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Quantified hemodynamic parameters of the venous system in multiple sclerosis: A systematic review. Mult Scler Relat Disord 2022; 57:103477. [PMID: 34990911 DOI: 10.1016/j.msard.2021.103477] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/28/2021] [Revised: 12/07/2021] [Accepted: 12/26/2021] [Indexed: 11/23/2022]
Abstract
BACKGROUND Multiple Sclerosis (MS) is a complex neurodegenerative condition that is influenced by a combination of genetic and environmental factors. Included in these factors is the venous system, however, the extent to which it influences the etiology of MS has yet to be fully characterised. The aim of this review is to critically summarize the literature available concerning the venous system in MS, primarily concerning specific data on the venous pressure and blood flow in this system. METHODS A systematic review was conducted with the application of the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) criteria. The advanced search functions of both the Scopus and PubMed databases were used to conduct the literature search, resulting in 136 unique articles initially identified. Applying relevant exclusion criteria, 22 of the studies were chosen for this review. RESULTS The selected studies were analysed for venous pressure and blood flow related findings, with 14 studies contributing data on the internal jugular vein (IJV) flow rate, 5 on blood flows of the intracranial venous sinuses, 2 on blood flow pulsatility and 6 supplying information relevant to the venous pressure (3 studies contributed to multiple areas). The general findings of the review included that the IJV flow was not significantly different between MS patients and controls, however, there were variances between stenotic (S) and non-stenotic (NS) MS patients. Due to the limited data in the other two areas defined in this review, further research is required to establish if any variances in MS are present. CONCLUSION It remains unclear if there are significant differences in many flow variables between MS patients and controls considered in this review. It would be advantageous if future work in this area focused on understanding the hemodynamics of this system, primarily concerning how the flow rate, venous pressure and vascular resistance are related, and any impact that these factors have on the etiology of MS.
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Zamboni P, Galeotti R, Salvi F, Giaquinta A, Setacci C, Alborino S, Guzzardi G, Sclafani SJ, Maietti E, Veroux P. Effects of Venous Angioplasty on Cerebral Lesions in Multiple Sclerosis: Expanded Analysis of the Brave Dreams Double-Blind, Sham-Controlled Randomized Trial. J Endovasc Ther 2019; 27:1526602819890110. [PMID: 31735108 PMCID: PMC6970429 DOI: 10.1177/1526602819890110] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Purpose: To evaluate if jugular vein flow restoration in various venographic defects indicative of chronic cerebrospinal venous insufficiency (CCSVI) in multiple sclerosis (MS) patients can have positive effects on cerebral lesions identified using magnetic resonance imaging (MRI). Materials and Methods: The Brave Dreams trial (ClinicalTrials.gov identifier NCT01371760) was a multicenter, randomized, parallel group, double-blind, sham-controlled trial to assess the efficacy of jugular venoplasty in MS patients with CCSVI. Between August 2012 and March 2016, 130 patients (mean age 39.9±10.6 years; 81 women) with relapsing/remitting (n=115) or secondary/progressive (n=15) MS were randomized 2:1 to venography plus angioplasty (n=86) or venography (sham; n=44). Patients and study personnel (except the interventionist) were masked to treatment assignment. MRI data acquired at 6 and 12 months after randomization were compared to the preoperative scan for new and/or >30% enlargement of T2 lesions plus new gadolinium enhancement of pre-existing lesions. The relative risks (RR) with 95% confidence interval (CI) were estimated and compared. In a post hoc assessment, venograms of patients who underwent venous angioplasty were graded as “favorable” (n=38) or “unfavorable” (n=30) for dilation according to the Giaquinta grading system by 4 investigators blinded to outcomes. These subgroups were also compared. Results: Of the 130 patients enrolled, 125 (96%) completed the 12-month MRI follow-up. Analysis showed that the likelihood of being free of new cerebral lesions at 1 year was significantly higher after venoplasty compared to the sham group (RR 1.42, 95% CI 1.00 to 2.01, p=0.032). Patients with favorable venograms had a significantly higher probability of being free of new cerebral lesions than patients with unfavorable venograms (RR 1.82, 95% CI 1.17 to 2.83, p=0.005) or patients in the sham arm (RR 1.66, 95% CI 1.16 to 2.37, p=0.005). Conclusion: Expanded analysis of the Brave Dreams data that included secondary/progressive MS patients in addition to the relapsing/remitting patients analyzed previously showed that venoplasty decreases new cerebral lesions at 1 year. Post hoc analysis confirmed the efficacy of the Giaquinta grading system in selecting patients appropriate for venoplasty who were more likely to be free from accumulation of new cerebral lesions at MRI.
