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Chronic cerebrospinal venous insufficiency (CCSVI) may be associated with multiple sclerosis (MS), although this is controversial and an active area of research. Correction of CCSVI has been attempted via percutaneous venoplasty. The intent of this procedure is to relieve MS symptoms by improving venous drainage of the central nervous system. Correction of CCSVI by this method may be referred to as the “Liberation Procedure.” Background Multiple sclerosis (MS) is generally considered a chronic inflammatory demyelinating disease of the central nervous system (brain, spinal cord, optic nerve) felt to be triggered by an autoimmune response to myelin. However, in part due to the periventricular predilection of the lesions of multiple sclerosis, vascular etiologies (chronic cerebrospinal venous insufficiency [CCSVI]) have also been considered. An animal model for MS was developed by injecting obstructing agents into the venous sinuses. This etiology, and treatment approach, for MS had not been actively pursued for many years; recent reports by a European researcher have renewed interest in this topic. The core foundation of this vascular theory is that there is abnormal venous drainage from the brain due to outflow obstruction in the draining jugular vein and/or azygos veins. This abnormal venous drainage, which is characterized by special ultrasound criteria, is said to cause intracerebral flow disturbance or outflow problems that lead to periventricular deposits. In the CCSVI theory, these deposits have a similarity to the iron deposits seen around the veins in the legs in patients with chronic deep vein thrombosis. Those studying this theory have promoted balloon dilatation, with or without stenting, to treat the outflow problems, thereby curing CCSVI and by the same token alleviating MS complaints. The following 5 criteria were defined by Zamboni et al. as features of CCSVI. In order to make the diagnosis of CCSVI, at least 2 of the 5 criteria need to be present: …
IT has been recently hypothesized that a phenomenon known as chronic cerebrospinal venous insufficiency (CCSVI) may play a significant role in the etiology, pathogenesis, and/or disease progression of multiple sclerosis (MS) (1,2). Preliminary studies suggest that anatomical and physiological abnormalities of venous blood flow are significantly more common in patients with clinical MS than in healthy control subjects or patients with other neurologic disorders (3– 6). Of particular interest has been the documentation of stenotic and occlusive lesions in the azygos and internal jugu- From the Mallinckrodt Institute of Radiology (S.V.), 510 S. Kingshighway Blvd., Box 8131, St. Louis, MO 63110-1076; Peripheral Vascular Laboratory (J.F.B.), Baptist Cardiac and Vascular Institute, Miami, Florida; Department of Medical Imaging (S.K.), Scarborough General Hospital; Department of Medical Imaging (K.J.M.), University of Toronto, Toronto, Ontario, Canada; Department of Radiology (C.M.B.), Utah Valley Regional Medical Center, Provo, Utah; and Department of Radiology (J.F.C.), Geisinger Health System, Danville, Pennsylvania. Received and accepted July 15, 2010. Address correspondence to S.V.; E-mail: firstname.lastname@example.org S.V. has received support for a NIH trial from Covidien and MEDRAD Interventional. None of the other authors have identified a conflict of interest. © SIR, 2010 DOI: 10.1016/j.jvir.2010.07.004
Chronic cerebrospinal venous insufficiency (CCSVI) may be associated with multiple sclerosis (MS), although this is controversial and an active area of research. Correction of CCSVI has been attempted via percutaneous venoplasty. The intent of this procedure is to relieve MS symptoms by improving venous drainage of the central nervous system. Correction of CCSVI by this method may be referred to as the “Liberation Procedure.” Background Multiple sclerosis (MS) is generally considered a chronic inflammatory demyelinating disease of the central nervous system (brain, spinal cord, optic nerve) felt to be triggered by an autoimmune response to myelin. However, in part due to the periventricular Current Procedural Terminology © American Medical Association. All Rights Reserved. Contains Public Information Diagnosis and Treatment of Chronic Cerebrospinal Venous Insufficiency in Multiple Sclerosis predilection of the lesions of multiple sclerosis, vascular etiologies (chronic cerebrospinal venous insufficiency [CCSVI]) have also been considered. An animal model for MS was developed by injecting obstructing agents into the venous sinuses. This etiology, and treatment approach for MS had not been actively pursued for many years; recent reports by a European researcher have renewed interest in this topic. The core foundation of this vascular theory is that there is abnormal venous drainage from the brain due to outflow obstruction in the draining jugular vein and/or azygos veins. This abnormal venous drainage, which is characterized by special ultrasound criteria, is said to cause intracerebral flow disturbance or outflow problems that lead to periventricular deposits. In the CCSVI theory, these deposits have a similarity to the iron deposits seen around the veins in the legs in patients with chronic deep vein thrombosis. Those studying this theory have promoted balloon dilatation, with or without stenting, to treat the outflow problems, thereby curing CCSVI and by the same token alleviating MS complaints.
