DrSclafani answers some questions

[drsclafani]

Dr. S,
1) Were her pain during and lack of improvement after the second procedure indications that caused you to investigate the VVs with venography?
2) Is VV venography something you routinely/only perform when indicated?
3) Did you also perform venography on the R-VV? Average size?

Cece, great analysis, great questions!

1. no. i investigated the vertebral vein based upon discoveries during the jugular venography and from imaging done in Ankara.
2. i do not do VV venography routinely because there is rarely anything to do. I personally dont think it is commonly involved in ccsvi
3. no did not. Average size is about 3 mm. it is often incomplete in the upper neck as it drains the vertebral plexus.

I might add that IVUS of the vertebral vein was exciting. It showed anatomy wonderfully and did confirm suspected abnormalities

[drsclafani]

The vein in the left image, possibly the right internal jugular, appears to have a twist in it that is impeding flow. The vein in the right image appears hightly disorganized at the top with contrast backfilling some collaterals. It also appears to have a potential blockage or constriction in this region. There appears to be a partial obstruction near the lower part of the vein in the image. My guess is that this could be a blocked valve or some other obstruction where it joins with another vein. Is this the left internal jugular? Was the prior treatment in the upper portion of the vein? It appears as though it may be damaged.

NHE

the upper vein is damaged but you are all assuming that the right image is the left jugular which it is not.
the right jugular (on the left) is n ot twisted, just dilated above the pathology which is a stiff lower jugular and immobile valve by IVUS. It was dilated without difficulty

[drsclafani]

It has been a while since I had the time to show an interesting case here.

This 41 year old woman visited me recently from Ankara turkey where she had previously undergone two venograms and venoplasties.
She had multiple angioplasties that resulted in clinical improvements during the first treatment. These improvements were short lasting, so she returned for another "more aggressive treatment a few months later.. She stated that no pain medications were given and that the procedure was quite painful. This treatment did not result in any return of improvements. She believed that her walking actually deteriorated after this treatment.

On my assessment she was a well dressed, organized, oriented, well speaking woman. She had weakness in both lower extremities, abnormal Rhomberg test, absent gag reflex, nystagmus and positive Babinski. Her gait was abnormal and she walked with a cane.

I performed venography which i begin to show you now.

The image below shows both internal jugular veins and a vertebral vein.

Can you tell me which is which?

what abnormalities do you see??

normally i would vote for Cece, but i think that the vertebral vein is the third one. Is it possible, and a catheter in it?..
The patient had no real ccsvi symptoms
Plus she was well dressed !

you are correct. the vertebral is the one on the right. Why a catheter in it....in good time

[drsclafani]

Ok, my knowledge is not very good, but my two cents;
- I also think that the right one is the vertebral. It seems to be very 'messed up' at the top, result of aggressive treatment?
- In the lower part of the right picture there seems to be a blockage, blocked valve??
- the middle one seems ok, but maybe a twist in the lower part.
- Left one is twisted, you can see the blood 'waiting' above the twist

Dont shoot me

Robert

robert, twists are really very uncommon, these veins are narrowed but not twisted. i think the twist is a misnomer.

you do not get shot.

[drsclafani]

It is a surprising case? Hmm.
Pelopidas, interesting, no real CCSVI symptoms...at least not the 'head' symptoms such as cogfog and disorientation. Weakness could be considered a CCSVI symptom. I suppose the vertebral vein could be doing a good enough job that the brain is drained, thus none of the 'brain' CCSVI symptoms, but then overloading the azygous and vertebral plexus systems, with injury to the spinal cord.
Did the patient have spinal MS lesions or brain lesions or both?

There were spinal lesions. But remember all these circulatory areas are interconnected and there is not a one to one correlation between location of venous stenoses and symptoms.

[drsclafani]

I don't think there's another ccsvi IR out there with a policy like this. There's one that offers half-price on second treatments. This is extremely patient-friendly, and it allows you to do the treatment as you think best. I will be interested in hearing how this affects your treatments going forward. Are there particular presentations of CCSVI that might benefit most from staged treatments? Would a patient who had a less than ideal looking endpoint be brought back for a second staged treatment? This also covers anyone who has a complication from the procedure, such as clotting, or anyone whose veins close up again soon after the procedure? This will also give you more information on the results of your techniques, if you get to see previously treated patients again within 90 days.

I also look forward to this opportunity. i can think of a few possible planned second procedures:
1. a highly resistant stenosis requiring very high pressures might be better suited to a planned second procedure rather than going overboard.
2. a questionable dissection, leading to an early ultrasound and second procedure
3. detection of an initially unrecognized lesion that is seen in retrospect after patient leaves the proceduree
4. an overly long procedure might be suspended with anticipated return.

I have to be judicious with this because the company still needs to at least make some profit to justify continuing the program. It is a for profit company.

We also will have a half priced policy for subsequent procedures. I will try to work out a technique that uses the data from the initial IVUS so that we can avoid the cost of the IVUS.

Yes, this really excites me. Compassionate care is important to me. Having patients worry about whether they can afford repeat procedures which many will need, is heartbreaking.

