Chronic cerebrospinal venous insufficiency in patients with multiple sclerosis

Azygos vein preservation revisited: impact on early outcomes after repair of esophageal atresia/tracheoesophageal fistula in newborns

Since the first successful repair of esophageal atresia/tracheoesophageal fistula (EA-TEF) was performed approximately 8 decades ago, surgeons have made considerable technical advances in solving intraoperative surgical challenges and reducing postoperative complications. According to some surgeons, preserving the Azygos vein makes this modification attractive. This study aimed to evaluate the benefits of preserving the Azygos vein during surgery for esophageal atresia with tracheoesophageal fistula and to highlight its advantages in reducing anastomotic leak, stricture, and other postoperative outcomes. This prospective comparative series was conducted between April 2020 and April 2023. The study included all newborns with EA-TEF eligible for primary repair. Patients were randomized to either Group A or B. Group A underwent Azygos vein preservation, whereas the remaining patients (Group B) underwent Azygos vein disconnection. Sixty-four patients were included in this study. Thirty-two patients (Group A) underwent Azygos vein preservation during EA-TEF repair, and the remaining thirty-two patients (Group B) underwent Azygos vein ligation and disconnection. Both groups were comparable in terms of demographics, clinical data, and operative findings (P > 0.05). Pneumonitis occurred in 4 patients in Group A and 16 patients in Group B. Anastomotic leaks occurred in two (6.2%) patients in Group A and six (18.7%) patients in Group B. There were two deaths in Group A and six deaths in Group B, with a significant difference between the two groups (P = 0.0485). Preserving the Azygos vein during esophageal atresia repair reduces the occurrence of postoperative pneumonia, leakage, and stenosis, and decreases postoperative mortality. Therefore, we declare that this modification is a significant and valuable addition to the current surgical procedures.

The influence of spinal venous blood pressure on cerebrospinal fluid pressure

In Alligator mississippiensis the spinal dura is surrounded by a venous sinus; pressure waves can propagate in the spinal venous blood, and these spinal venous pressures can be transmitted to the spinal cerebrospinal fluid (CSF). This study was designed to explore pressure transfer between the spinal venous blood and the spinal CSF. At rest the cardiac-related CSF pulsations are attenuated and delayed, while the ventilatory-related pulsations are amplified as they move from the spinal venous blood to the spinal CSF. Orthostatic gradients resulted in significant alterations of both cardiac- and ventilatory-related CSF pulsations. Manual lateral oscillations of the alligator's tail created pressure waves in the spinal CSF that propagated, with slight attenuation but no delay, to the cranial CSF. Oscillatory pressure pulsations in the spinal CSF and venous blood had little influence on the underlying ventilatory pulsations, though the same oscillatory pulsations reduced the ventilatory- and increased the cardiac-related pulsations in the cranial CSF. In Alligator the spinal venous anatomy creates a more complex pressure relationship between the venous and CSF systems than has been described in humans.

Cerebral venous disorders: Diagnosis and endovascular management

The role of the venous circulation in neurological diseases has been underestimated. In this review, we present an overview of the intracranial venous anatomy, venous disorders of the central nervous system, and options for endovascular management. We discuss the role the venous circulation plays in various neurological diseases including cerebrospinal fluid (CSF) disorders (intracranial hypertension and intracranial hypotension), arteriovenous diseases, and pulsatile tinnitus. We also shed light on emergent cerebral venous interventions including transvenous brain-computer interface implantation, transvenous treatment of communicating hydrocephalus, and the endovascular treatment of CSF-venous disorders.

Vascular multiple sclerosis: addressing the pathogenesis, genetics, pro-angiogenic factors, and vascular abnormalities, along with the role of vascular intervention

Dysfunction in the epithelium, breakdown of the blood-brain barrier, and consequent leukocyte and T-cell infiltration into the central nervous system define Vascular Multiple Sclerosis. Multiple sclerosis (MS) affects around 2.5 million individuals worldwide, is the leading cause of neurological impairment in young adults, and can have a variety of progressions and consequences. Despite significant discoveries in immunology and molecular biology, the root cause of MS is still not fully understood, as do the immunological triggers and causative pathways. Recent research into vascular anomalies associated with MS suggests that a vascular component may be pivotal to the etiology of MS, and there can be actually a completely new entity in the already available classification of MS, which can be called 'vascular multiple sclerosis'. Unlike the usual other causes of MS, vascular MS is not dependent on autoimmune pathophysiologic mechanisms, instead, it is caused due to the blood vessels pathology. This review aims to thoroughly analyze existing information and updates about the scattered available findings of genetics, pro-angiogenetic factors, and vascular abnormalities in this important spectrum, the vascular facets of MS.

Association between chronic cerebrospinal venous insufficiency and multiple sclerosis: a systematic review and meta-analysis

OBJECTIVES

Numerous studies have indicated that chronic cerebrospinal venous insufficiency is a potential factor in causing multiple sclerosis in recent years, but this conclusion remains unconfirmed. This meta-analysis examined the correlation between multiple sclerosis and chronic cerebrospinal venous insufficiency.

METHODS

We searched Embase and Medline (Ovid) for publications published from 1 January 2006 to 1 May 2022. The meta-analysis was performed following Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines.

RESULTS

Eligible studies (n=20) included 3069 participants from seven countries. Pooled analysis indicated that chronic cerebrospinal venous insufficiency was more frequent in patients with multiple sclerosis than in healthy controls (OR 3.36; 95% CI 1.92 to 5.85; p<0.001) with remarkable heterogeneity among studies (I2=79%). Results were more strongly correlated in subsequent sensitivity analyses, but heterogeneity was also more substantial. We removed studies that initially proposed a chronic cerebrospinal venous insufficiency team as well as studies by authors involved in or advocating endovascular therapies.

CONCLUSIONS

Chronic cerebrospinal venous insufficiency is significantly associated with multiple sclerosis and it is more prevalent in patients with multiple sclerosis than in healthy individuals, but considerable heterogeneity of results is still observed.

An anatomically detailed arterial-venous network model. Cerebral and coronary circulation

In recent years, several works have addressed the problem of modeling blood flow phenomena in veins, as a response to increasing interest in modeling pathological conditions occurring in the venous network and their connection with the rest of the circulatory system. In this context, one-dimensional models have proven to be extremely efficient in delivering predictions in agreement with in-vivo observations. Pursuing the increase of anatomical accuracy and its connection to physiological principles in haemodynamics simulations, the main aim of this work is to describe a novel closed-loop Anatomically-Detailed Arterial-Venous Network (ADAVN) model. An extremely refined description of the arterial network consisting of 2,185 arterial vessels is coupled to a novel venous network featuring high level of anatomical detail in cerebral and coronary vascular territories. The entire venous network comprises 189 venous vessels, 79 of which drain the brain and 14 are coronary veins. Fundamental physiological mechanisms accounting for the interaction of brain blood flow with the cerebro-spinal fluid and of the coronary circulation with the cardiac mechanics are considered. Several issues related to the coupling of arterial and venous vessels at the microcirculation level are discussed in detail. Numerical simulations are compared to patient records published in the literature to show the descriptive capabilities of the model. Furthermore, a local sensitivity analysis is performed, evidencing the high impact of the venous circulation on main cardiovascular variables.

The Negative Prognostic Role of Inflammatory Biomarkers in Patients With Chronic Cerebrospinal Venous Insufficiency

BACKGROUND

The pathologic consequences of inflammatory responses in chronic cerebrospinal venous insufficiency (CCSVI) remains poorly understood. Hence, this study was aimed to evaluate the peripheral inflammatory biomarkers in patients with intracranial and extracranial CCSVI pathology. In addition, the relationship between inflammatory cytokine profile and CCSVI prognosis was also evaluated.

METHODS

Patients diagnosed with CCSVI between July 2017 and July 2019 were included and subsequently divided into 3 groups based on the location of stenosis. The inflammatory biomarker assay included neutrophil-to-lymphocyte ratios (NLRs), platelet-to-lymphocyte ratios (PLRs), red blood cell distribution widths (RDW), C-reactive protein (CRP) levels, interleukin-6 (IL-6) levels, and neuron-specific enolase levels. Clinical outcomes were assessed using the modified Rankin Scale and Patient Global Impression of Change score. Univariate and multivariate regression analyses were performed to identify significant prognostic factors for poorer outcomes. Finally, we established a nomogram based on the multivariate regression analysis.

RESULTS

We enrolled 248 patients in total, including 102 males and 146 females, with an average age of 57.85±12.28 years. Compared with patients with internal jugular vein stenosis, cerebral venous sinus stenosis (CVSS) patients were mostly younger and had been suffering from headaches and severe papilledema. Higher levels of NLR, RDW, and CRP were also observed in the CVSS group. Multivariate analysis indicated that NLR, PLR, and IL-6 were the independent prognostic factors for poor CCSVI outcomes.

