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I can read it all by myself.

That's the goal. I'm interested in CCSVI. I’ve spent a little bit of time here at TIMS, first learning that a cytokine was and all about the variations of what is a white blood cell. Then I spent (and still spend) time on bacteria and antibiotics. So you might know just exactly the level of understanding I pursue. In a nutshell, I want to understand the “big words” and I want to find a logical connection between the concepts.

So, I have tried reading about CCSVI and I’ve been slammed with new words. I understand that I don’t need to understand all of them to be here, but that’s not how I do things. I have gone through all the pages of the CCSVI post and printed up most all linked material. I intend to read all of it and understand it. I started with Chung and Hu 2008, Jugular Venous Reflux. I did not make it through the second page. Please don’t try to explain it to me just yet. I want to leave a map here for the next person. So I begin my journey of new learning with ......


Artery’s In, Sinuses Out

I have started with trying to understand how blood flows around the brain. Blood flowing through the brain doesn’t seem to work like it does elsewhere in the body. The first thing I figured out is that there’s a bunch of red lines going into the brain (from the heart) and those are called arteries. There some blue lines coming out of the brain and those are called sinuses. It’s not entirely clear what’s happening in-between, but I don’t know if that’s important. Here’s a PowerPoint that was helpful for me:

Eriksson 2007 Neuroanatomy Related to Stroke

It’s not until you get the very end of the presentation that you can read about Venous Drainage. Goes to show you how much anybody realy has cared about this topic. But, I also learned of a part called “Arachnoid Villi”. Arachnoid Villi seem to be something of an exception to what we all think of as the impenetrable blood-brain-barrier (BBB). I don’t know if these matter at all in my trying to understand CCSVI or even MS, but I guess I was very surprised to read that these things are right there letting excess spinal fluid out and into the blood system. And then, the BBB isn’t so simple either.


Does it Mater

So I was wondering where is the BBB in all this. Well at least part of it is included in the Meninges (men-in-geez), which is made up of Dura Mater, Arachnoid Mater and Pia Mater.

McCaffrey, Unit 11. Blood Supply

“Many substances present in the blood supply are unable to pass through the meninges into the cells of the central nervous system. The blood brain barrier includes two components, the blood/cerebrospinal fluid barrier and the arachnoid barrier layer.
Cerebrospinal fluid is a filtrate of blood by the choroid plexuses (capillary networks) of the ventricles which are formed by fusion of the pia mater and the ependyma (ventricular lining). In the course of this process, not all components of blood are allowed to enter the brain. According to Webster, 1999, only clear plasma passes through, leaving blood cells behind.
The arachnoid barrier layer is a part of the arachnoid meningeal layer. It is formed by tight junctions between the endothelial cells of cerebral capillaries in the arachnoid mater.”

There were some really good diagrams of the Meninges here and a very nice diagram of the Arachnoid Villus here.


Name that Vein

Going back to Zamboni, his December 2008 paper has a really nice diagram in the back that describes the 4 types of Cerebrospinal Venous Insufficiency he observed. I’m not linking to it because I’m sure you have your own copy if not several printed up. Now that I know that red means arteries and that’s outbound blood (from the heart), I can focus on the blue veins that are inbound (to the heart). Here’s a really nice webpage I printed up in color to help me understand the labels: Blood Vessels. I have identified the IVC, L-REN, Vplex, SVC, AZY, IJVr and IJVl. I still don’t know what the VVs is or some of the other unlabelled lines.

Let me just say, I start this quest with NO knowledge of how the brain is designed. These few links above, will give you a HUGE awakening about the thing between your ears. I highly recommend, if you can, print the links up in COLOR because, 1) good reference material and 2) don't know how long those links will last.

I hope you don’t mind having an ABX’er along for the ride. Ken

Dr. Seuss for the CCSVI forum! Ken, I really do love you, if only for your mind and organizational skills

Thank you for taking the time to break down the circulatory system into bite size chunks.

You refer to a very important part of the CNS....the arachnoid villi.
Dr. Dake mentioned today that he thought Jeff's nausea and headache post op was due to his spinal fluid rebalancing (like the way some folks feel after a lumbar puncture), and I wondered how the heck that could happen without an LP...well, looks like the arachnoid villi needed to adjust to Jeff's very different hemodynamic flow. Thanks for sharing. I learn something new everyday around here!
cheer

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Not as perfect - Way too cool posting, great writing, Suess Humor (we always need a little of that!) fun links and graphics. I'm too pooped to read & go thru everything but first thing tomorrow am.....

