DrSclafani answers some questions

Donnchadh · Post by **Donnchadh** » Sun Jul 10, 2011 7:12 pm

drsclafani wrote:
Donnchadh wrote:Dr. Sclafani:

Has anyone been treated for stenosis in the sigmoid sinus?

Donnchadh
yes there are many reports of stenting of dural sinuses in the literature. But none to my knowledge have been reported in patients with MS or other demyelinating diseases.
I have only been looking at these sinuses in a limited number of patients and haven't seen any stenoses, and only one thrombosis.The most important finding i am noting is a prominent collateral vein going posteriorly

Sounds like what I suspect is going on with me. I had two stenosis in the internal jugular vein, which prompted the development of extensive collateral veins to bypass them. One stenosis is located very high up on the IJV. Even with the stenosis being opened, it's still easier for the blood to flow through the collateral veins since their intake entrance is located ahead of the sigmoid sinus. I think its not so much a stenosis per se, but a collapse of the sigmoid sinus from being bypassed.

Putting a stent in the sigmoid sinus scares the **** out of me.

My guesses only; as I am not a doctor.

Donnchadh

1eye · Post by **1eye** » Mon Jul 11, 2011 6:09 am

Dr. Sclafani:

Greetings, salutations and best wishes. I have a question for the round table, unless the answer would be so trivial as to embarrass the asker: I heard the only stupid question is one that isn't asked, so:

You could work up to it with a discussion of the health of the endothelium, the structure of the vein in cross-section, veins vs arteries, etc... I am (possibly mis-)informed, there are no smooth muscles in brain veins?

Why not? Are Starling Resistors and capillaries supposed to do all the flow control?

Perhaps an evolutionary biology answer, or maybe it's just to facilitate crossing the BBB when it is necessary. Anyway it does not trigger anything very intuitive for me, which may be a symptom...

If true, maybe this is another reason stenting veins up there doesn't take so well?

Thekla · Post by **Thekla** » Mon Jul 11, 2011 11:21 am

I know of one patient who had web-like occlusions in her sinus veins treated in her 2nd round. She had spectacular improvements after each round going from an EDSS of 7.5 or 8 to basically normal. I don't know that the sinus treatment was the key though, ijv and azygous were also treated and maybe a few others. She is an inspiration.

Donnchadh · Post by **Donnchadh** » Tue Jul 12, 2011 8:50 am

There is something I don't understand about the sigmoid sinus. The second IR who treated me told me he went as high as he could up the internal jugular vein with his wire, and couldn't go further.

How could a stent be implanted if the catheter wire can't traverse the sigmoid sinus? Has anyone ballooned the sigmoid sinus?

Donnchadh

KikiT · Post by **KikiT** » Tue Jul 12, 2011 1:00 pm

drsclafani wrote:
Donnchadh wrote:Dr. Sclafani:

Has anyone been treated for stenosis in the sigmoid sinus?

Donnchadh
yes there are many reports of stenting of dural sinuses in the literature. But none to my knowledge have been reported in patients with MS or other demyelinating diseases.
I have only been looking at these sinuses in a limited number of patients and havent seen any stenoses, and only one thrombosis.The most important finding i am noting is a prominent collateral vein going posteriorly

Is there a certain crireria why or why not you look into the dural sinus' of some patients and not others, or was I just a lucky one??????

KikiT · Post by **KikiT** » Tue Jul 12, 2011 1:19 pm

drsclafani wrote:
Donnchadh wrote:Dr. Sclafani:

Has anyone been treated for stenosis in the sigmoid sinus?

Donnchadh
yes there are many reports of stenting of dural sinuses in the literature. But none to my knowledge have been reported in patients with MS or other demyelinating diseases.
I have only been looking at these sinuses in a limited number of patients and havent seen any stenoses, and only one thrombosis.The most important finding i am noting is a prominent collateral vein going posteriorly

Is there a certain criteria why or why not you look into the dural sinus' of some patients and not others, or was I just lucky????

Cece · Post by **Cece** » Tue Jul 12, 2011 7:13 pm

I read his statement differently, kikit, could he mean he has only just begun looking at patients' dural sinuses and therefore it is a limited number?

