MS and CCSVI - - Get a Free Blog Here
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MS and CCSVI Dr Paul Thibault Phlebologist, Newcastle, Australia
Transcript of MS and CCSVI - - Get a Free Blog Here
MS and CCSVI
Dr Paul Thibault
Phlebologist, Newcastle, Australia
What is MS
• Considered to be a progressive, incurable, neurological disease with many symptoms:
Fatigue Tingling and numbness Loss of balance and muscle co-ordination Impaired vision Slurred speech Tremors and stiffness Bladder and bowel problems Problems with memory and concentration – brain fog Mood swings and depresssion
What is MS?
• Progressive inflammatory disease of the brain and spinal cord
• Disseminated scars “scleroses” occur in a peculiar distribution
• Distribution is generally around veins
• “Scleroses” characterised by myelin loss around axons
MS Prevalence Rates Newcastle, Australia 1961 -1996
per 100,000 1961 1981 1996
Males 16.5 24.6 33.1
Females 19.9 48.1 83.4
persons 18.2 36.5 58.6
Access Economics Report to MS Australia 2005
Access Economics Report to MS Australia 2005
What is MS?
• Past 50 yrs has been considered primarily as an Immune disease
• T cells appear to attack the myelin sheaths
• Treatment has been directed at preventing this T-cell attack
What causes the Immune Attack?
• Infection
• Other environmental factors
• Genetic predisposition
• Often said to be “auto-immune” but there is no known auto-immune antibody
John Kurtzke 1993
• “the weight of epidemiological evidence suggests that an immune system process is the “cart” rather than the “horse,” that there is a real possibility of (predominantly) one horse and not a herd of animals, and that this horse is a specific, albeit unidentified, infection.”
Epidemiologic Evidence for Multiple Sclerosis as an Infection: Clinical Microbiology Reviews 1993 p 382-427
Has there been any progress in 50 yrs?
• Disease (Immune) modifying drugs
• Expensive
• Not effective in progressive forms
• No proof of benefit in reducing long-term disability
• Can have serious side effects including death
Does Immune Demyelination Explain all the Symptoms of MS?
• Fatigue?
• Optic neuritis?
• Heat intolerance?
• Neck swelling?
• Symptoms of decreased cerebral perfusion
Evidence of Venous Involvement in MS
• Putnam & Adler 1937 • Veins in the neighborhood of sclerotic
plaques are often found to be engorged,
tortuous, surrounded by blood pigment, thrombosed or obstructed
• Arch Neurol Psychiatry 1937;38(1):1-15.
Evidence of Venous Involvement in MS
Lymphocytic infiltration of vein wall in acute MS lesion
Collagenous thickening of vein wall and organising endothelial encrustations in chronic plaque
Inflammatory Vasculitis in Multiple Sclerosis. Adams CWM. J Neuro Science 1985;69:269-83.
Evidence of Venous Involvement in MS
• Zamboni – CCSVI 2006
• Initial diagnosis with ultrasound
• Stenoses (narrowings) found in major extracranial veins
• Confirmed by venography and MRV
• Treating the stenoses with venoplasty could result in symptom improvement in MS
Opposition to Looking at MS from a Vascular Perspective
• Universally opposed and criticised by neurologists
• Stated to be dangerous
• No evidence of benefit
• No public access to the procedure in Australia for pwMS
The Problems with CCSVI
• Concept of congenital truncular malformations
• Venoplasty doesn’t help all pwMS
• Venoplasty frequently needs to be repeated
• The stenoses are likely to be just one aspect in the development of MS
Duplex Ultrasound Examination
Duplex Ultrasound Examination
Supine
Flow Volumes Right (ml/min)
Flow Volumes Left (ml/min)
Normal Values Flow volume ml/min
IJV (Proximal) 1816 504 430-970
IJV (Mid) 312 250 200-500
IJV (Distal) 333 270 150-400
Vertebral 53 2 20-60
Global Arterial Cerebral Blood Flow
658mls/min SD: 72mls/min
Sitting
IJV (Proximal) 350 194 0-170
IJV (Mid) 93 188 0-170
IJV (Distal) 42 154 0-170
Vertebral 144 54 99-330
Supine
Flow Volumes Right (ml/min)
Flow Volumes Left (ml/min)
Normal Values Flow volume ml/min
IJV (Proximal) 320 100 430-970
IJV (Mid) 110 70 200-500
IJV (Distal) 90 40 150-400
Vertebral 10 40 20-60
Global Arterial Cerebral Blood Flow
658mls/min SD: 72mls/min
Sitting
IJV (Proximal) 300 170 0-170
IJV (Mid) 80 0 0-170
IJV (Distal) 80 200 0-170
Vertebral 60 0 99-330
Normal
MS with CCSVI
Current Protocol
• MS patients diagnosed with “CCSVI” by Duplex Ultrasound
• MS patients then referred to Vascular Surgeon
• Further assessment with either MR or CT venography
• Finally venography and venoplasty
PATIENTS• Mean Age 48.7 (Range 19-69)• M:F 16:84
• MS Type– Remitting Relapsing 44%– Secondary Progressive 36%– Primary Progressive 20%
• Previous PTA Treatments– Nil 67%– 1 15%– 2 18%– 3 0%
Normal L IJV Venogram Stenosed L IJV Venogram
RESULTS of Venoplasty
• Primary Endpoint QOL (MS QOL 54 tool)
• Mean Pre-Treatment 554.14
• Mean Post-Treatment 856.11
• SD 290.6
• Improvement 54%***
***P=0.001
MSQOL 54 Score
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Pre-Treatment Post-Treatment
Patient 1
Patient 2
Patient 3
Patient 4
Patient 5
Patient 6
Patient 7
Patient 8
Patient 9
Patient 10
Patient 11
Patient 12
Patient 13
Patient 14
Patient 15
Patient 16
Patient 17
Before
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LF MT GA EA SC GB KD JP
Before
After
GACBF
GAFV, T-test for dependent samples
Mean Std.Dv. N Diff. Std.Dv. t df p
Before 901.375 232.7850
After 1238.750 199.8884 8 -337.375 318.5238 -2.99582 7 0.02
Test for Cerebral Perfusion
How can we achieve progress in treatment of MS?
• Research along the path of the immune theory has failed to produce any significant advances in the past 50 years
• A new direction needs to be taken
• The vascular association with MS is undeniable and needs to be thoroughly investigated
• Epidemiological evidence points to the need for more research into infective causes
How can we help patients now?
• Many pwMS have no alternative therapy and therefore no hope.
• pwMS with no private medical insurance have no avenue to investigate their venous disease
• This is discriminatory because others with venous obstructions have full Medicare access
• Action needs to be taken NOW
