Thursday, 31 May 2012

Research: CCSVI Monthly- May



BACKGROUND AND PURPOSE: CCSVI has been reported to occur at high frequency in MS. Its significance in relation to MR imaging parameters also needs to be determined, both in patients with MS and HCs. Therefore, this study determined the associations of CCSVI and conventional MR imaging outcomes in patients with MS and in HCs.


MATERIALS AND METHODS: T2, T1, and gadolinium lesion number, LV, and brain atrophy were assessed on 3T MR imaging in 301 subjects, of whom 162 had RRMS, 66 had secondary-progressive MS subtype, and 73 were HCs. CCSVI was assessed using extracranial and transcranial Doppler evaluation. The MR imaging measure differences were explored with 27 borderline cases for CCSVI, added to both the negative and positive CCSVI groups to assess sensitivity of the results of these cases.


RESULTS: No significant differences between subjects with and without CCSVI were found in any of the individual diagnostic subgroups or MS disease subtypes for lesion burden and atrophy measures, independently of the CCSVI classification criteria used, except for a trend for higher T2 lesion number (irrespective of how borderline cases were classified) and lower brain volume (when borderline cases were included in the positive group) in patients with RRMS with CCSVI. No CCSVI or MR imaging differences were found between 26 HCs with, or 47 without, a familial relationship.


CONCLUSIONS: CCSVI is not associated with more severe lesion burden or brain atrophy in patients with MS or in HCs.

                                            Trials in CCSVI BraveDreams or Deluded Visions?

Forbes TL et al. Surveillance and medical therapy following endovascular treatment of chronic cerebrospinal venous insufficiency. Vascular. 2012 May 10. [Epub ahead of print]
The debate regarding the possible link between chronic cerebrospinal venous insufficiency and multiple sclerosis (MS) is continuously becoming more and more contentious due to the current lack of level 1 evidence from randomized trials. Regardless of this continued uncertainty surrounding the safety and efficacy of this therapy, MS patients from Canada, and other jurisdictions, are traveling abroad to receive central venous angioplasty and, unfortunately, some also receive venous stents. They often return home with few instructions regarding follow-up or medical therapy. In response we propose some interim, practical recommendations for post-procedural surveillance and medical therapy, until further information is available.

Weinstock-Guttman B et al. Clinical correlates of chronic cerebrospinal venous insufficiency in multiple sclerosis. BMC Neurol. 2012 May 15;12(1):26. [Epub ahead of print]

BACKGROUND: Chronic cerebrospinal venous insufficiency (CCSVI) is a vascular condition characterized by anomalies of the primary veins outside the skull that has been reported to be associated with MS. In the blinded Combined Transcranial (TCD) and Extracranial Venous Doppler Evaluation (CTEVD) study, we found that prevalence of CCSVI was significantly higher in multiple sclerosis (MS) vs. healthy controls (HC) (56.1% vs. 22.7%, p < 0.001). The objective was to evaluate the clinical correlates of venous anomalies indicative of CCSVI in patients with MS

METHODS: The original study enrolled 499 subjects; 163 HC, 289 MS, 21 CIS and 26 subjects with other neurological disorders who underwent a clinical examination and a combined Doppler and TCD scan of the head and neck. This analysis was restricted to adult subjects with MS (RRMS: n = 181, SP-MS: n = 80 and PP-MS: n = 12). Disability status was evaluated by using the Kurtzke Expanded Disability Status Scale (EDSS) and MS severity scale (MSSS).

RESULTS: Disability was not associated with the presence ([greater than or equal to]2 venous hemodynamic criteria) or the severity of CCSVI, as measured with venous haemodynamic insufficiency severity score (VHISS). However, the severity of CCSVI was associated with the increased brainstem functional EDSS sub-score (p = 0.002). In logistic regression analysis, progressive MS (SPMS or PP-MS) vs. non-progressive status (including RR-MS) was associated with CCSVI diagnosis (p = 0.004, OR = 2.34, CI = 1.3-4.2).

CONCLUSIONS: The presence and severity of CCVSI in multiple sclerosis correlate with disease status, but has no or very limited association with clinical disability.




There have been a couple of articles that have questioned aspects of the CCSVI concept and there was an FDA safety warning posted earlier in the month 

Brant-Zawadzki MN, Bandari DS, Puangco JJ, Rubin BB The "liberation procedure" for multiple sclerosis: sacrificing science at the altar of consumer demand.  J Am Coll Radiol. 2012; 9:305-8.

There has been debate about this and the impartiality of the authors see Multiple sclerosis Resource Centre for example of commentary on this article
 
Baracchini C, Atzori M, Gallo P. CCSVI and MS: no meaning, no fact. Neurol Sci. 2012 May 9. [Epub ahead of print].  
 Prof G posted on this already.



I forgot to post this on Saturday but this month the balance of reports is essentially all negative.
More next month

Hampson CO, Soares GM, Jaffan AA et al. Reported outcomes after the endovascular treatment of chronic cerebrospinal venous insufficiency. Tech Vasc Interv Radiol. 2012 Jun;15(2):144-9. This study reviews the CCSVI studies so far and the complication rates

Mandato K, Englander M, Keating L, Vachon J, Siskin GP. Catheter venography and endovascular treatment of chronic cerebrospinal venous insufficiency. Tech Vasc Interv Radiol. 2012 Jun;15(2):121-
The review describes endovascular techniques employed to diagnose and treat patients with MS and CCSVI. 

McDonald S, Iceton JB. The use of Doppler ultrasound in the diagnosis of chronic cerebrospinal venous insufficiency. Tech Vasc Interv Radiol. 2012 Jun;15(2):113-20. 

This work aims to present a broad magnetic resonance imaging (MRI) protocol for use in the study of chronic cerebrospinal venous insufficiency (CCSVI). They cite that low total flow in the 2 dominant veins seemed to be the strongest indicator for risk of having blockage or thinnign of the vessel in the MS population.

Dake MD. Chronic cerebrospinal venous insufficiency and multiple sclerosis: history and background. Tech Vasc Interv Radiol. 2012 Jun;15(2):94-100.
A review presents the history of the relationship between the vascular system and MS and explores the background of basic and clinical investigations that led to the concept of CCSVI, as this is a review you know it all already.