CCSVI and MS: no meaning, no fact

Department of Neuroscience-SSPNRR, Stroke Unit, First Neurology Clinic, University of Padova, via Giustiniani, 5, 35128, Padua, Italy.
Neurological Sciences (Impact Factor: 1.45). 05/2012; 34(3). DOI: 10.1007/s10072-012-1101-2
Source: PubMed


A condition called "chronic cerebrospinal venous insufficiency" (CCSVI) has been postulated to play a role in the pathogenesis of multiple sclerosis (MS). This hypothesis implies that a complex pattern of extracranial venous stenosis determines a venous reflux into the brain of MS patients, followed by increased intravenous pressure, blood-brain barrier breakdown and iron deposition into the brain parenchyma, thus triggering a local inflammatory response. In this review, we critically analyze the scientific basis of CCSVI, the current literature on the relationship between CCSVI and MS, as well as the ultrasound methodology that has been claimed to provide evidence of impaired cerebral venous drainage. We show that no piece of the CCSVI theory has a solid supportive scientific evidence. The CCSVI appears to be a rather alien condition and its existence should be definitely questioned. Finally, no proven (i.e., based on strict scientific methodology and on the rules of evidence-based medicine) therapeutic effect of the "liberation" procedure (unblocking the extracranial venous obstruction using angioplasty) has been shown up to date.

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    • "Although the CCSVI hypothesis has provoked great controversy and debate in the MS research community since it was first presented [20,23,24,57-61], it gained popularity among MS patients because of the postulated possibility of venous insufficiency correction using endovascular procedures [28]. So far, there have been several contradictory studies published [28,46,49,62-68] and verified scientific evidence supportive of a causative relationship between CCSVI and MS is lacking [10,69]. "
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    ABSTRACT: The extra-cranial venous system is complex and not well studied in comparison to the peripheral venous system. A newly proposed vascular condition, named chronic cerebrospinal venous insufficiency (CCSVI), described initially in patients with multiple sclerosis (MS) has triggered intense interest in better understanding of the role of extra-cranial venous anomalies and developmental variants. So far, there is no established diagnostic imaging modality, non-invasive or invasive, that can serve as the "gold standard" for detection of these venous anomalies. However, consensus guidelines and standardized imaging protocols are emerging. Most likely, a multimodal imaging approach will ultimately be the most comprehensive means for screening, diagnostic and monitoring purposes. Further research is needed to determine the spectrum of extra-cranial venous pathology and to compare the imaging findings with pathological examinations. The ability to define and reliably detect noninvasively these anomalies is an essential step toward establishing their incidence and prevalence. The role for these anomalies in causing significant hemodynamic consequences for the intra-cranial venous drainage in MS patients and other neurologic disorders, and in aging, remains unproven.
    Full-text · Article · Jun 2013 · BMC Medicine
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    • "CCSVI is characterized by restricted venous outflow from the brain [8,64] due to occlusions, which can take several forms, including the presence of intra-luminal septa, membranes, and immobile valves, as well as segmentary hypoplasia of the veins [172]. CCSVI has proven to be a highly contentious issue [173,174], with a number researchers doubting its validity as a physiological phenomenon [173,175-179]. Notwithstanding this, biomechanically, CCSVI will tend to increase the venous pressure in the dural sinuses, which hypothetically could alter the dynamics of the intracranial CSF system and potentially influence CBF. "
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    ABSTRACT: Venous abnormalities contribute to the pathophysiology of several neurological conditions. This paper reviews the literature regarding venous abnormalities in multiple sclerosis (MS), leukoaraiosis, and normal-pressure hydrocephalus (NPH). The review is supplemented with hydrodynamic analysis to assess the effects on cerebrospinal fluid (CSF) dynamics and cerebral blood flow (CBF) of venous hypertension in general, and chronic cerebrospinal venous insufficiency (CCSVI) in particular. CCSVI-like venous anomalies seem unlikely to account for reduced CBF in patients with MS, thus other mechanisms must be at work, which increase the hydraulic resistance of the cerebral vascular bed in MS. Similarly, hydrodynamic changes appear to be responsible for reduced CBF in leukoaraiosis. The hydrodynamic properties of the periventricular veins make these vessels particularly vulnerable to ischemia and plaque formation. Venous hypertension in the dural sinuses can alter intracranial compliance. Consequently, venous hypertension may change the CSF dynamics, affecting the intracranial windkessel mechanism. MS and NPH appear to share some similar characteristics, with both conditions exhibiting increased CSF pulsatility in the aqueduct of Sylvius. CCSVI appears to be a real phenomenon associated with MS, which causes venous hypertension in the dural sinuses. However, the role of CCSVI in the pathophysiology of MS remains unclear.
    Full-text · Article · May 2013 · BMC Medicine
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    • "A large number of studies on CCSVI have been now reported from the Zamboni clinic as well as other clinics. Many of these studies could not demonstrate an increased incidence of CCSVI in MS, for example, the review by Baracchini and colleagues [43], whereas other studies find a greatly increased incidence of CCSVI in MS patients, for example, [44]. The differences in findings amongst different studies may be due to differing abilities to detect CCSVI. "
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    ABSTRACT: The evidence that hypoxia is a precipitating factor in causing early MS lesions includes increased protein levels of hypoxia-inducible factor-1 α ; presence of the D-110 hypoxia-inducible protein; increased expression of hypoxia-inducible genes in lesions as well as in adjacent normal-appearing white matter (NAWM); loss of myelin-associated glycoprotein in myelin of early MS lesions; a 50% reduction of blood flow through NAWM with areas of lowest blood flow having the greatest probability of lesion development. Why MS-like lesions develop following hypoxemic insults in some individuals but not in others is likely dependent upon the presence of immune predisposing factors that are governed genetically. Hypoperfusion may be due to decreased arterial supply, restricted venous return, or a combination of these. There are clinical trials ongoing or planned to treat chronic cerebrospinal venous insufficiency (CCSVI) through angioplasty. I suggest that it is important that clinical trials addressing vascular issues in MS should examine how the vascular intervention affects white matter perfusion and determine whether the extent of perfusion recovery and maintenance of this recovery is related to functional recovery and maintenance of functional recovery. Consideration should also be given to the possibility of arterial problems playing a role in hypoperfusion in some MS patients.
    Full-text · Article · Apr 2013
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