The linked Erikson stroke thing is really good!thamks for posting it!

I'd like to point out something in there that may be missed:

the CSf exchanges 500 ml of fluid every day, and similar to the synovial fluid of the joints it is in part responsible for exchange of metabolites--in other words when the brain needs to get rid of something it goes ito the CSF fluid and that is delivered to the blood for removal, the CSF is not directly part of circulation. The "old" csf is exchanged for "new" often. But because of this, the periventricular veins are a very high throughput vs other veins in the brain because a lot happens there.

That is why MS shows as periventricular lesions: that is the area first and most impacted by CCSVI because that is the part of the cerebral circulation moving the most fluid, and where backup can happen first.

This is one reason why the CCSVI model is better than the autoimmune model. If the immune system is primed to attck the brain--IT SHOULD HAVE NO PREFERENCE FOR TISSUE TO ATTACK-- As in ADEM, an autoimmune demyelinting disease, it should attack anywhere and everywhere, but MS doesn't; it attacks along the veins and specifically the periventricular veins.

this is very nicely explained by the CCSVI model:
The part of the brain circulation with the most demand is the area where the MS lesions start; obviously this is the area where CCSVI would show up first.
marie

But because of this, the periventricular veins are a very high throughput vs other veins in the brain because a lot happens there.

That is why MS shows as periventricular lesions: that is the area first and most impacted by CCSVI because that is the part of the cerebral circulation moving the most fluid, and where backup can happen first.

Thanks for the explanation, Marie. (I learned 2 new things today!) It sure makes sense using the CCSVI model. This part of the brain has the most circulatory "action" and reflux would stress the BBbarrier at these busy places....Jeff sure had a boatload of lesions in the periventricular area...makes sense now.

Question...a lumbar puncture can often cause painful headache...is this because of displacement of spinal fluid and a change in pressure, or is there another mechanism at work? Would this change in pressure explain the headache after stent placement? We were surprised of the severity of it.
AC

The brain is very constant in terms of the amount of volume there, the blood plus the CSF plus the parenchyma is the same volume all the time so if you get, say, atrophy the amount of CSf goes up to compensate for that and the overall volume stays the same.... this is because the skull is one size fits everything in there and you can't have the brain sloching around with air spce around it of course--some if one volume goes down something else has to go up. that's why MSers with atrophy have such big ventricles--full of fluid of course.

If you interefere with the system and suddenly take CSF it makes a terrible headache because it disturbs the balance and the body has to adjust and make up for it.

I am guessing that the suddenly restored blood flow resulted in changing fluid dynamics until this reached equilibrium again... because brain parenchyma plus CSF plus blood equals the total, and suddenly the blood volume backed up in there was reduced... Apparently yeserday the fluid dynamics were back in balance
marie

So I’m at a bit of a log jam. I’m going to wear out my Google at the pace I’m going. Obsessive? Moi? Cheer, it’s great to be loved for my obsessiveness. So I’ll do replies first. I have to come back to the spinal fluid pressure, it’s in the giant pile of paper. I do think there must be something to this that, at a minimum, is worth understanding. If a vein valve can malfunction, how about the arachnoid villi? Chris, promise to get back to this along the way. Thanks Peek. Marie, I agree, isn’t that interesting? It’s going to take a while for me to get caught up, but at least I’ve started.

Oh, I get it! It’s like a Tree!

So all these blue vein lines are like twigs on a tree and they’re all working back to the heart. There are TWO of them that funnel all the blood into the heart, the Superior Vena Cava (SVC) and the Inferior Vena Cava (IVC), on the top and bottom of the heart, respectively. So all these veins we are thinking about work their way back to those two.

So going backwards, the Renal Vein empties into the IVC and the Azygos and Internal Jugular Veins empty into the SVC. Here is the coolest website I could find for “decoding” this stuff; it’s called InstantAnatomy.net.

Stuff I’m not sure about is:

1) I can’t find anything that explains how the Renal Vein also empties into the Azygos Vein, ideally a diagram.
2) I can’t find explanation or diagrams that explain and show how the Vertebral Vein and Vertebral Plexus are or are not related and how the Vertebral Plexus is connected to the Azygos Vein.

I also found some cool illustrations here and here. Tonight I will backtrack and try reading about overall circulation to see if I can get at these questions in a more “big picture” way. I’m still not able to read page 2 of Chung and Hu, but I’m not giving up.

