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The notion that chronic cerebrospinal venous insufficiency (CCSVI) might underlie multiple sclerosis (MS) has taken the MS community by storm, as described in a recent news report in the New York Times. Unfortunately, this idea has generated enormous controversy, in large part because opportunists have taken advantage of the situation, performing interventional procedures (so-called “liberation” angioplasty) on MS patients for profit.
CCSVI refers to the concept that MS patients have central nervous system (CNS) venous stasis associated with anatomic abnormalities in major extraneural draining veins. The (unproven) assumption is that vein stenoses cause abnormal CNS venous drainage. This is an interesting concept, because most MS plaques are associated with small veins. According to the CCSVI hypothesis, venous stasis leads to red blood cell extravasation, iron deposition, local inflammation, and tissue damage.
The original reports indicated that 100% of MS patients and 0% of controls showed ultrasound evidence of CCSVI (J Neurol Sci 2009; 282:21). Other groups have been unable to confirm this clear delineation, finding CCSVI in only a subset of patients with MS as well as in some controls (Nervenarzt 2010; 81:740 and Ann Neurol 2010; 68:255 and 173).
Grady D. From M.S. patients, outcry for unproved treatment. The New York Times. Jun 28, 2010. (http://www.nytimes.com/2010/06/29/health/29vein.html)
Comment
Currently, research funding has been provided to several groups to try to determine whether they can reproduce the results of Zamboni et al. These studies should focus on patients with early MS and must be verified by angiography, the gold standard for detecting anatomic venous abnormalities.
I think it likely that CCSVI is present in a subset of MS patients. It is likely to be one of several risk factors for MS. I do not believe CCSVI causes MS. It is completely unknown at this time whether correction of the extraneural vein stenoses will be of any benefit whatsoever. Such treatment must be evaluated in controlled clinical trials. Everyone needs to take a deep breath and await results of the ongoing studies. If preliminary studies from independent groups duplicate the finding of CCSVI in a subset of MS, then more-definitive, multicenter studies can be arranged to evaluate the possible benefits of liberation angioplasty in such patients.
Performing individual angioplasties or stenting at this time is premature. It serves no scientific interest, muddies the water, discredits this interesting hypothesis, and puts patients at unnecessary and unjustified risk.