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Affiliation(s)
- Paolo Zamboni
- HUB Center for Venous and Lymphatics Disorders of the Emilia Romagna Region, S. Anna University Hospital, Ferrara, Italy
| | - Roberto Galeotti
- Unit of Interventional Radiology, S. Anna University Hospital, Ferrara, Italy
| | - Fabrizio Salvi
- IRCCS of the Neurosciences, Bellaria Hospital, Bologna, Italy
| | - Alessia Giaquinta
- Unit of Vascular Surgery and Transplantation, University of Catania, Italy
| | - Carlo Setacci
- Unit of Vascular Surgery, University of Siena, Siena, Italy
| | | | | | | | - Elisa Maietti
- Department of Biomedical and Neuromotor Sciences, University of Bologna Center for Clinical Epidemiology, School of Medicine, University of Ferrara, Italy
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Zamboni P, Tesio L, Galimberti S, Massacesi L, Salvi F, D'Alessandro R, Cenni P, Galeotti R, Papini D, D'Amico R, Simi S, Valsecchi MG, Filippini G. Efficacy and Safety of Extracranial Vein Angioplasty in Multiple Sclerosis: A Randomized Clinical Trial. JAMA Neurol 2019; 75:35-43. [PMID: 29150995 PMCID: PMC5833494 DOI: 10.1001/jamaneurol.2017.3825] [Citation(s) in RCA: 50] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Question What is the efficacy of venous percutaneous transluminal angioplasty (PTA) for chronic cerebrospinal venous insufficiency in patients with multiple sclerosis? Findings In the Brave Dreams trial, which included 115 patients with relapsing-remitting multiple sclerosis, venous PTA did not increase the proportion of patients who improved functionally nor did it reduce the mean number of new combined brain lesions on magnetic resonance imaging at 12 months. However, there was a tendency for more patients to become free of new lesions after venous PTA mainly because of a reduction in new lesions appearing 6 to 12 months after randomization. Meaning Venous PTA cannot be recommended for patients with relapsing-remitting multiple sclerosis. Importance Chronic cerebrospinal venous insufficiency (CCSVI) is characterized by restricted venous outflow from the brain and spinal cord. Whether this condition is associated with multiple sclerosis (MS) and whether venous percutaneous transluminal angioplasty (PTA) is beneficial in persons with MS and CCSVI is controversial. Objective To determine the efficacy and safety of venous PTA in patients with MS and CCSVI. Design, Setting, and Participants We analyzed 177 patients with relapsing-remitting MS; 62 were ineligible, including 47 (26.6%) who did not have CCSVI on color Doppler ultrasonography screening. A total of 115 patients were recruited in the study timeframe. All patients underwent a randomized, double-blind, sham-controlled, parallel-group trial in 6 MS centers in Italy. The trial began in August 2012 and concluded in March 2016; data were analyzed from April 2016 to September 2016. The analysis was intention to treat. Interventions Patients were randomly allocated (2:1) to either venous PTA or catheter venography without venous angioplasty (sham). Main Outcomes and Measures Two primary end points were assessed at 12 months: (1) a composite functional measure (ie, walking control, balance, manual dexterity, postvoid residual urine volume, and visual acuity) and (2) a measure of new combined brain lesions on magnetic resonance imaging, including the proportion of lesion-free patients. Combined lesions included T1 gadolinium-enhancing lesions plus new or enlarged T2 lesions. Results Of the included 115 patients with relapsing-remitting MS, 76 were allocated to the PTA group (45 female [59%]; mean [SD] age, 40.0 [10.3] years) and 39 to the sham group (29 female [74%]; mean [SD] age, 37.5 [10.6] years); 112 (97.4%) completed follow-up. No serious adverse events occurred. Flow restoration was achieved in 38 of 71 patients (54%) in the PTA group. The functional composite measure did not differ between the PTA and sham groups (41.7% vs 48.7%; odds ratio, 0.75; 95% CI, 0.34-1.68; P = .49). The mean (SD) number of combined lesions on magnetic resonance imaging at 6 to 12 months were 0.47 (1.19) in the PTA group vs 1.27 (2.65) in the sham group (mean ratio, 0.37; 95% CI, 0.15-0.91; P = .03: adjusted P = .09) and were 1.40 (4.21) in the PTA group vs 1.95 (3.73) in the sham group