One Endothelium, Two Endothelium

I’m not so sure I have this completely correct above, in the first post. I mean, it seems that endothelium can occur in more than one way and it’s working as protection of the brain, isn’t the same as how it works to protect a blood vessel. I suppose I’ll have to come back to this too.

Ken

Hi Napay,
Those are some great links! Thanks for posting them.

NHE

1) I can’t find anything that explains how the Renal Vein also empties into the Azygos Vein, ideally a diagram.

it does not, it goes to the IVC The azygos drains a lot of the abdominal cavity but the organs themselves, like kidneys and liver, have a more direct link to the vc system. You detoxify with these so you need quick sure direct drainage. do wiki renal vein or wiki azygos

I can’t find explanation or diagrams that explain and show how the Vertebral Vein and Vertebral Plexus are or are not related and how the Vertebral Plexus is connected to the Azygos Vein.

the vertebral veins go to the azygos right next to where the jugs go in to the subclavan just before they merge with the vc, shortened url
page down to get it all on that one..............

the plexi drain into the VV near the foramen magnum the giant hole at the bottom of your skull. Read this one not just pictures do it...
shortened url
I think it is important to remember that ALL of these are connected and they all drain into the VC within a few inches of one another. everything has to get to one of the venae cavae and thus into the heart. There is no other destination.

Most of the stenoses are found in the azygos or jugulars it seems so far; for some reason that size of vein seems to be the weak link (the femoral in the lower body is similar in terms of place in the circulation system and is the problem for leg drainage), but Dr Dake feels that every one of us will have a unique pattern of stenosis, individual for you and only known once the MRV/venography is done.

The schelling papers made a lot out of the progressive person having something different about the CSF pressures--I don't think that is panning out at all, itis more an azygos stenosis backing up the VV's and that causing the spinal lesions so the complexity he projected is less than it seemed there. He wrote years ago we have much better technology today.......

It takes 1000 words to undo a Picture

Renal Vein
Not connected to the Azygos; Renal vein is connected to the IVC. Thank you Marie. This raises an interesting complexity in my effort to understand Zamboni, The diagrams in the back of his paper look like the Azygos is connected to the Renal vein. I understand that it does not, but it’s tough right now to unthink this because I was of the understanding that there was a connection there as appears to be drawn.

I also understand that I will need to detail out the “Figure 3” narrative in order to really comprehend this. My goal is to have a functioning understanding of what the flow is supposed to be so I can then understand the deviant flow of CCSVI.

Vertebral Vein
Marie, what a find! Some of the best pictures I’ve seen yet. I know you linked it above, but I would like it to be really visible here ---- WikiMD – Veins of the Neck. I can really see here that the Vertebral vein is a head and neck thing and not a spine thing as I assumed from the diagrams in Zamboni’s paper. I don’t mean to be criticizing Zamboni; shouldn’t sound that way, just making it clear that for me it was unclear. I went back to InstantAnatomy and, sure enough found the Vertebral Vein right exactly were it’s supposed to be. I actually think I’m going to try to redraw Zamboni’s diagrams starting with this one as the starting point. I also, think that trying to redraw them will help me make better sense of all this.

Vertebral Plexus
I’m having trouble with this one. If the Vertebral Plexus drain into the Vertebral Veins, then the Vertebral Plexus is entirely in the head and neck where the Vertebral Vein is, yes? But, in Zamboni’s diagram, the Vertebral Plexus seem to empty into the Azygos. Here are some diagrams I found that might help, but might not. They started out looking interesting, but couldn’t find the Vertebral Plexus on them. Cool diagrams from Vesalius website; which by the way was free despite appearing to require a registration.

Next Logical Wonderment

So while I’m busy with my crayons drawing up a new diagram, Marie, I need to thank you again for the link to Cheer’s explanation of how this is linked to blood brain barrier breach:

cheerleader wrote:Just to clarify...it's NOT about venous pressure in the brain and spine, it IS about backflow, or "reflux." The stenosis block the flow of blood back to the heart and created reflux. The demyelinating lesions are not "edema", (which is swelling), but are created due to edema and reflux causing a break of the blood brain barrier and deposition of all kinds of things into the brain that shouldn't be there. This is what activates the demyelinating process.

As I try to put this together, I have trouble envisioning a blocked Renal Vein. I mean, it looks so big and short. I guess I just have to draw the line there and accept that the dang thing gets blocked and causes backflow. So, in the case of the Renal vein, we’re talking about the kidney. I like this example because it’s neutral to MS. Where does the blood go? In the case of the kidney, there doesn’t seem to be many places this could go except out in the urine, but then, wouldn’t someone notice that? I’m certain there is a logical answer for this. A few days ago, I would have looked at the Type D diagram and assumed that Renal blockage would send the blood back up the Vertebral Plexus, but those don’t seem to be attached anymore.