He mentioned yesterday that if a patient has a vein that joins and flows into the jugular, it can give the appearance of the vein having flow, when really it is from the other vein flowing in and not the jugular itself draining blood from the brain. Without following all the way to the dural sinuses, it is impossible to know for sure.

drsclafani · Post by **drsclafani** » Wed Jul 13, 2011 3:39 am

Donnchadh wrote:There is something I don't understand about the sigmoid sinus. The second IR who treated me told me he went as high as he could up the internal jugular vein with his wire, and couldn't go further.

How could a stent be implanted if the catheter wire can't traverse the sigmoid sinus? Has anyone ballooned the sigmoid sinus?

Donnchadh

\
I certainly cannot speak for your doctors.
my personal experience with dural sinus cathterization started with my involvement with ccsvi. I am personally not going to treat anything in those sinuses for quite some time, except for attempts to eliminate some thrombus. I will refer to an interventional neuroradiologist who has more familiarity than I. This is not ready for most IRs iIMHO
now all i have to do is find an INR who will accept the ccsvi concept!!

drsclafani · Post by **drsclafani** » Wed Jul 13, 2011 3:41 am

KikiT wrote:
drsclafani wrote:
Donnchadh wrote:Dr. Sclafani:

Has anyone been treated for stenosis in the sigmoid sinus?

Donnchadh
yes there are many reports of stenting of dural sinuses in the literature. But none to my knowledge have been reported in patients with MS or other demyelinating diseases.
I have only been looking at these sinuses in a limited number of patients and havent seen any stenoses, and only one thrombosis.The most important finding i am noting is a prominent collateral vein going posteriorly
Is there a certain crireria why or why not you look into the dural sinus' of some patients and not others, or was I just a lucky one??????

the criteria is that i have learned that it is important to check the connection between the brain veins and the neck veins in order to see completely the cerebrospinal outflow. Changes in technique make it much safer now for me to approach that catheterization. The guidewire i am using is very much smaller and more delicate.

drsclafani · Post by **drsclafani** » Wed Jul 13, 2011 3:43 am

Cece wrote:I read his statement differently, kikit, could he mean he has only just begun looking at patients' dural sinuses and therefore it is a limited number?

He mentioned yesterday that if a patient has a vein that joins and flows into the jugular, it can give the appearance of the vein having flow, when really it is from the other vein flowing in and not the jugular itself draining blood from the brain. Without following all the way to the dural sinuses, it is impossible to know for sure.

correct Cece. to clarify your words, the IJV has branches, that can drain into it. So if you see flow in the jugular vein but do not see the entire jugular vein up into the head, how do you know if the brain vein is connected to the neck vein.

as a kid,i recall a song about that body parts connected to other body parts. i guess is stuck with me. i was born a doctor, you know

Donnchadh · Post by **Donnchadh** » Wed Jul 13, 2011 4:20 am

drsclafani wrote:
Donnchadh wrote:There is something I don't understand about the sigmoid sinus. The second IR who treated me told me he went as high as he could up the internal jugular vein with his wire, and couldn't go further.

How could a stent be implanted if the catheter wire can't traverse the sigmoid sinus? Has anyone ballooned the sigmoid sinus?

Donnchadh
I certainly cannot speak for your doctors.
my personal experience with dural sinus cathterization started with my involvement with ccsvi. I am personally not going to treat anything in those sinuses for quite some time, except for attempts to eliminate some thrombus. I will refer to an interventional neuroradiologist who has more familiarity than I. This is not ready for most IRs iIMHO
now all i have to do is find an INR who will accept the ccsvi concept!!

An "interventional neuroradiologist" sounds like a specialist's specialist! Must be a rare breed. My remaining symptoms are tolerable (or at least no longer getting worse) so I will simply wait for the "art" to emerge and mature. I have had three separate procedures done* and lucked out in that there were no complications, but don't want to press my remaining luck.

At least, I understand what's wrong and where it's located-sigmoid sinus. Meanwhile, it will give a chance for my veins to fully recover.

*wanted to add, that with advances in treatment today, I think it could been done with only one procedure. But that's the price of being an early adopter-the infamous learning curve.

Donnchadh

magoo · Post by **magoo** » Wed Jul 13, 2011 6:34 am

drsclafani wrote:
magoo wrote:
drsclafani wrote:
the internal jugular vein carries approximatly 375 ml per minuted out of the brain. the Azygous probably drains about 50-75 ml per minute. Add it up the cerebrospinal venous flow is about800-1000 ml per minute.