at 0 to 12 months (mean ratio, 0.72; 95% CI, 0.32-1.63; P = .45; adjusted P = .45). At follow-up after 6 to 12 months, 58 of 70 patients (83%) in the PTA group and 22 of 33 (67%) in the sham group were free of new lesions on magnetic resonance imaging (odds ratio, 2.64; 95% CI, 1.11-6.28; P = .03; adjusted P = .09). At 0 to 12 months, 46 of 73 patients (63.0%) in the PTA group and 18 of 37 (49%) in the sham group were free of new lesions on magnetic resonance imaging (odds ratio, 1.80; 95% CI, 0.81-4.01; P = .15; adjusted P = .30). Conclusion and Relevance Venous PTA has proven to be a safe but largely ineffective technique; the treatment cannot be recommended in patients with MS. Trial Registration clinicaltrials.gov Identifier: NCT01371760
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Affiliation(s)
- Paolo Zamboni
- Translational Surgery and Vascular Diseases Centre, University of Ferrara Hospital, Ferrara, Italy
| | - Luigi Tesio
- Department of Biomedical Sciences for Health, Chair of Physical and Rehabilitation Medicine, University of Milan, Milan, Italy.,Italian Auxologico Institute, Milan, Italy
| | - Stefania Galimberti
- Center of Biostatistics for Clinical Epidemiology, School of Medicine and Surgery, University of Milan-Bicocca, Milan, Italy
| | - Luca Massacesi
- Department of Neurosciences Drugs and Child Health, University of Florence, Florence, Italy
| | - Fabrizio Salvi
- Institute of the Neurological Science, Bellaria Hospital, Bologna, Italy
| | | | | | | | - Donato Papini
- Regional Agency for Health and Social Care, Regione Emilia-Romagna, Italy
| | - Roberto D'Amico
- Department of Diagnostic, Clinical and Public Health Medicine, University of Modena and Reggio Emilia, Modena, Italy
| | - Silvana Simi
- MS Cochrane Group. Institute of Clinical Physiology, Pisa, Italy
| | - Maria Grazia Valsecchi
- Center of Biostatistics for Clinical Epidemiology, School of Medicine and Surgery, University of Milan-Bicocca, Milan, Italy
| | - Graziella Filippini
- Scientific Director's Office, Carlo Besta Foundation and Neurological Institute, Milan, Italy
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Optimism, enthusiasm, responsibility. J Vasc Surg Venous Lymphat Disord 2017; 5:775-776. [DOI: 10.1016/j.jvsv.2017.07.002] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/02/2017] [Accepted: 07/12/2017] [Indexed: 11/22/2022]
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Neural Vascular Mechanism for the Cerebral Blood Flow Autoregulation after Hemorrhagic Stroke. Neural Plast 2017; 2017:5819514. [PMID: 29104807 PMCID: PMC5634612 DOI: 10.1155/2017/5819514] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/30/2017] [Accepted: 09/11/2017] [Indexed: 12/21/2022] Open
Abstract
During the initial stages of hemorrhagic stroke, including intracerebral hemorrhage and subarachnoid hemorrhage, the reflex mechanisms are activated to protect cerebral perfusion, but secondary dysfunction of cerebral flow autoregulation will eventually reduce global cerebral blood flow and the delivery of metabolic substrates, leading to generalized cerebral ischemia, hypoxia, and ultimately, neuronal cell death. Cerebral blood flow is controlled by various regulatory mechanisms, including prevailing arterial pressure, intracranial pressure, arterial blood gases, neural activity, and metabolic demand. Evoked by the concept of vascular neural network, the unveiled neural vascular mechanism gains more and more attentions. Astrocyte, neuron, pericyte, endothelium, and so forth are formed as a communicate network to regulate with each other as well as the cerebral blood flow. However, the signaling molecules responsible for this communication between these new players and blood vessels are yet to be definitively confirmed. Recent evidence suggested the pivotal role of transcriptional mechanism, including but not limited to miRNA, lncRNA, exosome, and so forth, for the cerebral blood flow autoregulation. In the present review, we sought to summarize the hemodynamic changes and underline neural vascular mechanism for cerebral blood flow autoregulation in stroke-prone state and after hemorrhagic stroke and hopefully provide more systematic and innovative research interests for the pathophysiology and therapeutic strategies of hemorrhagic stroke.
