Endovascular Therapy for Chronic Cerebrospinal Venous Insufficiency in Multiple Sclerosis

Department of Neurology, Froedtert Hospital and Medical College of Wisconsin Milwaukee, WI, USA.
Frontiers in Neurology 07/2011; 2:44. DOI: 10.3389/fneur.2011.00044
Source: PubMed


Recent reports have emerged suggesting that multiple sclerosis (MS) may be due to abnormal venous outflow from the central nervous system, termed chronic cerebrospinal venous insufficiency (CCSVI). These reports have generated strong interest and controversy over the prospect of a treatable cause of this chronic debilitating disease. This review aims to describe the proposed association between CCSVI and MS, summarize the current data, and discuss the role of endovascular therapy and the need for rigorous randomized clinical trials to evaluate this association and treatment.

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    ABSTRACT: Multiple sclerosis (MS) is a leading cause of neurological disability in young adults. The most widely accepted hypothesis regarding its pathogenesis is that it is an immune-mediated disease. It has been hypothesised more recently that chronic venous congestion may be an important factor in the pathogenesis of MS. This concept has been named 'chronic cerebrospinal venous insufficiency' (CCSVI) and is characterised by stenoses of either the internal jugular or azygos veins, or both. It is suggested that these stenoses restrict the normal blood flow from the brain, causing the deposition of iron in the brain and the eventual triggering of an auto-immune response. The proposed treatment for CCSVI is percutaneous transluminal angioplasty, also known as the 'liberation procedure', which is claimed to improve the blood flow in the brain thereby alleviating some of the symptoms of MS. To assess the effects of percutaneous transluminal angioplasty for the treatment of CCSVI in people with MS. We searched the following databases up to June 2012: The Cochrane Multiple Sclerosis and Rare Diseases of the Central Nervous System Group Specialised Register, CENTRAL in The Cochrane Library 2012, Issue 5, MEDLINE (from 1946), EMBASE (from 1974), and reference lists of articles. We also searched several online trials registries for ongoing trials. Randomised controlled trials assessing the effects of percutaneous transluminal angioplasty in adults with multiple sclerosis, that have been diagnosed to have CCSVI. Our searches retrieved 159 references, six of which were to ongoing trials. Based on assessment of the title or abstract, or both, we excluded all of the studies, with the exception of one which was evaluated following examination of the full text report. However, this study also did not meet our inclusion criteria and was subsequently excluded. No randomised controlled trials met our inclusion criteria. There is currently no high level evidence to support or refute the efficacy or safety of percutaneous transluminal angioplasty for treatment of CCSVI in people with MS. Clinical practice should be guided by evidence supported by well-designed randomised controlled trials: closure of some of the gaps in the evidence may be feasible at the time of completion of the six ongoing clinical trials.
    Full-text · Article · Dec 2012 · Cochrane database of systematic reviews (Online)
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    ABSTRACT: The craniovertebral venous system consists of cranial veins and veins of vertebral column. These veins are interconnected with no valves, allowing blood to flow freely in both directions. The veins of brain, dural venous sinuses, diploic veins and emissary veins belong to cranial veins. The veins of vertebral column consist of external and internal vertebral venous plexus and of basivertebral veins. The vertebral veins, posterior intercostals veins, lumbar veins and lateral sacral veins drain blood directly from craniovertebral venous system in azigos vein or in superior and inferior vena cava. The craniovertebral venous system with other venous systems are forming numerous anastomosis, which in pathological conditions represent a collateral pathway for blood to the heart and allow the direct spread of neoplasms of the thoracic, abdominal and pelvic cavity in the area of the cranium and spine. In addition, the significance of cranial veins and veins of the upper part of the respiratory system are part of the selective brain cooling mechanism which is particulary important in condition of hyperthermia. © 2015, Croatian Medical Association and School of Medicine. All rights reserved.
    Full-text · Article · Dec 2015