CONCLUSIONS

The clinical presentations and increases in NLR, PLR, IL-6, and CRP levels could be distinctly marked in patients with CVSS-related CCSVI than that in internal jugular vein stenosis-related CCSVI, indicating poor prognostic outcomes in these patients. A proinflammatory state might be associated with CCSVI pathology.

Biomechanical changes of the common carotid artery and internal jugular vein in patients with multiple sclerosis

PURPOSE

Investigations of the hemodynamic changes of the venous system in patients with multiple sclerosis (MS) have shown contradictory results. Herein, the biomechanical parameters of the internal jugular vein (IJV) and common carotid artery (CCA) of MS patients were extracted and compared to healthy individuals.

METHODS

B-mode and Doppler sequential ultrasound images of 64 IJVs and CCAs of women including 22 healthy individuals, 22 relapsing-remitting multiple sclerosis (RRMS) patients, and 20 primary-progressive multiple sclerosis (PPMS) patients were recorded and processed. The biomechanical parameters of the IJV and the CCA walls during three cardiac cycles were calculated.

RESULTS

The IJV maximum and minimum pressures were higher in the MS patients than in the healthy subjects, by 31% and 19% in RRMS patients and 39% and 24% in PPMS patients. The venous wall thicknesses in RRMS and PPMS patients were 51% and 60% higher than in healthy subjects, respectively. IJV distensibility in RRMS and PPMS patients was 70% and 75% lower, and compliance was 40% and 59% lower than in healthy subjects. The maximum intima-media thicknesses of the CCAs were 38% and 24%, and the minimum intima-media thicknesses were 27% and 23% higher in RRMS and PPMS patients than in healthy individuals, respectively. The shear modulus of CCA walls in RRMS and PPMS patients was 17% and 31%, and the radial elastic moduli were 47% and 9% higher than in healthy individuals.

CONCLUSION

Some physical and biomechanical parameters of the CCA and IJV showed significant differences between MS patients and healthy individuals.

[Changes in venous circulation in patients with multiple sclerosis]

Multiple sclerosis (MS) is a common neurological disease, especially among people of young working age, and the number of MS cases registered in the world and in the Russian Federation tends to increase. The pathogenesis of MS is based on the theory of damage to its own myelin sheath as a result of activation of autoreactive T cells, which also leads to damage to both oligodendrocytes and axons. In addition, the role of vascular factor in the pathogenesis of MS is discussed in the literature periodically and several areas of research of vascular dysfunction in patients are identified. This article provides a retrospective analysis of the available literature dating from the 19th century to the present time in order to find the relationship between MS and changes in venous circulation.

Association of Age-Related Spontaneous Internal Jugular Vein Reflux with Cognitive Impairment and Incident Dementia

BACKGROUND

It remains unclear whether changes in the venous circulation contribute to cognitive decline.

OBJECTIVE

This study aimed to clarify whether the spontaneous jugular vein reflux (JVR) is associated with cognitive impairment and incident dementia.

METHODS

Patients with any evidence of cerebral vessel disease on magnetic resonance imaging (MRI) were consecutively enrolled between October 2015 to July 2019. We employed carotid duplex sonography to measure the internal jugular vein (IJV). The subjects were classified into two groups based on the degree of JVR on either side: none, mild (JVR(-) group) and moderate, severe (JVR (+) group) JVR. They underwent both the Mini-Mental State Examination (MMSE) and Montreal Cognitive Assessment-Japanese (MoCA-J) global tests. Their cognitive status was prospectively assessed until March 2023.

RESULTS

302 patients with an MMSE score ≥24 underwent duplex sonography of the IJV. Among them, 91 had spontaneous JVR on either side. Both MMSE and MoCA-J were significantly lower in patients with JVR (+) group than in the JVR (-) group. After the adjustment for risk factors and MRI findings, intergroup differences in MoCA-J remained significant. Among the cognitive subdomains, median executive function and memory scores were significantly lower in the JVR (+) group than in the JVR (-) group. During the median 5.2-year follow-up, 11 patients with incident dementia were diagnosed. Patients with severe JVR were significantly more likely to be diagnosed with dementia (log-rank test, p = 0.031).

CONCLUSIONS

Spontaneous IJV reflux especially severe JVR, was associated with global cognitive function, and potentially with incident dementia.

Internal Jugular Vein Geometry Under Multiple Inclination Angles with 3D Low-Field MRI in Healthy Volunteers

BACKGROUND

Cerebral venous pathways are subjected to geometrical and patency changes due to body position. The internal jugular veins (IJVs) are the main venous drainage pathway in supine position. Their patency and geometry should be evaluated under different body inclination angles over a three-dimensional (3D) volume in the healthy situation to better understand pathological cases.

PURPOSE

To investigate whether positional changes in the body can affect the geometrical properties and patency of the venous system.

STUDY TYPE

Prospective.

POPULATION

15 healthy volunteers, of which seven males and median age 22 years in a range of 19-59.

FIELD STRENGTH/SEQUENCE

A 0.25-T tiltable MRI system was used to scan volunteers in 90° (sitting position), 69°, 45°, 21°, and 0° (supine position) in the transverse plane with the top at vertebra C2. A gradient echo sequence was used.

ASSESSMENT

Three observers assessed IJVs on patency and created automatic centerlines from which diameter and patency were analysed perpendicular to the vessel at every 4 mm starting at the level of C2.

STATISTICAL TESTS

A Student's t test was used to find statistical difference (p < 0.05) in average IJV diameters per inclination angle.

RESULTS

The amount of fully collapsed IJVs increased from 33% to 93% (left IJV) and 14% to 80% (right IJV) when increasing the inclination angle from 0° to 90°. In both IJVs, the mean diameter (±SD) of the open vessels was significantly higher at 0° than 90° with 6.3 ± 0.5 mm vs. 4.4 ± 0.1 mm (left IJV) and 6.6 ± 0.6 mm vs. 4.3 ± 0.4 mm (right IJV).

DATA CONCLUSION

Tiltable low-field MRI can be used to assess IJV geometry and its associated venous pathways in 3D under multiple inclination angles. Next to a higher amount of collapsed vessels, the average diameter of noncollapsed vessels decreases with increasing inclination angles for both left and right IJVs.

LEVEL OF EVIDENCE

2 TECHNICAL EFFICACY STAGE: 1.

Modelling of the dilated sagittal sinuses found in multiple sclerosis suggests increased wall stiffness may be a contributing factor

The cross-sectional area of the superior sagittal sinus (SSS) is larger in multiple sclerosis than normal and correlates with disease severity and progression. The sinus could be enlarged due to a decrease in the pressure difference between the lumen and the subarachnoid space, an increase in wall thickness or increased wall stiffness. The cross-sectional area of the SSS and straight sinus (ST) were measured in 103 patients with multiple sclerosis and compared to 50 controls. The cross-sectional area of the SSS and ST were increased by 20% and 13% compared to the controls (p = 0.005 and 0.02 respectively). The deflection of the wall of the sinus was estimated. The change in pressure gradient, wall thickness or elastic modulus between groups was calculated by modelling the walls as simply supported beams. To account for these findings, the modelling suggests either a 70% reduction in transmural venous pressure or a 2.4 fold increase in SSS wall stiffness plus an 11% increase in wall thickness or a combination of changes. An increase in sinus pressure, although the most straight forward possibility to account for the change in sinus size may exist in only a minority of patients. An increase in sinus wall stiffness and thickness may need further investigation.

The BE COOL Treatments (Batroxobin, oxygEn, Conditioning, and cOOLing): Emerging Adjunct Therapies for Ischemic Cerebrovascular Disease

Ischemic cerebrovascular disease (ICD), the most common neurological disease worldwide, can be classified based on the onset time (acute/chronic) and the type of cerebral blood vessel involved (artery or venous sinus). Classifications include acute ischemic stroke (AIS)/transient ischemic attack (TIA), chronic cerebral circulation insufficiency (CCCI), acute cerebral venous sinus thrombosis (CVST), and chronic cerebrospinal venous insufficiency (CCSVI). The pathogenesis of cerebral arterial ischemia may be correlated with cerebral venous ischemia through decreased cerebral perfusion. The core treatment goals for both arterial and venous ICDs include perfusion recovery, reduction of cerebral ischemic injury, and preservation of the neuronal integrity of the involved region as soon as possible; however, therapy based on the current guidelines for either acute ischemic events or chronic cerebral ischemia is not ideal because the recurrence rate of AIS or CVST is still very high. Therefore, this review discusses the neuroprotective effects of four novel potential ICD treatments with high translation rates, known as the BE COOL treatments (Batroxobin, oxygEn, Conditioning, and cOOLing), and subsequently analyzes how BE COOL treatments are used in clinical settings. The combination of batroxobin, oxygen, conditioning, and cooling may be a promising intervention for preserving ischemic tissues.