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Krogias C, Gold R, Chan A, Triantafyllou N, Voumvourakis K, Tsivgoulis G. Brain Hyperechogenicities are not Associated with Venous Insufficiency in Multiple Sclerosis: A Pilot Neurosonology Study. J Neuroimaging 2015; 26:150-5. [DOI: 10.1111/jon.12248] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/09/2015] [Accepted: 03/02/2015] [Indexed: 01/05/2023] Open
Affiliation(s)
- Christos Krogias
- Department of Neurology, St. Josef-Hospital, Medical Faculty; Ruhr University; Bochum Germany
| | - Ralf Gold
- Department of Neurology, St. Josef-Hospital, Medical Faculty; Ruhr University; Bochum Germany
| | - Andrew Chan
- Department of Neurology, St. Josef-Hospital, Medical Faculty; Ruhr University; Bochum Germany
| | - Nikos Triantafyllou
- 1st Department of Neurology, School of Medicine; University of Athens; Greece
| | | | - Georgios Tsivgoulis
- 2 Department of Neurology, “Attikon” Hospital, School of Medicine; University of Athens; Greece
- International Clinical Research Center, Department of Neurology; St. Anne's University Hospital in Brno; Czech Republic
- Department of Neurology; University of Tennessee Health Science Center; Memphis TN USA
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Belbasis L, Bellou V, Evangelou E, Ioannidis JPA, Tzoulaki I. Environmental risk factors and multiple sclerosis: an umbrella review of systematic reviews and meta-analyses. Lancet Neurol 2015; 14:263-73. [DOI: 10.1016/s1474-4422(14)70267-4] [Citation(s) in RCA: 412] [Impact Index Per Article: 45.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
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Raz E, Pontecorvo S, Barra V, Marincola BC, Morreale M, Tinelli E, Saba L, Di Paolo PL, Aceti A, Catalano C, Francia A, Caramia F. MR venography in patients with multiple sclerosis and correlation with clinical and MRI parameters. J Neuroimaging 2014; 24:492-7. [PMID: 25340182 DOI: 10.1111/jon.12066] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022] Open
Abstract
BACKGROUND AND PURPOSE Multiple sclerosis (MS) has been associated with chronic cerebrospinal venous insufficiency. We aim to evaluate the correlation between extracranial veins stenosis evaluated with MR venography (MRV) and clinical/MR parameters of MS. METHODS In 29 consecutive MS patients we performed a standard brain MRI protocol, completed by the evaluation of extra-cerebral venous system using a phase-contrast and a Volumetric Interpolated Breath Hold Examination (VIBE) sequence before and after gadolinium. The T2-proton density images were used to calculate the lesion volume. The jugular veins were evaluated qualitatively (in terms of presence and severity of stenoses) and quantitatively (degree of stenosis). The phase-contrast images were analyzed to calculate the average and peak velocity in the internal jugular veins. RESULTS Postcontrast VIBE successfully showed the jugular veins in all the subjects. T2-lesion-volume was 8.2 [4.6] cm³. A stenosis of the internal jugular veins > of 50% was observed in 10/29(33%) patients. No significant correlation was observed between T2-lesion-volume and degree-of-stenosis (r = .362, P = .302). No different flow parameters were found in the subgroups of patients with and without stenosis (P = .54). CONCLUSIONS In MS the presence/severity of jugular vein stenosis identified with 3T-MRV is not related to MR-visible tissue damage. Moreover no abnormal flow parameters were found in stenosed veins.
