Phlebological Review
eISSN: 1509-5738
ISSN: 1232-7174
Phlebological Review
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1/2018
vol. 26
 
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Editorial

Chronic cerebrospinal venous insufficiency theory after the Brave Dreams study

Marian Simka

Phlebological Review 2018; 26 1: 1-3
Online publish date: 2018/06/20
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Multiple sclerosis (MS) is a chronic disease of the central nervous system. It is generally accepted by neurologists that it is an autoimmune disease, which is caused by an attack against nervous tissue antigens, primarily myelin, and that this reaction is executed by reactive T cells. However, what is actually causing this immune reaction still remains enigmatic. Moreover, there is strong evidence that MS, in addition to its immunoinflammatory aspect, at its core is a neurodegenerative disorder, casting doubt at the autoimmune paradigm [1-3]. Therapeutic strategies for MS predominantly target inflammatory cascade or modify the immune response. These pharmacological treatments are somewhat effective, but they cannot cure patients or protect them from the disability that is usually seen in those with long-lasting MS.
About 10 years ago an Italian vascular surgeon Paolo Zamboni strode into this rather murky milieu with his chronic cerebrospinal venous insufficiency (CCSVI) theory. He demonstrated that MS patients present with haemodynamically significant lesions in the extracranial veins draining the brain, primarily in the internal jugular veins (IJV) – an entity that had not been known before [4, 5]. He also challenged the autoimmune paradigm, claiming that these venous blockages play a primary role in initiating pathological reactions of MS, including inflammation and chronic cerebral ischaemia. At that time Zamboni and his colleagues also presented results of a pilot study, which showed clinical improvement in MS patients after endovascular balloon angioplasty of pathological IJVs and azygous veins [6].
Consequently, the CCSVI hypothesis began to be hotly debated within the scientific community. Not surprisingly, this new idea was generally welcomed by vascular interventionalists [7] but vigorously challenged by neurologists [8]. During following years a number of open-label studies on endovascular management of CCSVI lesions were published. These treatments usually utilised balloon angioplasty, but in some patients an off-label stenting of the IJVs was also performed. These studies demonstrated the safety of such treatments, especially if balloon angioplasty was used [9-14]. On the other hand, these surveys revealed that endovascular angioplasty in this venous territory is not easy. Technical success after standard balloon angioplasty could be as low as 50%. This rate could be improved using high-pressure balloons and long inflation times,...


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