Esophageal Atresia and Tracheoesophageal Fistula: A Retrospective Review from a Tertiary Care Institute

BACKGROUND

A survey of neonates with esophageal atresia and tracheoesophageal fistula (EA ± TEF) to determine additional factors responsible for poor surgical outcomes in our institution where employing an improved standard of care can ameliorate the outcome.

MATERIALS AND METHODS

We carried out a retrospective review of 54 neonates, who underwent surgical repair of EA± TEF over a 5-year period. We collected data regarding the patients' demographics, perioperative findings, records of neonatal intensive care, and ascertained the effects of gender, gestational age, birth weight, age at operation, type of anomaly, coexisting major anomalies, preoperative inotrope therapy, and duration of postoperative ventilation on the surgical outcome.

RESULTS

The mortality rate was 51.9%, out of which, 42.8% of neonates succumbed to ventilator-associated conditions. Age at the time of surgery, gestational age, preoperative inotrope support, presence of coexisting anomalies, and duration of postoperative ventilation were determined as the significant variables predicting mortality(P < 0.05). The area under the Receiver Operating Curve showed the duration of postoperative ventilation as the best indicator of mortality. The Logistic regression model (χ² = 11.204, P = 0.019) with the above-mentioned variables showed that neonates who were operated before 2.5 days and who required <74.5 hours of postoperative ventilation were 3.91 and 48.30 times more likely to survive respectively, than their counterparts.

CONCLUSION

A delay in surgery due to delayed diagnosis and or delayed transportation to tertiary centres and prolonged ventilatory support have an additional detrimental effect on the surgical outcomes of EA ± TEF.

Flow volume measurement of arterial venous and cerebrospinal fluid in patients with multiple sclerosis

Background Multiple sclerosis (MS) is usually described as an autoimmune disease, although the exact mechanism of the disease remains unknown. There have been studies reporting that venous flow abnormalities may be involved in the pathogenesis of MS or many of the associated clinical manifestations.

Objective The aim of this study was to evaluate flow volumes of the middle cerebral artery (MCA), transverse sinus (TS), and cerebral aqueduct using phase contrast magnetic resonance imaging (PC-MRI) in relapsing-remitting MS patients and a control group.

Methods We included 34 patients diagnosed by the McDonald criteria, revised in 2017, as well as 15 healthy controls matched by age and sex. The MRI scans were performed using a 1.5-T superconducting scanner. Axial T1-weighted, T2-weighted, and PC-MRI sequences were performed for the quantitative investigation of flow volume measurements. Quantitative analyses of flows were performed using flow analyses program PC-MRI angiography software. A circular region of interest was placed manually into the cerebral aqueduct, bilateral MCA, and TS.

Results Flow volumes of the cerebral aqueduct and MCA were not statistically significant between the MS and control groups. The flow volumes of the TS for the patient group were lower than those of the control group, and this difference was statistically significant.

Conclusions A reduced TS flow volume in MS patients was noted in the present study when compared with the control group, suggesting a relation between venous pathologies and MS. Further studies are needed to understand whether this relation is causal or epiphenomenal.

Cerebrospinal fluid dynamics coupled to the global circulation in holistic setting: Mathematical models, numerical methods and applications

This paper presents a mathematical model of the global, arterio-venous circulation in the entire human body, coupled to a refined description of the cerebrospinal fluid (CSF) dynamics in the craniospinal cavity. The present model represents a substantially revised version of the original Müller-Toro mathematical model. It includes one-dimensional (1D), non-linear systems of partial differential equations for 323 major blood vessels and 85 zero-dimensional, differential-algebraic systems for the remaining components. Highlights include the myogenic mechanism of cerebral blood regulation; refined vasculature for the inner ear, the brainstem and the cerebellum; and viscoelastic, rather than purely elastic, models for all blood vessels, arterial and venous. The derived 1D parabolic systems of partial differential equations for all major vessels are approximated by hyperbolic systems with stiff source terms following a relaxation approach. A major novelty of this paper is the coupling of the circulation, as described, to a refined description of the CSF dynamics in the craniospinal cavity, following Linninger et al. The numerical solution methodology employed to approximate the hyperbolic non-linear systems of partial differential equations with stiff source terms is based on the Arbitrary DERivative Riemann problem finite volume framework, supplemented with a well-balanced formulation, and a local time stepping procedure. The full model is validated through comparison of computational results against published data and bespoke MRI measurements. Then we present two medical applications: (i) transverse sinus stenoses and their relation to Idiopathic Intracranial Hypertension; and (ii) extra-cranial venous strictures and their impact in the inner ear circulation, and its implications for Ménière's disease.

Quantified hemodynamic parameters of the venous system in multiple sclerosis: A systematic review

BACKGROUND

Multiple Sclerosis (MS) is a complex neurodegenerative condition that is influenced by a combination of genetic and environmental factors. Included in these factors is the venous system, however, the extent to which it influences the etiology of MS has yet to be fully characterised. The aim of this review is to critically summarize the literature available concerning the venous system in MS, primarily concerning specific data on the venous pressure and blood flow in this system.

METHODS

A systematic review was conducted with the application of the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) criteria. The advanced search functions of both the Scopus and PubMed databases were used to conduct the literature search, resulting in 136 unique articles initially identified. Applying relevant exclusion criteria, 22 of the studies were chosen for this review.

RESULTS

The selected studies were analysed for venous pressure and blood flow related findings, with 14 studies contributing data on the internal jugular vein (IJV) flow rate, 5 on blood flows of the intracranial venous sinuses, 2 on blood flow pulsatility and 6 supplying information relevant to the venous pressure (3 studies contributed to multiple areas). The general findings of the review included that the IJV flow was not significantly different between MS patients and controls, however, there were variances between stenotic (S) and non-stenotic (NS) MS patients. Due to the limited data in the other two areas defined in this review, further research is required to establish if any variances in MS are present.

CONCLUSION

It remains unclear if there are significant differences in many flow variables between MS patients and controls considered in this review. It would be advantageous if future work in this area focused on understanding the hemodynamics of this system, primarily concerning how the flow rate, venous pressure and vascular resistance are related, and any impact that these factors have on the etiology of MS.

Combination of Genomic and Transcriptomic Approaches Highlights Vascular and Circadian Clock Components in Multiple Sclerosis

Aiming at exploring vascular components in multiple sclerosis (MS) with brain outflow disturbance, we combined transcriptome analysis in MS internal jugular vein (IJV) wall with WES in MS families with vertical transmission of disease. Main results were the differential expression in IJV wall of 16 MS-GWAS genes and of seven genes (GRIN2A, GRIN2B, IL20RB, IL26, PER3, PITX2, and PPARGC1A) not previously indicated by GWAS but encoding for proteins functionally interacting with MS candidate gene products. Strikingly, 22/23 genes have been previously associated with vascular or neuronal traits/diseases, nine encoded for transcriptional factors/regulators and six (CAMK2G, GRIN2A, GRIN2B, N1RD1, PER3, PPARGC1A) for circadian entrainment/rhythm components. Among the WES low-frequency (MAF ≤ 0.04) SNPs (n = 7) filtered in the 16 genes, the NR1D1 rs17616365 showed significantly different MAF in the Network for Italian Genomes affected cohort than in the 1000 Genome Project Tuscany samples. This pattern was also detected in five nonintronic variants (GRIN2B rs1805482, PER3 rs2640909, PPARGC1A rs2970847, rs8192678, and rs3755863) in genes coding for functional partners. Overall, the study proposes specific markers and low-frequency variants that might help (i) to understand perturbed biological processes in vascular tissues contributing to MS disease, and (ii) to characterize MS susceptibility genes for functional association with disease-pathways.

Does the venous pressure theory of multiple sclerosis pathophysiology deserve a second chance?

The theory that multiple sclerosis is related to venous pressure has been discredited due to previous operator dependent diagnostic criteria and premature attempts at treatment. (1) An elevation in venous pressure may only be a component of the compliance changes found in MS. (2) The neck veins may only supply a component of the venous pressure elevation found intracranially. Although a more targeted approach towards neck angioplasty (both towards disease subtype and those with more favorable stenoses) may be beneficial, we would advocate caution. We encourage others to give the venous pressure theory a second chance and to replicate our work.

What are the ideal characteristics of a venous stent?