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Tsivgoulis G, Sergentanis TN, Chan A, Voumvourakis K, Triantafyllou N, Psaltopoulou T, Gold R, Krogias C. Chronic cerebrospinal venous insufficiency and multiple sclerosis: a comprehensive meta-analysis of case-control studies. Ther Adv Neurol Disord 2014; 7:114-36. [PMID: 24587827 DOI: 10.1177/1756285613499425] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
OBJECTIVES Chronic cerebrospinal venous insufficiency (CCSVI) has recently been implicated in the pathogenesis of multiple sclerosis (MS). This comprehensive meta-analysis of case-control studies investigates the association of CCSVI with MS. METHODS Through Medline, EMBASE and Cochrane database searches, case-control ultrasound studies comparing CCSVI frequency among patients with MS and healthy controls were identified. RESULTS We identified 19 eligible studies including 1250 patients with MS and 899 healthy controls. The pooled analysis showed that CCSVI was associated with MS [odds ratio (OR) 8.35; 95% confidence interval (CI) 3.44-20.31; p < 0.001) with considerable heterogeneity across studies (I (2) = 80.1%). This association was substantially attenuated in sensitivity analyses excluding studies that were carried out by the group that originally described CCSVI, included investigators who had also been involved in publications advocating endovascular procedures for CCSVI treatment, or were conducted in Italy. Our most conservative sensitivity analysis combining different exclusion criteria yielded no association of CCSVI with MS (OR 1.35; 95% CI 0.62-2.93; p = 0.453) without any heterogeneity (I (2) = 0%). CONCLUSION There is considerable heterogeneity across different case-control studies evaluating the association of CCSVI and MS. The greatest factor contributing to this heterogeneity appears to be the involvement of investigators in other publications supporting endovascular procedures as a novel MS treatment.
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Affiliation(s)
- Georgios Tsivgoulis
- Second Department of Neurology, 'Attikon' Hospital, School of Medicine, University of Athens, Iras 39, Gerakas Attikis, 15344, Athens, Greece and International Clinical Research Center, St Anne's University Hospital Brno, Brno, Czech Republic
| | - Theodoros N Sergentanis
- Department of Hygiene, Epidemiology and Medical Statistics, School of Medicine, University of Athens, Athens, Greece
| | - Andrew Chan
- Department of Neurology, Ruhr University, St Josef-Hospital, Bochum, Germany
| | - Konstantinos Voumvourakis
- Second Department of Neurology, 'Attikon' Hospital, School of Medicine, University of Athens, Athens, Greece
| | - Nikos Triantafyllou
- First Department of Neurology, 'Eginition' Hospital, School of Medicine, University of Athens, Athens, Greece
| | - Theodora Psaltopoulou
- Department of Hygiene, Epidemiology and Medical Statistics, School of Medicine, University of Athens, Athens, Greece
| | - Ralf Gold
- Department of Neurology, Ruhr University, St Josef-Hospital, Bochum, Germany
| | - Christos Krogias
- Department of Neurology, Ruhr University, St Josef-Hospital, Bochum, Germany
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Ghezzi A. Funding CCSVI research is/was a waste of valuable time, money and intellectual energy: yes. Mult Scler 2014; 19:855-7. [PMID: 23712524 DOI: 10.1177/1352458513479825] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Affiliation(s)
- Angelo Ghezzi
- Ospedale di Gallarate, Centro Studi Sclerosi Multipla, Via Pastori 4, Gallarate 21013, Italy.
