318212a901; published ahead of print April 13, 2011).

DOI: 10.1002/ana.22451 VC 2011 American Neurological Association 1

None of this data matters because doppler is not very accurate in diagnosing CCSVI.

so .... you now are saying .... the BNAC results [ which I believe were based on Doppler ...] ...... are not valid either ?

You made my day , Scorpion .



Mr. Success

Doppler is extremely accurate in diagnosing CCSVI. Doppler has been maligned by people who do not want CCSVI cheaply diagnosed, using very questionable methods. Come on, guys, this isn't magic. It works, and this letter makes it clear that we should continue to use it. A fluoroscope will be used to verify it, and as Dr. Sclafani has found, once in a great while the Doppler result may not match the venography, but in most cases it is very reliable.

I disagree with you 1eye .

Yes , down dirty and quick ..... would be nice [ talking Doppler here]

not to mention - affordable - ..... but ..................

too operator dependant ..........

not the " gold standard "


You should know this.



Mr. Success

I am not sure what the definition for 'possible MS' is but Scorpion is right, if possible MS is the same as regular MS then the 16% figure is very low, probably due to the imperfect doppler imaging.

But, working with the figures they have, it supports the importance of CCSVI as a factor in MS, possibly a causal factor. Still an excellent analysis especially if this was ignored by the actual researchers.

We recently had WeWillBeatMS turn up positive for CCSVI on Doppler but negative on venogram and IVUS. Imperfect doppler imaging as explanation?

Dr. Sclafani has found CCSVI in approximately 149 out of 150 MS patients. Those are numbers I can trust. Especially since I was one of them.

..

'possible MS' is not MS. If there is any sign, it has likely gone into remission. It is like CIS. He is saying: people who have had an episode are demonstrably more (16%) likely to have CCSVI, and healthy people are only 2% likely to have CCSVI.

I would not say this information is not valuable, or that it says anything about how useful Doppler is.

CCSVI, unlike early "MS", does not go into remission.

Again I am surprised about some misconceptions on a disease like MS.

On the onset of MS it sometimes takes month/years to get the final diagnosis.

In this stage the difference between healthy and pwMS MUST(!) be subtle.

So the relative difference 2% to 16% is high for this type of slow chronic disease at the onset.

At the onset absolute values do not really matter. At the late stages about 90% have CCSVI.

So CCSVI seems to be directly correlated with MS from the onset to the end.

Now the question is: Is CCSVI a risk factor or the cause (may depend to some degree on definition)
of MS or is it the result of the disease.

At the moment my guess is that it is a high risk factor like smoking for lung cancer.

R.

The best thing about this letter to the Editor is the journal that it appears in and he audience it has.

The smartest neurologist will start studying CCSVI more and the tide will turn.

se1956 wrote:So the relative difference 2% to 16% is high for this type of slow chronic disease at the onset.

At the onset absolute values do not really matter. At the late stages about 90% have CCSVI.

So CCSVI seems to be directly correlated with MS from the onset to the end.

Actually, this would suggest that CCSVI is caused or made worse by MS, not the other way round since having MS for awhile increases the likelyhood of CCSVI, which is relatively rare (only 1/6 or so of patients) have it initially, but almost all after years of MS.

se1956 wrote:At the moment my guess is that it is a high risk factor like smoking for lung cancer.
R.

Actually, to my understanding, smoking actually causes cancer, is not just a risk factor that is correlated but has no causative basis. I am not sure yet if CCSVI is or is not causative. The data is yet to be developed.

Risk factor or causative factor, what we need to know is if we relieve the CCSVI, for example by angioplasty, does that relieve the MS, either symptoms of MS or progression. Stay tuned, data being developed.

CCSVI vascular anomalies are from birth, this creates an environment of lower than normal cerebral oxygen and glucose, these conditions trigger many microparticles including Endothelin1. Endothelin1 is found extremely high in pwMS. (Hundereda of times normal) Endothelin1 causes fibrosity ( stiffness)and hypertrophy ( thickening) of blood vessel walls which could make CCSVI get worse over many years..........., then other things are deposited such as infectious agents that get to linger or iron residue from turbulent RBCs. The iron conplicates things by making causing oxidative stress and once the CCSVI gets severe it would cause the things that bring on symptoms we call MS..... the route cause is low perfusion of the brain mitochondria, which lead to cell damage and death........the immune system attempts to add the tissue repair and clean up. So there are many things occuring very slowly and in many cases intermittently, due to positions......also some folks have worse CCSVI -the actual blockages-


Its quite variable and if it was that easy, it wouldnt have taken this long to discover.

Just put your finger over a garden hose, 25%, 50%,75% and see what it does to the flow .........

..... careful with the garden hose analogy , MegansMom ..... I tried it once ....and an Ex- Sunday school teacher ..... got all pissy with me

anyway ..... we all know now , thanks to the good work of Dr. Sclafani , that veins are certainly not constructed like garden hoses.

thanks to Dr. Sclafani's , IVUS , discoveries ...... we now know the internal structure of veins . Webs , flaps , what have you. Throw in a few "pancaked'' areas ....... and is it any wonder ...... any blood would flow through these strictures.

this in turn must be why ...... catheters occasionaly get stuck inside the veins being treated . so with that thought in mind - and I've said this before - HOW IS IT POSSIBLE FOR A STENT TO MIGRATE out of such a vein ?

So much to learn ...... so much to discover ......

Let us hope ...... all new graduates of Neurology ...... throw out all the old outdated textbooks .......... and embrace the New Horizon of Neurological care ......... and accept CCSVI ......... and accept the concept .


Mr. Success