This study aimed to investigate the prevalence and clinical relevance of chronic cerebrospinal venous insufficiency (CCSVI) in multiple sclerosis (MS) patients and healthy controls using extra- and intracranial colour Doppler sonography. Methods: We examined 146 MS patients, presenting with a clinically isolated syndrome, relapsing-remitting, secondary progressive, or primary progressive MS, and 38 healthy controls. Sonographic examination was performed according to Zamboni’s protocol and was performed by three independent sonographers. The results of sonographic examination were compared with clinical and demographic characteristics of the patients. Results: CCSVI, defined as the presence of at least two positive Zamboni’s criteria, was found in 76% of MS patients and 16% of control subjects. B-mode anomalies of internal jugular veins, such as stenosis, malformed valves, annuli, and septa were the most common lesions detected in MS patients (80.8%) and controls (47.4%). We observed a positive correlation between sonographic diagnosis of CCSVI and the patients’ age (p = 0.003). However, such a correlation was not found in controls (p = 0.635). Notably, no significant correlations were found between sonographic signs of CCSVI and clinical characteristics of MS, except for absent flow in the jugular veins, which was found more often in primary (p<0.005) and secondary (p<0.05) progressive patients compared with non-progressive patients. Absent flow in jugular veins was significantly correlated with patients’ age (p < 0.0001). Conclusions: Sonographically defined CCSVI is common in MS patients. However, CCSVI appears to be primarily associated with the patient’s age, and poorly correlated with the clinical course of the disease. Keywords: Multiple sclerosis, Venous insufficiency, Ultrasonography ...
CCSVI- Chronic Cerebrospinal Venous Insufficiency E. Mark Haacke, PhD McMaster University Hamilton, Ontario Wayne State University Detroit, Michigan 48201 Acknowledgements • David Hubbard, MD for MS data • Salvatore Sclafani, MD, for images • Monte Harvill, MD for slides • Liu Jiangtao, MD for MS data • Wei Feng, PhD for processing flow data • Gabriela Trifan, MD for image analysis • David Utriainen, for image analysis • Meng Li, MS, for perfusion TSM data • Jaladhar Neelavalli, PhD for SWIM support MULTIPLE SCLEROSIS In Canada: ►55,000-75,000 MS patients ► most common neurological disease affecting young adults ►~1,000 new cases of MS diagnosed each year ► Economic impact > $1 billion annually The symptoms - mild to debilitating : vision problems; loss of balance and/or coordination, extreme fatigue, speech or memory failure; muscle stiffness and paralysis. CCSVI Chronic cerebrospinal venous insufficiency Zamboni noted narrowing of the veins at the neck or spine was restricting blood flow and potentially high levels of iron were accumulating in the brain (65 case studies) ...