Historically, the stents used in the venous system were not dedicated scaffolds. They were largely adapted arterial stents. An essential feature of a venous stent is compliance, in order to adapt its crosssectional area to the vein. It should also be crush resistant, corrosion resistant and fatigue resistant. The material should be radiopaque, for follow-up. Another characteristic of the ideal venous stent is flexibility, to adapt its shape to the vein, not vice versa. The scaffold should be uncovered too, in order to avoid the occlusion of collaterals. The ideal venous stent should not migrate, so it is necessary a large diameter and a long length. The radial force is important to prevent migration. However, current stents derived from arterial use display high radial force, which could affect the patency of the thin venous wall. Alternatively, if the stent has an anchor point, that permits a passive anchoring, the radial force required to avoid migration will be lower. Dedicated venous stents were not available until very recently. Furthermore, there is a preclinical study about a new compliant nitinol stent, denominated Petalo CVS. Out of the commonest causes of large veins obstruction, dedicated venous stent could also treat other diseases described more recently, such as the jugular variant of the Eagle syndrome, JEDI syndrome and jugular lesions of the chronic cerebrospinal venous insufficiency that result unfavorable for angioplasty according to Giaquinta classification.

An Overview of Venous Abnormalities Related to the Development of Lesions in Multiple Sclerosis

The etiology of multiple sclerosis (MS) is currently understood to be autoimmune. However, there is a long history and growing evidence for disrupted vasculature and flow within the disease pathology. A broad review of the literature related to vascular effects in MS revealed a suggestive role for abnormal flow in the medullary vein system. Evidence for venous involvement in multiple sclerosis dates back to the early pathological work by Charcot and Bourneville, in the mid-nineteenth century. Pioneering work by Adams in the 1980s demonstrated vasculitis within the walls of veins and venules proximal to active MS lesions. And more recently, magnetic resonance imaging (MRI) has been used to show manifestations of the central vein as a precursor to the development of new MS lesions, and high-resolution MRI using Ferumoxytol has been used to reveal the microvasculature that has previously only been demonstrated in cadaver brains. Both approaches may shed new light into the structural changes occurring in MS lesions. The material covered in this review shows that multiple pathophysiological events may occur sequentially, in parallel, or in a vicious circle which include: endothelial damage, venous collagenosis and fibrin deposition, loss of vessel compliance, venous hypertension, perfusion reduction followed by ischemia, medullary vein dilation and local vascular remodeling. We come to the conclusion that a potential source of MS lesions is due to locally disrupted flow which in turn leads to remodeling of the medullary veins followed by endothelial damage with the subsequent escape of glial cells, cytokines, etc. These ultimately lead to the cascade of inflammatory and demyelinating events which ensue in the course of the disease.

The Impact of SARS-CoV-2 Infection on the Development of Neurodegeneration in Multiple Sclerosis

The novel coronavirus disease 2019 (COVID-19) pandemic, caused by severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), remains a global challenge. Currently, there is some information on the consequences of COVID-19 infection in multiple sclerosis (MS) patients, as it is a newly discovered coronavirus, but its far-reaching effects on participation in neurodegenerative diseases seem to be significant. Recent cases reports showed that SARS-CoV-2 may be responsible for initiating the demyelination process in people who previously had no symptoms associated with any nervous system disorders. It is presently known that infection of SARS-CoV-2 evokes cytokine storm syndrome, which may be one of the factors leading to the acute cerebrovascular disease. One of the substantial problems is the coexistence of cerebrovascular disease and MS in an individual's life span. Epidemiological studies showed an enhanced risk of death rate from vascular disabilities in MS patients of approximately 30%. It has been demonstrated that patients with severe SARS-CoV-2 infection usually show increased levels of D-dimer, fibrinogen, C-reactive protein (CRP), and overactivation of blood platelets, which are essential elements of prothrombotic events. In this review, the latest knowledge gathered during an ongoing pandemic of SARS-CoV-2 infection on the neurodegeneration processes in MS is discussed.

An overview of randomized controlled trials on endovascular treatment for chronic cerebrospinal venous insufficiency in multiple sclerosis patients

About ten years ago it was hoped that venous angioplasty for abnormal veins, primarily the internal jugular veins, will be a much awaited treatment for multiple sclerosis. Yet, a majority of randomized clinical trials on endovascular treatment for chronic cerebrospinal venous insufficiency did not reveal clinical efficacy of these procedures in multiple sclerosis patients. Still, a detailed analysis of these trials suggests that they were poorly designed, underpowered and endovascular techniques used were often far from being optimal. Nonetheless, even considering weak points of these trials, it can be concluded that venous angioplasty should not be used as a routine treatment modality in multiple sclerosis patients. Still, a possibility that some patients may benefit from endovascular treatment cannot be ruled out. This may concern patients at early stage of the disease and presenting with lesions that can easily be managed with balloon angioplasty. Therefore, we need more studies evaluating clinical efficacy of venous angioplasty in selected subgroups of multiple sclerosis patients. Importantly, it has already been demonstrated that venous angioplasty in multiple sclerosis patients is a safe procedure. Thus, also from an ethical point of view, such trials seem justifiable.

Pathogenesis and Management in Cerebrovenous Outflow Disorders

In keeping with its status as one of the major causes of disability and mortality worldwide, brain damage induced by cerebral arterial disease has been the subject of several decades of scientific investigation, which has resulted in a vastly improved understanding of its pathogenesis. Brain injury mediated by venous etiologies, however, such as cerebral, jugular, and vertebral venous outflow disturbance, have been largely ignored by clinicians. Unfortunately, this inattention is not proportional to the severity of cerebral venous diseases, as the impact they exact on the quality of life of affected patients may be no less than that of arterial diseases. This is evident in disease sequelae such as cerebral venous thrombosis (CVT)-mediated visual impairment, epilepsy, and intracranial hypertension; and the long-term unbearable head noise, tinnitus, headache, dizziness, sleeping disorder, and even severe intracranial hypertension induced by non-thrombotic cerebral venous sinus (CVS) stenosis and/or internal jugular venous (IJV) stenosis. In addition, the vertebral venous system (VVS), a large volume, valveless vascular network that stretches from the brain to the pelvis, provides a conduit for diffuse transmission of tumors, infections, or emboli, with potentially devastating clinical consequences. Moreover, the lack of specific features and focal neurologic signs seen with arterial etiologies render cerebral venous disease prone to both to misdiagnoses and missed diagnoses. It is therefore imperative that awareness be raised, and that as comprehensive an understanding as possible of these issues be cultivated. In this review, we attempt to facilitate these goals by systematically summarizing recent advances in the diagnosis and treatment of these entities, including CVT, CVS stenosis, and IJV stenosis, with the aim of providing a valid, practical reference for clinicians.

"I Will Respect the Autonomy of My Patient": A Scoping Review of Shared Decision Making in Multiple Sclerosis

Background

Patient autonomy is a bioethical principle that was strengthened in the revised Declaration of Geneva. Shared decision making (SDM) is particularly relevant in the management of multiple sclerosis (MS) because many preference-sensitive decisions have to be made during the disease course. We aimed to summarize the available evidence on SDM in the MS field and to inform future research and practice.

Methods

We performed a scoping review by searching MEDLINE (past 5 years). Studies were included if they reported primary/secondary research and focused on SDM related to people with MS. Data were grouped into topics, with results presented in narrative form.

Results

From 865 references, we included 55 studies conducted mostly in Europe. Half of the studies were observational, followed by qualitative (20%), mixed-methods (17%), randomized controlled trials (RCTs, 5%), quasi-experimental (5%), and reviews (4%). Most studies addressed people with relapsing-remitting MS (85%); the remaining addressed health care professionals, patients' significant others, or a combination. We identified five main topics: decisions on disease-modifying drugs, decisions on chronic cerebrospinal venous insufficiency treatment, information provision and patient education, health literacy, and risk knowledge.

Conclusions

The high proportion of included studies on SDM in MS in Europe suggests an earlier adoption of these concepts in this area. Decisions on disease-modifying drugs was the prevalent topic. Only 5% of studies were RCTs, indicating that more research is needed to study the effectiveness of SDM interventions. Studies addressing people with primary and secondary progressive MS are also needed.

Clinical Classification and Collateral Circulation in Chronic Cerebrospinal Venous Insufficiency

Background: As an indispensable part of the cerebral venous system, the extracranial cerebrospinal venous system is not fully recognized. This study aimed to analyze the clinical classification and imaging characteristics of chronic cerebrospinal venous insufficiency (CCSVI) quantitatively.

Methods: A total of 128 patients, who were diagnosed as CCSVI by jugular ultrasound and contrast-enhanced magnetic resonance venography (CE-MRV), were enrolled from May 2018 through May 2019. For the patients with possible extraluminal compression, computed tomography venography (CTV) was applied to estimate the degree of internal jugular venous stenosis (IJVS) and rank the vertebral venous collateral circulation.

