DrSclafani answers some questions

[NZer1]

Dr. Sclafani to present "The many reasons of failure to improve or hold on to improvements after CCSVI treatment"

Quote;
“The highlights of my career always involve acceptance by peers and patients of unconventional solutions to desperate situations. The future of medicine is never predictable. Breakthroughs happen when someone sees something hidden in plain sight. Innovation in medicine requires obsession to the goal; one must have the grandiosity to believe that you can solve the problem, the courage to see that skepticism and rejection are constructive aids to success and the humility to recognize that the innovator is merely a vehicle to a better world. “

[drsclafani]

The left seems to have a candy-cane twist and the dye seems to pool lower down. Looks like a septum or something is holding it in? The right seems non-existent, and if no dye is getting past the jugulars at all, maybe there just aren't enough others and collateral veins, to handle what should be the jugulars' flow in prone position?

Also, I had another question. Do you examine or what the flow looks like in both upright and prone? Not to treat spinal veins, but just as a double-check before treatment??

Candy canes are for christmas. I do not accept the "candy cane" as significant. it is described in the azygos vein but when you take a deep breath this narrowing goes away completely.

the images of the left IJV are just underfilling and "dribbling" via collaterals from the right sided injection. We will have to look at the venogram from the same sided injection of contrast media.

[drsclafani]

What could be the causes of dural sinus obstruction?

It could be a clot, and if it's a removable clot, all the better. Or there could be agenesis (of the right tranverse sinus) or an over-sized arachnoid granulation.

People with CCSVI could be at increased risk for sinus thrombosis due to flow being slowed because of jugular obstructions; it certainly seems to follow.

..and some kind of tumor

and most commonly, a congenital abnormality.

[drsclafani]

I'm guessing here but the way the flow reverses and the region around the brain stem/foramen magnum I am suspicious of a Chiari Malformation.

I also get the impression there are 'twists' or internal plaques in veins because of the way that the blood is pooling in places. Really hard to see what is happening in a still one dimension image?

here are a couple of lateral views of the right internal jugular vein.



#1 you have already seen.
#2 is a lateral view of a different injection of contrast media in the right internal jugular vein (RIJV) shows the contrast hugging the base of the skull (red arrows). This is the right Occipital sinus. The dye goes up to the torcular herophili where it then drains into the left transverse sinus (orange arrows) and then down the left internal jugular vein (black arrow)
#3 is another venogram with the guidewire advanced as far asit was possible to advance it. the wire is coiled on itself at an impass (green oval circle). There is no flow in the more posterior part of the right transverse sinus. The contrast media is draining through a very large occipital emissary vein (black dashed arrow)

It turns out that the patient had a severe bout of headaches several years earlier. MRI and MRV diagnosed a "blood clot in the brain" for which she was given heparin and then coumadin. Since no one would treat a hemorrhage in the brain with anticoagulants, I conclude that the patient had a blood clot in the dural sinus which is treated by anticoagulation.

So the diagnosis on the right side is thrombosis of the transverse sinus in addition to right internal jugular vein stenosis at the inferior jugular bulb caused by valvular malformation.

[cheerleader]

Hi Doc--
Great case. Look forward to finally meeting you in Canada this September!
Another cause of dural sinus stenosis can be idiopathic intracranial hypertension (IHH, was known as pseudotumor cerebri)
IHH can cause thrombosis, as well as headache, tinnitus, and visual loss. Our family has learned a bunch about this condition....
not sure if it's part of this patient's profile.
cheer (Joan)

[Cece]

So the diagnosis on the right side is thrombosis of the transverse sinus in addition to right internal jugular vein stenosis at the inferior jugular bulb caused by valvular malformation.

Treatment is angioplasty of the valve and, for the sinus, either attempted flushing of clot or no treatment or referral to a neurointerventional radiologist partner? If it's a complete impasse, I guess no treatment is the answer. Stenting can be done in sinuses but that's if it was a partial occlusion and this is a complete occlusion? The guidewire does not get through from this side but did you try from the other side?

[NZer1]

Dr S the term 'clot' seems very loose.