The aim of this open-label study was to assess extracranial Doppler criteria of chronic cerebrospinal venous insufficiency in multiple sclerosis patients. Methods. Seventy patients were assessed: 49 with relapsing-remitting, 5 with primary progressive and 16 with secondary progressive multiple sclerosis. The patients were aged 15-58 years and they suffered from multiple sclerosis for 0.5-40 years. Sonographic signs of abnormal venous outflow were detected in 64 patients (91.4%). Results. We found at least two of four extracranial criteria in 63 patients (90.0%), confirming that multiple sclerosis is stronghly associated with chronic cerebrospinal venous insufficiency. Additional transcranial investigations may increase the rate of patients found positive in our survey. Reflux in internal jugular and/or vertebral veins was present in 31 cases (42.8%), stenosis of internal jugular veins in 61 cases (87.1%), not detectable flow in internal jugular and/or vertebral veins in 37 cases (52.9%) and negative difference in cross-sectional area of the internal jugular vein assessed in the supine vs. sitting position in 28 cases (40.0%). Flow abnormalities in the vertebral veins were found in 8 patients (11.4%). Pathologic structures (membranaceous or netlike septa, or inverted valves) in the junction of internal jugular vein with brachiocephalic vein were found in 41 patients (58.6%), in 15 patients (21.4%) on one side only and in 26 patients (37.1%) bilaterally. Conclusion. Multiple sclerosis is highly correlated with chronic cerebrospinal venous insufficiency. These abnormalities in the extracranial veins draining the central nervous system can exist in various combinations. The most common pathology in our patients was the presence of an inverted valve or another pathologic structure (like membranaceous or netlike septum) in the area of junction of the IJV with the brachiocephalic vein. [Int Angiol 2010;29:109-14] Key words: Color Ultrasonography, Doppler, color - Multiple sclerosis - Venous insufficiency. Received on November 6, 2009; resubmitted on December 3, 2009; accepted for publication on December 30, 2009.
Background: It has been proposed by Zamboni and colleagues that multiple sclerosis is caused by chronic cerebrospinal venous insufficiency, a term used to describe ultrasound-detectable abnormalities in the anatomy and flow of intra- and extracerebral veins. We conducted a meta-analysis of studies that reported the frequency of chronic cerebrospinal venous insufficiency among patients with and those without multiple sclerosis. Methods: We searched MEDLINE and EMBASE as well as bibliographies of relevant articles for eligible studies. We included studies if they used ultrasound to diagnose chronic cerebrospinal venous insufficiency and compared the frequency of the venous abnormalities among patients with and those without multiple sclerosis. Results: We identified eight eligible studies: all included healthy controls, and four of them also included a control group of patients with neurologic diseases other than multiple sclerosis. Chronic cerebrospinal venous insufficiency was more frequent among patients with multiple sclerosis is a chronic demyelinating and degenerative disease of the central nervous system. The exact cause remains unknown, but most evidence favours an autoimmune mechanism.1 In 2006, Zamboni and colleagues proposed that multiple sclerosis is caused by abnormalities in the direction and pathway of cerebral venous flow, leading to deposition of iron in the brain, which triggers an autoimmune reaction.2 They reported that patients with multiple sclerosis had a higher frequency of abnormalities of anatomy and flow in the internal jugular, deep cerebral, vertebral and azygous veins than individuals without multiple sclerosis had.3,4 They called this condition chronic cerebrospinal venous insufficiency. They further described detection of this © 2011 Canadian Medical Association or its licensors
Date: 01/08/2008 Product Description: AMSOIL EaA728 Air Filter Subject: 7.3-liter Ford OEM Air Filter Box Design Constraints OBJECTIVE: Communicate a problem with the design of Ford air induction boxes on 7.3L-equipped diesel vehicles which leads to premature air filter restriction gauge warnings when using EaA728 Air Filters. ISSUES: The life expectancy of the EaA728 Air Filter is less than the specified duration due to issues with Ford original equipment manufacturer (OEM) filter housing design. TECHNICAL DISCUSSION: AMSOIL has documented problems with premature air restriction on EaA728 Air Filters installed on Ford vehicles equipped with 7.3L diesel engines. The problem appears via premature triggering of air filter restriction gauges. In some cases, the problem is severe enough to create performance issues, including lack of engine power. A typical non-turbo-equipped 7.3L diesel engine requires roughly 280 CFM air flow to comfortably perform without combustion starving issues, including lack of engine power. A turbo-equipped diesel engine requires 466 CFM air flow to avoid similar issues. Another way to predict air-flow-related performance issues is through a filter face velocity calculation. Donaldson Company Inc.(DCI), a wellrespected filter manufacturer, uses this calculation to measure the amount of air an engine requires for optimum fuel combustion. A lower value in the face velocity represents better performance. A face velocity of 7-10 is optimal for diesel-fueled engines, whether turbo-charged or not. A Ford 7.3L OEM filter was tested with this predictive calculation under both turbo and non-turbo condiSubmitted By: RH
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