Results: The causes of extraluminal compression induced IJVS included osseous compression (78.95%), carotid artery (24.21%), sternocleidomastoid muscle (5.79%), swollen lymph node (1.05%), and unknown reasons (5.26%). The subtypes of non-compression CCSVI included the high jugular bulb (77.27%), fenestration of the internal jugular vein (IJV) (7.27%), internal jugular phlebectasia (2.73%), tortuous IJV (0.91%), IJV thrombosis (14.55%), and elongated venous valves with/without erythrocyte aggregation (13.64%). For extraluminal compression induced IJVS, the ratio of severe vertebral venous expansion was higher in the severe IJVS group than that in the mild IJVS group (p < 0.001). The IJVS degree was higher in the severe vertebral venous expansion group than in the mild vertebral venous expansion group (p < 0.001).

Conclusions: A multimodal diagnostic system is necessary to improve the diagnostic accuracy of CCSVI. The vertebral venous system is an important collateral circulation for CCSVI, which may be a promising indicator for evaluating IJVS degree.

Jugular Venous Reflux Can Mimic Posterior Fossa Dural Arteriovenous Fistulas on MRI-MRA

Dural arteriovenous fistulas (DAVFs) are high-flow acquired shunts that can carry high risk of intracranial hemorrhage. Because DAVFs can often be managed by endovascular means, early and accurate diagnosis can markedly improve patient morbidity. Time-of-flight and arterial spin-labeling MRA have increased the diagnostic utility of MRI for DAVF by showing hemodynamic rather than anatomic evidence of shunting. The purpose of this article is to describe the cases of seven patients who had co-localization of arterial spin-labeling signal intensity and time-of-flight flow-related enhancement in the left skull base, resulting in a misdiagnosis of DAVF and a recommendation for catheter angiography by the interpreting radiologist. Benign jugular venous reflux is identified as a common mechanism in each case, and the physiology behind this imaging pitfall is described. An algorithmic diagnostic approach to differentiating physiologic venous reflux from true posterior skull base DAVFs is presented.

Clinical characteristics and neuroimaging findings in eagle syndrome induced internal jugular vein stenosis

Background

Eagle syndrome is a condition that causes pharyngeal pain, facial pain, swallowing difficulties, and symptoms of arterial impingement due to the elongated styloid process. However, few reports were about eagle syndrome with venous compression up to now. This study aimed to identify the clinical profiles of the internal jugular vein stenosis (IJVS) related eagle syndrome comprehensively.

Methods

A total of 27 patients, who were diagnosed as IJVS induced by styloid process compression were enrolled. The clinical manifestations and imaging features were analyzed.

Results

Styloid process compression was presented in all of the 27 IJVS patients, in which, the top three symptoms included insomnia (81.5%), tinnitus (63.0%) and head noises (63.0%). The most vulnerable segment of internal jugular vein (IJV) was J3 segment (96.3%). The average styloid process length in our study was 3.7 cm. Hearing impairment was more common in bilateral IJVS (68.8% vs. 18.2%, P=0.018). One patient reported significant relief of symptoms at 1 year follow-up after underwent styloidectomy combined with stenting.

Conclusions

Neurological symptoms of eagle syndrome induced IJVS were various, including either arterial or venous issues. Better understanding of this disease entity may be helpful for clinical diagnosis and treatment.

Probable risk factors of internal jugular vein stenosis in Chinese patients-A real-world cohort study

OBJECTIVES

Extracranial venous anomalies, especially internal jugular vein stenosis (IJVS), have recently received increasing attention, however, its etiologies are uncertain. This study aimed to explore the probable risk factors of IJVS in Chinese PATIENTS AND METHODS: Eligible patients with IJVS confirmed by contrast-enhanced magnetic resonance venography (CE-MRV) were enrolled from October 2017 through October 2018. Probable risk factors were analyzed, including the conditions that may result in IJV wall damage, extraluminal compression, gender and age.

RESULTS

A total of 133 patients enrolled in the final analysis, including 73 females and 60 males, the mean age were 54.83 ± 15.25 years. In this IJVS cohort, the top two risks were previous hepatitis B virus (HBV) infection (48.9 %) and osseous compression (41.4 %). The IJVS cohort was divided into two subsets: extraluminal compression and non-compression. In the former, osseous compression (80.9 %) was the top risk factor, other risks including arterial (22.1 %) and lymph node compression (2.9 %). While, in the latter subset, the most common risk factor was previous HBV infection (46.2 %). In addition, cerebral venous sinus thrombosis (CVST) in non-compression subset was more common than that in extraluminal compression subset (21.5 % VS. 2.9 %, p = 0.001). When considered the gender (Male vs. Female), the ratios were 28.3 % vs. 0 % of smoking, p < 0.001, 16.67 % vs. 1.37 % of hyperhomocysteinemia, p = 0.002, and 11.67 % vs. 1.37 % of hyperuricemia, p = 0.023. In the subset with age less than 45 years, the top three risks included CVST (56.25 %), immunological diseases (55.56 %), and hyperhomocysteinemia (50.00 %), while, in the subset with the ages over 60 years, type-2 diabetes (66.66 %), carotid artery compression (53.33 %), previous HBV infection (52.31 %), and osseous compression (49.09 %) were more common than others.

CONCLUSION

This study illustrates the probable risks of IJVS may be diverse, in which osseous compression and previous HBV infection may be the top two probable risks of IJVS in Chinese. This is the biggest difference from previous reports based on Caucasian.

Clinical and neuroimaging correlates among cohorts of cerebral arteriostenosis, venostenosis and arterio-venous stenosis

The purpose of this study was to discriminate the clinical and imaging correlates of cerebral arterial stenosis (CAS), venous stenosis (CVS) and arterio-venous stenosis (CAVS) in the clinical setting. Patients were classified into three groups: CAS (n = 75), CVS (n=74) and CAVS (n=67). Focal neurological deficits were the prominent presenting symptoms in CAS group, while venous turbulence related symptoms were common in both CVS and CAVS group. Risk factor analysis showed the OR (95%CI) for diabetes, male gender and age in CAS vs. CVS group were 13.67(2.71, 68.85), 6.69(2.39, 18.67) and 1.07(1.03, 1.12) respectively. Male gender, diabetes and age in CAVS vs. CAS groups were 0.27(0.11, 0.63), 0.26(0.10, 0.67) and 1.09(1.04, 1.14) respectively, while age in CAVS vs. CVS group was 1.11(1.07, 1.15). The white matter lesions (WMLs) in CAS group varied in size, with clear boundaries asymmetrically distributed in bilateral hemispheres. CVS-induced WMLs revealed a bilaterally symmetric, cloudy-like appearance. The cerebral perfusion was asymmetrically reduced in CAS but symmetrically reduced in CVS group. The clinical characteristics and neuroimaging presentations were different among patients with CAS, CVS and CAVS. We recommended for aged patients, both arterial and venous imaging should be considered in diagnosis of cerebral stenotic vascular disorders.

Effects of Venous Angioplasty on Cerebral Lesions in Multiple Sclerosis: Expanded Analysis of the Brave Dreams Double-Blind, Sham-Controlled Randomized Trial

Purpose:

To evaluate if jugular vein flow restoration in various venographic defects indicative of chronic cerebrospinal venous insufficiency (CCSVI) in multiple sclerosis (MS) patients can have positive effects on cerebral lesions identified using magnetic resonance imaging (MRI).

Materials and Methods:

The Brave Dreams trial (ClinicalTrials.gov identifier NCT01371760) was a multicenter, randomized, parallel group, double-blind, sham-controlled trial to assess the efficacy of jugular venoplasty in MS patients with CCSVI. Between August 2012 and March 2016, 130 patients (mean age 39.9±10.6 years; 81 women) with relapsing/remitting (n=115) or secondary/progressive (n=15) MS were randomized 2:1 to venography plus angioplasty (n=86) or venography (sham; n=44). Patients and study personnel (except the interventionist) were masked to treatment assignment. MRI data acquired at 6 and 12 months after randomization were compared to the preoperative scan for new and/or >30% enlargement of T2 lesions plus new gadolinium enhancement of pre-existing lesions. The relative risks (RR) with 95% confidence interval (CI) were estimated and compared. In a post hoc assessment, venograms of patients who underwent venous angioplasty were graded as “favorable” (n=38) or “unfavorable” (n=30) for dilation according to the Giaquinta grading system by 4 investigators blinded to outcomes. These subgroups were also compared.

Results:

Of the 130 patients enrolled, 125 (96%) completed the 12-month MRI follow-up. Analysis showed that the likelihood of being free of new cerebral lesions at 1 year was significantly higher after venoplasty compared to the sham group (RR 1.42, 95% CI 1.00 to 2.01, p=0.032). Patients with favorable venograms had a significantly higher probability of being free of new cerebral lesions than patients with unfavorable venograms (RR 1.82, 95% CI 1.17 to 2.83, p=0.005) or patients in the sham arm (RR 1.66, 95% CI 1.16 to 2.37, p=0.005).