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Gafson AR, Giovannoni G. CCSVI-A. A call to clinicans and scientists to vocalise in an Internet age. Mult Scler Relat Disord 2013; 3:143-6. [PMID: 25878001 DOI: 10.1016/j.msard.2013.10.005] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/29/2013] [Revised: 08/28/2013] [Accepted: 10/13/2013] [Indexed: 10/26/2022]
Abstract
In 2008, Paulo Zamboni pioneered the 'liberation procedure' for treating multiple sclerosis (MS), claiming that MS is caused by an abnormality of venous drainage which he called chronic cerebrospinal venous insufficiency (CCSVI). CCSVI has been very controversial, both socio-politically and scientifically after going 'viral' via social media. In late 2012, only 56 original scientific research papers had been published on the 'CCSVI syndrome'; however, over 1,150,000 hits on Google existed when searching for the term 'chronic cerebrospinal venous insufficiency' or CCSVI. It is unclear whether the scientific community's response to CCSVI was influenced by Zamboni's original articles, a reactionary response to the 'social phenomenon' of CCSVI or indeed a complex interplay between both these factors. Furthermore, the epidemiology of this 'social phenomenon' remains un-investigated. A PubMed literature search revealed that the greatest level of public interest in CCSVI, as measured by Google Trends, occurred after only 30% of primary articles and 11% of negative studies were submitted for publication. The epicentre of social epidemic has been divided between Italy and Canada. Whilst Canadian scientists had yet to publish a primary article on CCSVI, it had a relative 76% search volume on Google Trends. It is likely that this public interest was sparked by media and political opportunism and fuelled by social media that was disconnected from the scientific community. Our findings call for a concerted effort for clinicians and scientists to engage with the public to ensure that uptake and spread of scientific discoveries via social media are viewed and interpreted in an appropriate context. Examples of how this may be achieved will also be discussed.
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Affiliation(s)
- Arie R Gafson
- Queen Mary University of London, Blizard Institute, Barts and The London School of Medicine and Dentistry, 4 Newark St, London E1 2AT, United Kingdom.
| | - Gavin Giovannoni
- Queen Mary University of London, Blizard Institute, Barts and The London School of Medicine and Dentistry, 4 Newark St, London E1 2AT, United Kingdom
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Alexander JS, Prouty L, Tsunoda I, Ganta CV, Minagar A. Venous endothelial injury in central nervous system diseases. BMC Med 2013; 11:219. [PMID: 24228622 PMCID: PMC3851779 DOI: 10.1186/1741-7015-11-219] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/12/2013] [Accepted: 09/09/2013] [Indexed: 02/08/2023] Open
Abstract
The role of the venous system in the pathogenesis of inflammatory neurological/neurodegenerative diseases remains largely unknown and underinvestigated. Aside from cerebral venous infarcts, thromboembolic events, and cerebrovascular bleeding, several inflammatory central nervous system (CNS) diseases, such as multiple sclerosis (MS), acute disseminated encephalomyelitis (ADEM), and optic neuritis, appear to be associated with venous vascular dysfunction, and the neuropathologic hallmark of these diseases is a perivenous, rather than arterial, lesion. Such findings raise fundamental questions about the nature of these diseases, such as the reasons why their pathognomonic lesions do not develop around the arteries and what exactly are the roles of cerebral venous inflammation in their pathogenesis. Apart from this inflammatory-based view, a new hypothesis with more focus on the hemodynamic features of the cerebral and extracerebral venous system suggests that MS pathophysiology might be associated with the venous system that drains the CNS. Such a hypothesis, if proven correct, opens new therapeutic windows in MS and other neuroinflammatory diseases. Here, we present a comprehensive review of the pathophysiology of MS, ADEM, pseudotumor cerebri, and optic neuritis, with an emphasis on the roles of venous vascular system programming and dysfunction in their pathogenesis. We consider the fundamental differences between arterial and venous endothelium, their dissimilar responses to inflammation, and the potential theoretical contributions of venous insufficiency in the pathogenesis of neurovascular diseases.
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Affiliation(s)
- Jonathan S Alexander
- Department of Molecular and Cellular Physiology, LSU Health Sciences Center, 1501 Kings Highway, Shreveport, LA 71130-3932, USA.