[Cece]

that "beautiful vein" in the middle is actually the left IJV. Yet it is the beast as you will see. It had excellent flow, but that flow was not from the brain

Beauty and the beast, is it? Was there a blockage in the dural sinus, maybe after the vertebral vein so that flow from the brain went down the vert? (edited: ok, you said in a different post that the upper LIJV was damaged, so that would be the blockage.) Was the flow in the left jugular coming from the face? How unusual.

The left jugular appears blocked. Irregular appearance down at the area of the valves with dark contrast, and the usual CCSVI appearance of a cluster of small collaterals at the top of the jugular.

yes indeed but you got to the answer because you misinterpreted the enlarged vertebral vein for an internal jugular vein. The difference between good and lucky is that the person who is good knows when she is lucky. were you good or lucky, cece?

The difference between good and lucky is reproducibility! Better to be good always than lucky sometimes....
I will try to be comforted by the fact that, back when there was a doctors' thread, one of the first questions posed was how to identify the jugular when there were more than one possibilities. There was disagreement among the participating doctors. It was a surprise because I hadn't known that was a question that needed considering. We don't make it easy for our doctors, with our tangled veins.

[npost999]

just got home Dr. S, trip home was not bad at all. No major differences that I can tell yet, but I'll keep in touch & follow up.

It was great meeting you and being in your skilled hands.

NP

[drsclafani]

just got home Dr. S, trip home was not bad at all. No major differences that I can tell yet, but I'll keep in touch & follow up.

It was great meeting you and being in your skilled hands.

NP

first do no harm and so far that has been accomplished. I look forward to some good news

s

[HappyPoet]

DrS, now that we know she has spinal lesions, a general question: IIRC, according to Dr. Schelling's theory, the lowest spinal cord lesion will be at the lowest point of reflux. What modalities can image how far down the VVP such reflux travels?

[drsclafani]

DrS, now that we know she has spinal lesions, a general question: IIRC, according to Dr. Schelling's theory, the lowest spinal cord lesion will be at the lowest point of reflux. What modalities can image how far down the VVP such reflux travels?

I cannot answer that. With the discovery of the potential impact of the Nutcracker syndrome , reflux can extend down to the bottom of the spinal cord. Remember that the spinal cord ends around the twelfth thoracic vertebra also the perivertebral plexus extends down to the sacrum

[HappyPoet]

DrS, now that we know she has spinal lesions, a general question: IIRC, according to Dr. Schelling's theory, the lowest spinal cord lesion will be at the lowest point of reflux. What modalities can image how far down the VVP such reflux travels?

I cannot answer that. With the discovery of the potential impact of the Nutcracker syndrome , reflux can extend down to the bottom of the spinal cord. Remember that the spinal cord ends around the twelfth thoracic vertebra also the perivertebral plexus extends down to the sacrum

Very interesting. Could a lesion at a certain level, therefore, be an indication of possible Nutcracker syndrome and at what level would that be? Do you think IJV blockages alone could force reflux to travel below that level? At what levels are her spinal lesions?

Also, a related personal question: I have new T5/T6 lesions, yet my IJVs (PTA one year ago) and Azygos are fine; going by Dr. Schelling's theory, any ideas where refluxed blood to those cord levels might be coming from?

[drsclafani]

DrS, now that we know she has spinal lesions, a general question: IIRC, according to Dr. Schelling's theory, the lowest spinal cord lesion will be at the lowest point of reflux. What modalities can image how far down the VVP such reflux travels?

I cannot answer that. With the discovery of the potential impact of the Nutcracker syndrome , reflux can extend down to the bottom of the spinal cord. Remember that the spinal cord ends around the twelfth thoracic vertebra also the perivertebral plexus extends down to the sacrum

Very interesting. Could a lesion at a certain level, therefore, be an indication of possible Nutcracker syndrome and at what level would that be? Do you think IJV blockages alone could force reflux to travel below that level? At what levels are her spinal lesions?

Also, a related personal question: I have new T5/T6 lesions, yet my IJVs (PTA one year ago) and Azygos are fine; going by Dr. Schelling's theory, any ideas where refluxed blood to those cord levels might be coming from?

Personally, i do not believe that you can pinpoint the location of obstructions based upon the location of lesions. I always see the venous system as a continuum.

[Cece]

Very interesting. Could a lesion at a certain level, therefore, be an indication of possible Nutcracker syndrome and at what level would that be? Do you think IJV blockages alone could force reflux to travel below that level? At what levels are her spinal lesions?

Also, a related personal question: I have new T5/T6 lesions, yet my IJVs (PTA one year ago) and Azygos are fine; going by Dr. Schelling's theory, any ideas where refluxed blood to those cord levels might be coming from?

Were you ever checked for Nutcracker, HP? It can be diagnosed with noninvasive doppler ultrasound ( www.ajronline.org/content/172/1/39.abstract )
Very sorry to hear about the new lesions.

[HappyPoet]

Cece, thanks, I didn't know DUS can diagnose NS. Originally, I had been thinking along the lines of webs or septums being inside the hemiazygos as a possibility for the new lesions. Although I don't seem to have any symptoms of NS, for peace of mind, I'll ask to be checked for it at my next follow-up DUS.