Conclusion:

Expanded analysis of the Brave Dreams data that included secondary/progressive MS patients in addition to the relapsing/remitting patients analyzed previously showed that venoplasty decreases new cerebral lesions at 1 year. Post hoc analysis confirmed the efficacy of the Giaquinta grading system in selecting patients appropriate for venoplasty who were more likely to be free from accumulation of new cerebral lesions at MRI.

Probable factors affecting clinical outcomes of internal jugular vein stenosis

Background

Internal jugular vein stenosis (IJVS) has recently aroused increasing interests, whereas, the factors affecting its clinical outcomes are not clear. This study aims to explore the probable factors affected clinical prognosis by evaluating the IJVS with different etiologies and strategies.

Methods

Patients with IJVS confirmed by contrast-enhanced magnetic resonance venography (CE-MRV) were enrolled from October 2017 through October 2018. One-year clinical outcomes of the IJVS cases enrolled in this study were assessed by outpatient and telephone follow-up using the Patient Global Impression of Change (PGIC) scores. According to the etiologies, patients were divided into thrombotic IJVS and non-thrombotic IJVS groups. And further, non-thrombotic IJVS group was divided into external compression and non-external compression subgroups. Outcomes of IJVS with different etiologies and strategies were compared and the probable prognostic factors were analyzed.

Results

A total of 118 eligible patients enrolled in this study, including 76 females and 42 males, mean aged 55.07±14.61 years. The average follow-up duration after discharge was 13.22±3.80 months. According to the PGIC scores, we categorized patients as good outcome and poor outcome groups. For thrombotic IJVS, patients underwent standard anticoagulant obtained remarkable PGIC improvement (100.0% vs. 33.3%, P=0.038). For non-thrombotic IJVS, stenting showed benefit in non-external compression subgroup (26.9% vs. 3.3%, P=0.019) but not in external compression subgroup. In addition, we found that in this Chinese IJVS cohort, poor outcomes involved old age (P=0.004), type 2 diabetes mellitus (P=0.036), previous hepatitis B virus (HBV) infection (P=0.027), and head noises (P=0.002). Multivariate logistic regression analysis indicated that continuous head noises [P=0.045, odds ratio (OR): 2.412, 95% confidence interval (CI): 1.019-5.711], as a unique symptom of IJVS may be significantly related to poor outcomes.

Conclusions

In this Chinese cohort, elderly degenerative bone compression, type 2 diabetes mellitus, and previous HBV infection are the top-three probable etiologies of non-thrombotic IJVS and may involve poor outcome. Long-term head noises may predict IJVS and with poor outcome. Thrombosis-induced IJVS may get benefit from standard anticoagulation. Non-external compression IJVS can be corrected by stenting.

Fluid dynamics of thoracic cavity venous flow in multiple sclerosis

This paper hypothesizes, based on fluid dynamics principles, that in multiple sclerosis (MS) non-laminar, vortex blood flow occurs in the superior vena cava (SVC) and brachiocephalic veins (BVs), particularly at junctions with their tributary veins. The physics-based analysis demonstrates that the morphology and physical attributes of the major thoracic veins, and their tributary confluent veins, together with the attributes of the flowing blood, predict transition from laminar to non-laminar flow, primarily vortex flow, at select vein curvatures and junctions. Non-laminar, vortex flow results in the development of immobile stenotic valves and intraluminal flow obstructions, particularly in the internal jugular veins (IJVs) and in the azygos vein (AV) at their confluences with the SVC or BVs. Clinical trials' observations of vascular flow show that regions of low and reversing flow are associated with endothelial malformation. The physics-based analysis predicts the growth of intraluminal flaps and septa at segments of vein curvature and flow confluences. The analysis demonstrates positive correlations between predicted and clinically observed elongation of valve leaflets and between the predicted and observed prevalence of immobile valves at various venous flow confluences. The analysis predicts the formation of sclerotic plaques at venous junctions and curvatures, in locations that are analogous to plaques in atherosclerosis. The analysis predicts that increasing venous compliance increases the laminarity of venous flow and reduces the prevalence and severity of vein malformations and plaques, a potentially significant clinical result. An over-arching observation is that the correlations between predicted phenomena and clinically observed phenomena are sufficiently positive that the physics-based approach represents a new means for understanding the relationships between venous flow in MS and clinically observed venous malformations.

No association between variations in extracranial venous anatomy and clinical outcomes in multiple sclerosis patients over 5 years

Background

No longitudinal, long-term, follow-up studies have explored the association between presence and severity of variations in extracranial venous anatomy, and clinical outcomes in patients with multiple sclerosis (MS).

Objective

This prospective 5-year follow-up study assessed the relationship of variations in extracranial venous anatomy, indicative of chronic cerebrospinal venous insufficiency (CCSVI) on Doppler sonography, according to the International Society for Neurovascular Disease (ISNVD) proposed consensus criteria, with clinical outcomes and disease progression in MS patients.

Methods

90 MS patients (52 relapsing-remitting, RRMS and 38 secondary-progressive, SPMS) and 38 age- and sex-matched HIs were prospectively followed for 5.5 years. Extracranial and transcranial Doppler-based venous hemodynamic assessment was conducted at baseline and follow-up to determine the extent of variations in extracranial venous anatomy. Change in Expanded Disability Status Scale (∆EDSS), development of disability progression (DP) and annualized relapse rate (ARR) were assessed.

Results

No significant differences were observed in MS patients, based on their presence of variations in extracranial venous anatomy at baseline or at the follow-up, in ∆EDSS, development of DP or ARR. While more MS patients had ISNVD CCSVI criteria fulfilled at baseline compared to HIs (58% vs. 37%, p = 0.03), no differences were found at the 5-year follow-up (61% vs. 56%, p = 0.486).

Discussion

This is the longest follow-up study assessing the longitudinal relationship between the presence of variations in extracranial venous anatomy and clinical outcomes in MS patients. Conclusion: The presence of variations in extracranial venous anatomy does not influence clinical outcomes over the 5-year follow-up in MS patients.

Electronic supplementary material

The online version of this article (10.1186/s12883-019-1350-2) contains supplementary material, which is available to authorized users.

Percutaneous transluminal angioplasty for treatment of chronic cerebrospinal venous insufficiency (CCSVI) in people with multiple sclerosis

BACKGROUND

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 that intraluminal defects, compression, or hypoplasia in the internal jugular or azygos veins may be important factors in the pathogenesis of MS. This condition has been named 'chronic cerebrospinal venous insufficiency' (CCSVI). It has been suggested that these intraluminal defects restrict the normal blood flow from the brain and spinal cord, causing the deposition of iron in the brain and the eventual triggering of an auto-immune response. The proposed treatment for CCSVI is venous percutaneous transluminal angioplasty (PTA), which is claimed to improve the blood flow in the brain thereby alleviating some of the symptoms of MS. This is an update of a review first published in 2012.

OBJECTIVES

To assess the benefit and safety of venous PTA in people with MS and CCSVI.

SEARCH METHODS

We searched the Cochrane Multiple Sclerosis and Rare Diseases of the Central Nervous System Group's Specialised Register up to 30 August 2018, CENTRAL (in the Cochrane Library 2018, issue 8), MEDLINE up to 30 August 2018, Embase up to 30 August 2018, metaRegister of Controlled Trials, ClinicalTrials.gov., the Australian New Zealand Clinical Trials Registry, and the World Health Organization (WHO) International Clinical Trials Registry platform. We examined the bibliographies of the included and excluded studies.

SELECTION CRITERIA

We included randomised controlled trials (RCTs) in which PTA and sham interventions were compared in adults with MS and CCSVI.

DATA COLLECTION AND ANALYSIS

Two authors independently assessed study eligibility and risk of bias, and extracted data. We reported results as risk ratios (RR) with 95% confidence intervals (CI). We performed statistical analyses using the random-effects model; and we assessed the certainty of the evidence using GRADE.