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Zwischenberger BA, Beasley MM, Davenport DL, Xenos ES. Meta-Analysis of the Correlation Between Chronic Cerebrospinal Venous Insufficiency and Multiple Sclerosis. Vasc Endovascular Surg 2013; 47:620-4. [DOI: 10.1177/1538574413503562] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/13/2023]
Abstract
Purpose: To determine whether a correlation exists between chronic cerebrospinal venous insufficiency (CCSVI) and multiple sclerosis (MS). Materials and Methods: A meta-analysis of the current literature was performed to evaluate the frequency of CCSVI, diagnosed by echo color Doppler criteria, in patients with MS and in normal controls. Results: In all, 19 studies were identified from January 2005 through February 2013; however, 3 studies were excluded due to duplicate data and 3 additional studies because 0 patients fulfilled CCSVI criteria in both MS and control groups. In order to improve homogeneity, 4 outlier studies were also removed from the analysis. Analysis of the remaining 9 studies demonstrated a significant correlation between CCSVI and MS (odds ratio 1.885, P < .0001) with no significant heterogeneity of the studies ( I2 = 18, P = .279). Conclusions: The meta-analysis demonstrated a correlation between CCSVI and MS. However, there was no evidence that CCSVI has a causative role in MS.
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Affiliation(s)
| | - Mary M. Beasley
- College of Medicine, University of Kentucky, Lexington, KY, USA
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Lupattelli T, Bellagamba G, Righi E, Di Donna V, Flaishman I, Fazioli R, Garaci F, Onorati P. Feasibility and safety of endovascular treatment for chronic cerebrospinal venous insufficiency in patients with multiple sclerosis. J Vasc Surg 2013; 58:1609-18. [PMID: 23948669 DOI: 10.1016/j.jvs.2013.05.108] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/08/2013] [Revised: 04/17/2013] [Accepted: 05/28/2013] [Indexed: 10/26/2022]
Abstract
OBJECTIVE Chronic cerebrospinal venous insufficiency (CCSVI) is a recently discovered syndrome mainly due to stenoses of internal jugular (IJV) and/or azygos (AZ) veins. The present study retrospectively evaluates the feasibility and safety of endovascular treatment for CCSVI in a cohort of patients with multiple sclerosis (MS). METHODS From September 2010 to October 2012, 1202 consecutive patients were admitted to undergo phlebograpy ± endovascular treatment for CCSVI. All the patients had previously been found positive at color Doppler sonography (CDS) for at least two Zamboni criteria for CCSVI and had a neurologist-confirmed diagnosis of MS. Only symptomatic MS were considered for treatment. Percutaneous transluminal angioplasty was carried out as an outpatient procedure at two different institutes. Primary procedures, regarded as the first balloon angioplasty ever performed for CCSVI, and secondary (reintervention) procedures, regarded as interventions performed after venous disease recurrence, were carried out in 86.5% (1037 of 1199) and 13.5% (162 of 1199) of patients, respectively. Procedural success and complications within 30 days were recorded. RESULTS Phlebography followed by endovascular recanalization was carried out in 1999 patients consisting of 1219 interventions. Balloon angioplasty alone was performed in 1205 out of 1219 (98.9%) procedures, whereas additional stent placement was required in the remaining 14 procedures (1.1%) following unsuccessful attempts at AZ dilatation. No stents were ever implanted in the IJV. The feasibility rate was as high as 99.2% (1209 interventions). Major complications included one (0.1%) AZ rupture occurring during balloon dilatation and requiring blood transfusion, one (0.1%) severe bleeding in the groin requiring open surgery, two (0.2%) surgical openings of the common femoral vein to remove balloon fragments, and three (0.2%) left IJV thromboses. The overall major and minor complication rates at 30 days were 0.6% and 2.5%, respectively. CONCLUSIONS Endovascular treatment for CCSVI appears feasible and safe. However, a proper learning curve can dramatically lower the rate of adverse events. In our experience, the vast majority of complications occurred in the first 400 cases performed.
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Affiliation(s)
- Tommaso Lupattelli
- Vascular and Endovascular Unit, Istituto Clinico Cardiologico (ICC) Gruppo Villa Maria (GVM) Sanità, Rome, Italy.
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Clinical outcomes in multiple sclerosis patients following venous angioplasty. Can J Neurol Sci 2013; 40:141-3. [PMID: 23419560 DOI: 10.1017/s0317167100013652] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
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