Each renal vein drains 500 ml per minute.

obstruction of the renal vein means that about 500 ml of blood needs collateral blood flow. One of the important collateral veins is the hemiazygous which connects to the azygous. So if half of that blood went through the azygous, it would markedly increase the volume traversing that area. If two or three of the major cerebrospinal veins are occluded, you can see how the added drainage of renal venous flow through the cerebrospinal circulation is going to impact on ccsvi

does that help?
Yes, Dr. Scalfani, that does help. Thank you.
Another inquiry...Do you examine and treat this area, and if so, how often are you finding problems? If you do not examine this area, why? Is it only important to treat if you have significant blockages in the Azygous?
I hope your symposium is a great success! Wish I could make it!
initially i looked periodically or when azygous disease was noted but more recently i am looking at it routinely and am finding nutcracker more frequently. Yesterday i found one in a patient with bilateral jugular valvular stenoses and a normal azygous vein (but with a large hemiazygous vein making me suspect that i was going to find a nutcracker syndrome). I did find one and stented it. It will be interesting to see how the patient does after this treatment.

Ideally it would have been more interesting to treat only the jugular valvular stenoses. Then after three months go back and treat the renal vein obstruction. But I chose not to propose that to the patient.

Thank you for your answer. I had not heard the term "nutcracker" before and learned quite a bit after reading about it. It is interesting to learn that you would stent this area. Since I had the nutcracker and the MT with no stents, I wonder about retreatment in the future. Hmmmm, maybe I'll have to get to NY when the time comes?

Cece · Post by **Cece** » Wed Jul 13, 2011 7:18 am

At one point during my follow-up procedure on Monday, he was expecting because of the fast flow in my extra-large azygous, that he would find a renal stenosis. Prior to the procedure, he discussed this as a possibility. Had it been found, which it was not, he would have stented the renal vein.

Unlike the jugulars which have variable flow dependent on posture, the renal vein has constant flow and the risks of clotting or complications with a stent seem to be less.

Did you read Dr. Arata's opinion that the renal and iliac veins should not be checked in the absence of symptoms, that this was somewhat akin to battery? But from a patient's perspective, whenever I hear of people who have learned they have a renal stenosis or MT, they want to know this.

Cece · Post by **Cece** » Wed Jul 13, 2011 7:31 am

as a kid,i recall a song about that body parts connected to other body parts. i guess is stuck with me. i was born a doctor, you know

"Be not afraid of greatness: some are born great, some achieve greatness, and some have greatness thrust upon them." ;)

We are fortunate to have some truly great doctors working on CCSVI.

Thanks for clarifying my words, I did not mean that the jugular went all the way to the brain and it sounded that way from what I said.

Brain vein = dural sinus, neck vein = jugular.

drsclafani · Post by **drsclafani** » Wed Jul 13, 2011 8:38 am

magoo wrote:
drsclafani wrote:
magoo wrote:
Yes, Dr. Scalfani, that does help. Thank you.
Another inquiry...Do you examine and treat this area, and if so, how often are you finding problems? If you do not examine this area, why? Is it only important to treat if you have significant blockages in the Azygous?
I hope your symposium is a great success! Wish I could make it!
initially i looked periodically or when azygous disease was noted but more recently i am looking at it routinely and am finding nutcracker more frequently. Yesterday i found one in a patient with bilateral jugular valvular stenoses and a normal azygous vein (but with a large hemiazygous vein making me suspect that i was going to find a nutcracker syndrome). I did find one and stented it. It will be interesting to see how the patient does after this treatment.

Ideally it would have been more interesting to treat only the jugular valvular stenoses. Then after three months go back and treat the renal vein obstruction. But I chose not to propose that to the patient.
Thank you for your answer. I had not heard the term "nutcracker" before and learned quite a bit after reading about it. It is interesting to learn that you would stent this area. Since I had the nutcracker and the MT with no stents, I wonder about retreatment in the future. Hmmmm, maybe I'll have to get to NY when the time comes?

nutcracker and MT are both compression stenoses. Thus balloon angioplasty is not expected to be effective long term in either