MAIN RESULTS

We included three RCTs (238 participants) in this update. One hundred and thirty-four participants were randomised to PTA and 104 to sham treatment. We attributed low risk of bias to two (67%) studies for sequence generation and two (67%) studies for performance bias. All studies were at a low risk of detection bias, attrition bias, reporting bias and other potential sources of bias.There was moderate-quality evidence to suggest that venous PTA did not increase the proportion of patients who had operative or post-operative serious adverse events compared with the sham procedure (RR 3.33, 95% CI 0.36 to 30.44; 3 studies, 238 participants); nor did it increase the proportion of patients who improved on a functional composite measure including walking control, balance, manual dexterity, postvoid residual urine volume, and visual acuity over 12-month follow-up (RR 0.84, 95% CI 0.55 to 1.30; 1 study, 110 participants); nor did it reduce the proportion of patients who experienced new relapses at six- or 12-month follow-up (RR 0.87, 95% CI 0.51 to 1.49; 3 studies, 235 participants). There was no effect of venous PTA on disability worsening measured by the Expanded Disability Status Scale, which was reported at follow-up intervals of six months (one study), 11 months (one study) and 12 months (one study). Quality of life was reported in two studies with no difference between treatment groups. Moderate or severe pain during or post venography was reported in both PTA and sham-procedure participants in all included studies. Venous PTA was not effective in restoring blood flow assessed at one-month (one study) or 12-month follow-up (one study).

AUTHORS' CONCLUSIONS

This systematic review identified moderate-quality evidence that, compared with sham procedure, venous PTA intervention did not provide benefit on patient-centred outcomes (disability, physical or cognitive functions, relapses, quality of life) in people with MS. Venous PTA has proven to be a safe technique but in view of the available evidence of its ineffectiveness, this intervention cannot be recommended in people with MS. All ongoing trials were withdrawn or terminated and hence this updated review is conclusive. No further randomised clinical studies are needed.

Cervical spondylotic internal jugular venous compression syndrome

Aims

This study aimed to identify the clinical profiles of cervical spondylosis‐related internal jugular vein stenosis (IJVS) comprehensively.

Methods

A total of 46 patients, who were diagnosed as IJVS induced by cervical spondylotic compression were recruited. The clinical manifestations and imaging features of IJVS were presented particularly in this study.

Results

Vascular stenosis was present in 69 out of the 92 internal jugular veins, in which, 50.7% (35/69) of the stenotic vessels were compressed by the transverse process of C1, and 44.9% (31/69) by the transverse process of C1 combined with the styloid process. The transverse process of C1 compression was more common in unilateral IJVS (69.6% vs 41.3%, P = 0.027) while the transverse process of C1 combined with the styloid process compression had a higher propensity to occur in bilateral IJVS (52.2% vs 30.4%, P = 0.087). A representative case underwent the resection of the elongated left lateral mass of C1 and styloid process. His symptoms were ameliorated obviously at 6‐month follow‐up.

Conclusions

This study proposes cervical spondylotic internal jugular venous compression syndrome as a brand‐new cervical spondylotic subtype. A better understanding of this disease entity can be of great relevance to clinicians in making a proper diagnosis.

Hemodynamics of cerebral veins analyzed by 2d and 4d flow mri and ultrasound in healthy volunteers and patients with multiple sclerosis

BACKGROUND

Hemodynamic alterations of extracranial veins are considered an etiologic factor in multiple sclerosis (MS). However, ultrasound and MRI studies could not confirm a pathophysiological link. Because of technical challenges using standard diagnostics, information about the involvement of superficial intracranial veins in proximity to the affected brain in MS is scarce.

PURPOSE

To comprehensively investigate the hemodynamics of intracranial veins and of the venous outflow tract in MS patients and controls.

STUDY TYPE

Prospective.

POPULATION

Twenty-eight patients with relapsing-remitting MS (EDSS1.9 ± 1.1; range 0-3) and 41 healthy controls.

FIELD STRENGTH/SEQUENCE

3T/2D phase-contrast and time-resolved 4D flow MRI, extra- and transcranial sonography.

ASSESSMENT

Hemodynamics within the superficial and deep intracranial venous system and outflow tract including the internal, basal, and great cerebral vein, straight, superior sagittal, and transverse sinuses, internal jugular and vertebral veins. Sonography adhered to the chronic cerebrospinal venous insufficiency (CCSVI) criteria.

STATISTICAL TESTS

Multivariate repeated measure analysis of variance, Student's two-sample t-test, chi-square, Fisher's exact test; separate analysis of the entire cohort and 32 age- and sex-matched participants.

RESULTS

Multi- and univariate main effects of the factor group (MS patient vs. control) and its interactions with the factor vessel position (lower flow within dorsal superior sagittal sinus in MS, 3 ± 1 ml/s vs. 3.8 ± 1 ml/s; P < 0.05) in the uncontrolled cohort were attributable to age-related differences. Age- and sex-matched pairs showed a different velocity gradient in a single segment within the deep cerebral veins (great cerebral vein, vena cerebri magna [VCM] 7.6 ± 1.7 cm/s; straight sinus [StS] 10.5 ± 2.2 cm/s vs. volunteers: VCM 9.2 ± 2.3 cm/s; StS 10.2 ± 2.3 cm/s; P = 0.01), reaching comparable velocities instantaneously downstream. Sonography was not statistically different between groups.

DATA CONCLUSION

Consistent with previous studies focusing on extracranial hemodynamics, our comprehensive analysis of intracerebral venous blood flow did not reveal relevant differences between MS patients and controls. Level of Evidence 1. Technical Efficacy Stage 3. J. Magn. Reson. Imaging 2020;51:205-217.

Vascular aspects of multiple sclerosis: emphasis on perfusion and cardiovascular comorbidities

INTRODUCTION

Multiple sclerosis (MS) is a chronic inflammatory, demyelinating, and neurodegenerative disease of the central nervous system. Over the last two decades, more favorable MS long-term outcomes have contributed toward increase in prevalence of the aged MS population. Emergence of age-associated pathology, such as cardiovascular diseases, may interact with the MS pathophysiology and further contribute to disease progression. Areas covered: This review summarizes the cardiovascular involvement in MS pathology, its disease activity, and progression. The cardiovascular health, the presence of various cardiovascular diseases, and their effect on MS cognitive performance are further explored. In similar fashion, the emerging evidence of a higher incidence of extracranial arterial pathology and its association with brain MS pathology are discussed. Finally, the authors outline the methodologies behind specific perfusion magnetic resonance imaging (MRI) and ultrasound Doppler techniques, which allow measurement of disease-specific and age-specific vascular changes in the aging population and MS patients. Expert opinion: Cardiovascular pathology significantly contributes to worse clinical and MRI-derived disease outcomes in MS. Global and regional cerebral hypoperfusion may be associated with poorer physical and cognitive performance. Prevention, improved detection, and treatment of the cardiovascular-based pathology may improve the overall long-term health of MS patients.

Role of age-related alterations of the cerebral venous circulation in the pathogenesis of vascular cognitive impairment

There has been an increasing appreciation of the role of vascular contributions to cognitive impairment and dementia (VCID) associated with old age. Strong preclinical and translational evidence links age-related dysfunction and structural alterations of the cerebral arteries, arterioles, and capillaries to the pathogenesis of many types of dementia in the elderly, including Alzheimer's disease. The low-pressure, low-velocity, and large-volume venous circulation of the brain also plays critical roles in the maintenance of homeostasis in the central nervous system. Despite its physiological importance, the role of age-related alterations of the brain venous circulation in the pathogenesis of vascular cognitive impairment and dementia is much less understood. This overview discusses the role of cerebral veins in the pathogenesis of VCID. Pathophysiological consequences of age-related dysregulation of the cerebral venous circulation are explored, including blood-brain barrier disruption, neuroinflammation, exacerbation of neurodegeneration, development of cerebral microhemorrhages of venous origin, altered production of cerebrospinal fluid, impaired function of the glymphatics system, dysregulation of cerebral blood flow, and ischemic neuronal dysfunction and damage. Understanding the age-related functional and phenotypic alterations of the cerebral venous circulation is critical for developing new preventive, diagnostic, and therapeutic approaches to preserve brain health in older individuals.

"Waiting for Science to Catch up with Practice": an examination of 10-year YouTube trends in discussions of chronic cerebral spinal venous insufficiency treatment for multiple sclerosis

Objective: The objective of this longitudinal study examined, first, whether people with multiple sclerosis who previously advocated for angioplasty to treat chronic cerebral spinal venous insufficiency (CCSVI) through YouTube continued reporting benefits. Second, it examined a new cohort reporting on CCSVI treatment, and third, whether perspectives have changed.Method: YouTube videos from August 2011 to January 2019 related to CCSVI were retrieved. Once retrieved, all videos were compiled, classified and analyzed. Categorical data were reported and a pre-determined code-book was used to code videos. Data from the videos were extracted and analyzed using discourse analysis.Results: 1293 videos related to CCSVI were uploaded by 54 people with multiple sclerosis who met the inclusion criteria. YouTube videos uploaded by people with multiple sclerosis have shifted in volume and message. The initial surge in interest in CCSVI treatment has diminished, but there still exists strong advocates for its use. There appears to be an inconsistency between positive results, actual improvements in symptoms, and the overall messages reported. Very little long-term data was available as the procedure is relatively new.Conclusion: Practitioners may be faced with pressure to provide unproven treatments in the future and should be understanding but evidence-driven when supporting multiple sclerosis therapies.