I have been pondering this case and naturally we all will think, ok,
what has caused the restriction,
when did it happen,
why didn't it resolve naturally,
is there more problems down stream that are slowing the flow,
will this reoccur,
is the 'clot' able to be analysed to find out it's composition,
was this caused by medications,
was it caused by bacteria,
was it caused by diet/plaque,
is there other veins that will have the same issue,
why this particular place,
how long has it taken for the collaterals to form and enable by-pass,
has this occurred due to injury/falls/trauma,
is this going to be a common finding,
if there is 'clotting' is it also happening at capillaries,
how does this link to the symptoms and lesions that this patient has,
are the lesions that this patient has on MRI typical vein centred 'MS' lesions as per Franz Schelling?

There are many more questions of course and my brain is not functional at the moment to think further, but I will keep thinking about this ;)

Nigel

[mo_en]

actually the guidewire in figure 8 goes from the left internal jugular vein across the sinuses and down into the right internal jugular vein. That caused me some confusion.

The guidewire goes through both transverse sinuses, doesn't it? Yet, the blood refuses to go down the right one. Maybe, relieving the valvular obstruction will reduce the resistance of this path?

[pelopidas]

A really rare case report, worth publishing!

[Needled]

Dr. S,
Are you still surprised at the types and variety of problems you're finding, 3 1/2 years after performing your first ccsvi procedure?
Cheryle

[Cece]

Did the patient experiences any changes in MS status (onset or worsening or ?) around the time of the dural sinus thrombosis occurring several years back?

[NHE]

Dr. Sclafani,
So what steps were taken for treatment and what effects, improvements or otherwise, were reported by the patient?

[drsclafani]

So the diagnosis on the right side is thrombosis of the transverse sinus in addition to right internal jugular vein stenosis at the inferior jugular bulb caused by valvular malformation.

Treatment is angioplasty of the valve and, for the sinus, either attempted flushing of clot or no treatment or referral to a neurointerventional radiologist partner? If it's a complete impasse, I guess no treatment is the answer. Stenting can be done in sinuses but that's if it was a partial occlusion and this is a complete occlusion? The guidewire does not get through from this side but did you try from the other side?

I did. image #1 shows the guidewire going through a catheter in the left internal jugular vein, into the left dural sinuses, then into the right dural sinuses to exit through the jugular foramen into the right internal jugular vein. I thought it would be easy to get the catheter to follow but it would not pass the midline.



The reason is seen in image #2. The guidewire actually crossed the midline in this small vein, too small to get the catheter to advance beyond it.The little beak (purple arrow) shows the occluded transverse sinus ending.

[drsclafani]

Dr S the term 'clot' seems very loose.

I have been pondering this case and naturally we all will think, ok,
what has caused the restriction,
when did it happen,
why didn't it resolve naturally,
is there more problems down stream that are slowing the flow,
will this reoccur,
is the 'clot' able to be analysed to find out it's composition,
was this caused by medications,
was it caused by bacteria,
was it caused by diet/plaque,
is there other veins that will have the same issue,
why this particular place,
how long has it taken for the collaterals to form and enable by-pass,
has this occurred due to injury/falls/trauma,
is this going to be a common finding,
if there is 'clotting' is it also happening at capillaries,
how does this link to the symptoms and lesions that this patient has,
are the lesions that this patient has on MRI typical vein centred 'MS' lesions as per Franz Schelling?

There are many more questions of course and my brain is not functional at the moment to think further, but I will keep thinking about this ;)

Nigel

Good comments Nigel

in this case the patient has bilateral internal jugular valvular stenoses at the inferior jugular bulb. This would cause slow flow, but we rarely see occlusions like these in the dural sinuses. This patient was on birth control pills which is a procoagulant and known to cause venous thrombosis

[drsclafani]

actually the guidewire in figure 8 goes from the left internal jugular vein across the sinuses and down into the right internal jugular vein. That caused me some confusion.

The guidewire goes through both transverse sinuses, doesn't it? Yet, the blood refuses to go down the right one. Maybe, relieving the valvular obstruction will reduce the resistance of this path?

Actually, the contrast media does not go down the right sinus but rather through a collateral.