High School Biology

So I just need to add something here that just keeps popping up in my head. I was the kid who crawled out of high school biology in a cold sweat during the movie about the heart. That was me, crawling the entire length of the school to the nurses office (thank God it was during classes) where I stayed most all the rest of the day. Blood has always bothered me and reading this stuff has been hard. But, I'm doing it and I think it's getting better. I say this because I've realized today that 1) Gray's Anatomy is AWESOME and 2) I can look at this stuff with a purpose that overcomes any childhood fears I may be lugging around. WikiMD is Fantastic! I have printed up a nice color booklet that will take me into the weekend.

Ken

Ken I am just lost where is this blocked renal vein in diagram that you are anxious to understand?

The vertebral plexus drain to the vertebral vein hooked up at the foramen magnum it said in the neck link... I can't see that specific connection in any greys anatomy deals they said it in the paragraph. According to one of Zamboni's things I read somewhere the backup can go all the way down to the lumbar veins in some people.

But it almost does not matter because Kim may not have any blockage of the azygos--it may be just her jugular.... The MRV will enlighten it for her specifically.

here's the thing and it is a big difference vs the other things we've been dealing in: there is a test and it shows a specific abnormality for that individual--that is the beauty of this, there is hard evidence for each person. I love that about it.

mrhodes40 wrote:Ken I am just lost where is this blocked renal vein in diagram that you are anxious to understand?

In Type D, there is a red X on the chart on the L-REN vein. At least, that's how it looks. I'll be back more tomorrow. Thanks for helping me. Ken

notasperfectasyou wrote:

mrhodes40 wrote:Ken I am just lost where is this blocked renal vein in diagram that you are anxious to understand?

In Type D, there is a red X on the chart on the L-REN vein. At least, that's how it looks. I'll be back more tomorrow. Thanks for helping me. Ken

Ken, that's still showing blockage in the azygos, which continues into the left renal vein (see how the line w/ arrow (L-REN) is only for the short segment?) Type D, primary progressive MS, involves multiple stenosis in the azygos. The exact location of the blockage will be unique to the individual. Dr. Dake told us that Jeff's jugular stenosis was higher than most...and would have been missed if we had done doppler alone. Each MS patient will have variations of these patterns, and each will be unique. The MRV will be the method of diagnosis for CCSVI.

As Marie says-

here's the thing and it is a big difference vs the other things we've been dealing in: there is a test and it shows a specific abnormality for that individual--that is the beauty of this, there is hard evidence for each person. I love that about it.

Me too!
cheer

Ah, I see it is confusing those sort of model diagrams, but heres some verbiage from above those diagrams regarding what was seen on venography explaining it

Most cases involved membranous obstruction of the junction with the superior
vena cava, twisting, or, less frequently, septum and atresia as can be seen in
the x-rays in Figure 2a; in 12 cases the azygous system presented stenoses
at several points up to even atresia of the lumbar plexuses (18%) (Fig. 2c).
As for the jugular veins, they were found to be stenosed unilaterally or
bilaterally in 59/65 patients (91%). The stenoses were frequently annulus and
septum, followed by atresia; no twisting was observed (Fig. 2b).
Finally the number of extracranial venous wall stenoses did not differ
significantly in patients treated with immunosuppressant/immunomodulator
agents or in never-treated patients (p= ns, Fischer exact test).

when I saw the diagram I thought that lowest x represented the occassional person with the lumbar issue. There is no way MSers have renal vein blockage or we'd all have kidney failure and this would have been figured out long ago so that is impossible...see renal vein thrombosis here

(In fact that is one reason why this model is so good: if there is a proven blockage in an organ's vein, like the thrombosis mentioned in the kidney link, it hurts the organ....why would the brain be different? HOW could the brain be different?)

But I want to point out again the critical issue: even if a person has pattern D they may not have a stenosis pattern that looks anything like that drawing at all, in fact Dr Dake thinks those diagrams and descriptions of patterns are way too limited and that each person will be utterly unique, the commonality being stenosis SOMEWHERE in the veins that drain the brain.

I love to read over the Dec '08 paper and remind myself of some of the interesting facts, for example they defined a sigificant stenosis as something in excess of 50% blockage and all MSers had that on venogram. Venograms are a reliable diagnostic so that is comforting to me as I plan to see Dr Dake next monday for the MRV / MRA.