Oxidative Stress Related to Iron Metabolism in Relapsing Remitting Multiple Sclerosis Patients With Low Disability

Oxidative status may play a role in chronic inflammation and neurodegeneration which are considered critical etiopathogenetic factors in Multiple Sclerosis (MS), both in the early phase of the disease and in the progressive one. The aim of this study is to explore oxidative status related to iron metabolism in peripheral blood of stable Relapsing-Remitting MS with low disability. We studied 60 Relapsing-Remitting MS patients (age 37.2 ± 9.06, EDSS median 1.0), and 40 healthy controls (age 40.3 ± 10.86). We measured total hydroperoxides (dROMs test) and Total Antioxidant Status (TAS), along with the iron metabolism biomarkers: Iron (Fe), ferritin (Ferr), transferrin (Tf), transferrin saturation (Tfsat), and ceruloplasmin (Cp) panel biomarkers [concentration (iCp) and enzymatic activity (eCp), copper (Cu), ceruloplasmin specific activity (eCp:iCp), copper to ceruloplasmin ratio (Cu:Cp), non-ceruloplasmin copper (nCp-Cu)]. We computed also the Cp:Tf ratio as an index of oxidative stress related to iron metabolism. We found lower TAS levels in MS patients than in healthy controls (CTRL) and normal reference level and higher dROMs and Cp:Tf ratio in MS than in healthy controls. Cp and Cu were higher in MS while biomarkers of iron metabolism were not different between patients and controls. Both in controls and MS, dROMs correlated with iCp (CTRL r = 0.821, p < 0.001; MS r = 0.775 p < 0.001) and eCp (CTRL r = 0.734, p < 0.001; MS r = 0.820 p < 0.001). Moreover, only in MS group iCp correlated negatively with Tfsat (r = -0.257, p = 0.047). Dividing MS patients in “untreated” group and “treated” group, we found a significant difference in Fe values [F(2, 97) = 10.136, p < 0.001]; in particular “MS untreated” showed higher mean values (mean = 114.5, SD = 39.37 μg/dL) than CTRL (mean 78.6, SD = 27.55 μg/dL p = 0.001) and “MS treated” (mean = 72.4, SD = 38.08 μg/dL; p < 0.001). Moreover, “MS untreated” showed significantly higher values of Cp:Tf (mean = 10.19, SD = 1.77^∗10^-2; p = 0.015), than CTRL (mean = 9.03, SD = 1.46 ^∗10^-2). These results suggest that chronic oxidative stress is relevant also in the remitting phase of the disease in patients with low disability and short disease duration. Therefore, treatment with antioxidants may be beneficial also in the early stage of the disease to preserve neuronal reserve.

Potential Involvement of Impaired Venous Outflow from the Brain in Neurodegeneration: Lessons Learned from the Research on Chronic Cerebrospinal Venous Insufficiency

About 10 years ago, the so-called chronic cerebrospinal venous insufficiency syndrome was discovered. This clinical entity, which is associated with extracranial venous abnormalities that impair venous outflow from the brain, was initially found exclusively in multiple sclerosis patients. Currently, we know that such venous lesions can also be revealed in other neurological pathologies, including Alzheimer's and Parkinson's diseases. Although direct causative role of chronic cerebrospinal venous insufficiency in these neurological diseases still remains elusive, in this paper, we suggest that perhaps an abnormal venous drainage of the brain affects functioning of the glymphatic system, which in turn results in the accumulation of pathological proteins in the cerebral tissue (such as β-synuclein, β-amyloid and α-synuclein) and triggers the venous outflow from the cranial cavity and circulation of the cerebrospinal fluid in the settings of neurodegenerative disease.

Neck vein obstruction: Diagnosis and the role of chronic persistent Chlamydophila pneumoniae infection

Background

The objective of this review is to describe the diagnosis of neck vein obstruction and the possible role of chronic persistent Chlamydophila pneumoniae infection in producing the syndrome of chronic cerebrospinal venous obstruction.

Method

The normal patterns of flow in the neck veins are described and guidelines for interpretation of the quantitative duplex ultrasound examination of the extracranial neck veins are developed.

Result

An infective cause of neck vein obstruction is proposed and from a literature search of the role of the obligate intracellular bacterium Chlamydophila pneumoniae in vascular and chronic diseases, a diagnostic protocol for confirming chronic persistent Chlamydophila pneumoniae infection, which includes the quantitative duplex ultrasound examination and specific blood tests are suggested.

Conclusion

Further research to validate this diagnostic protocol is required.

The Central Vein: FLAIR Signal Abnormalities Associated with Developmental Venous Anomalies in Patients with Multiple Sclerosis

BACKGROUND AND PURPOSE

Demyelination is a recently recognized cause of FLAIR hyperintensities associated with developmental venous anomalies. Our purpose was to quantify the prevalence of white matter signal abnormalities associated with developmental venous anomalies in patients with multiple sclerosis compared with controls.

MATERIALS AND METHODS

A retrospective, blinded, multireader study compared the prevalence of FLAIR hyperintense signal abnormalities adjacent to developmental venous anomalies in patients with MS compared with controls (patients with developmental venous anomalies without MS). Study findings were positive if a central vein was demonstrated using FLAIR and contrast-enhanced fat-saturated T1 sequences. Imaging parameters also included developmental venous anomaly location, developmental venous anomaly drainage, white matter lesion size, and depth of white matter lesions. Clinical parameters included age, sex, and the presence of confounding variables (hypertension, diabetes, migraines, and/or vasculopathy).

RESULTS

FLAIR signal abnormality was present around 47.3% (35/74) of developmental venous anomalies in patients with MS, and 13.5% (10/74) of developmental venous anomalies in the control group (P < .001). The multivariate logistic regression model controlling for covariates (including migraines, hypertension, diabetes mellitus, vasculopathy, age, sex, and drainage direction of developmental venous anomalies) showed that the odds of FLAIR hyperintensity around developmental venous anomalies was 6.7-fold higher in patients with MS (relative risk MS = 6.68; 95% CI, 2.79-15.97; P < .001).

CONCLUSIONS

The association of developmental venous anomalies and FLAIR hyperintensities was more common in patients with MS, which suggests that the underlying demyelinating pathologic process of MS may be the cause of this propensity in patients with MS. Impaired venous drainage in the territory of developmental venous anomalies may predispose to development of these lesions, and an associated central vein is helpful in understanding an atypical location of MS plaques.

A Computational Model for the Dynamics of Cerebrospinal Fluid in the Spinal Subarachnoid Space

Global models for the dynamics of coupled fluid compartments of the central nervous system (CNS) require simplified representations of the individual components which are both accurate and computationally efficient. This paper presents a one-dimensional model for computing the flow of cerebrospinal fluid (CSF) within the spinal subarachnoid space (SSAS) under the simplifying assumption that it consists of two coaxial tubes representing the spinal cord and the dura. A rigorous analysis of the first-order nonlinear system demonstrates that the system is elliptic-hyperbolic, and hence ill-posed, for some values of parameters, being hyperbolic otherwise. In addition, the system cannot be written in conservation-law form, and thus, an appropriate numerical approach is required, namely the path conservative approach. The designed computational algorithm is shown to be second-order accurate in both space and time, capable of handling strongly nonlinear discontinuities, and a method of coupling it with an unsteady inflow condition is presented. Such an approach is sufficiently rapid to be integrated into a global, closed-loop model for computing the dynamics of coupled fluid compartments of the CNS.

Possible Role of Glymphatic System of the Brain in the Pathogenesis of High-Altitude Cerebral Edema

In this article, we suggest that the glymphatic system of the brain can play an important role in the pathogenesis of high-altitude cerebral edema (HACE). Water enters the intercellular space of the brain primarily through aquaporin-4 (AQP-4) water channels, the main component of the glymphatic system, whereas acetazolamide, pharmacological agent used in the prevention of HACE, is the blocker of the AQP-4 molecule. In animal experiments, cerebral edema caused by hypobaric hypoxia was associated with an increased expression of AQP-4 by astrocytes. Also, the glymphatic system is primarily active during sleep, although sleep at high altitude is a well-known risk factor of developing HACE. All these findings support our hypothesis. We suggest that future research on the prevention and treatment of HACE should involve factors that are already known to modify activity of the glymphatic system, such as angiotensin-converting enzyme inhibitors or other pharmaceutical agents affecting noradrenergic system of the brain, body posture during sleep, anatomy of the veins draining the cranial cavity, and the influence of physical activity before and during exposure to high altitude, especially in relation to sleep.