Chronic cerebrospinal venous insufficiency is unlikely to be a direct trigger of multiple sclerosis

Abstract Background Chronic cerebrospinal venous insufficiency, a vascular pathology affecting the veins draining the central nervous system can accompany multiple sclerosis and is suspected to be involved in its pathogenesis. Objective This study was aimed at exploring a potential role for chronic cerebrospinal venous insufficiency in triggering multiple sclerosis. If it were venous abnormalities responsible for neurological pathology, one should expect negative correlation, i.e. more severe vascular lesions in the patients with early onset of multiple sclerosis. Methods Localization and degree of venous blockages in 350 multiple sclerosis patients were assessed using catheter venography. …

Is digital necrosis in COVID-19 caused by neutrophil extracellular traps: Potential therapeutic strategies

Some of the COVID-19 patients present with ischemic lesions of their finger and toes. Standard anticoagulant therapy is usually unsuccessful for the treatment of this unique presentation of COVID-19. In this review current evidence is presented, which supports the hypothesis that these necrotic lesions are primarily related to the formation of neutrophil extracellular traps is blood vessels. Also, currently available and potential pharmaco-logical methods of the management of this unique thrombotic complication are discussed. Drugs that possibly could be used in COVID-19 patients suffering from acute ischemia of distal parts of the extremities particularly comprise DNase I and DNase1L3, whi…

Recent advances in understanding the lymphatic and glymphatic systems of the brain

This review summarises current knowledge on the lymphatic system of the brain. It has long been believed that the central nervous system is characterised by the lack of a lymphatic system and that the role of the lymphatic system is played by cerebrospinal fluid. Recently, research has shown that not only is the brain equipped with its own unique lymphatic system, but also that this system consists of two anatomically and functionally distinct parts. One part of this system is a classic lymphatic system, i.e. the structure composed of genuine lymphatic vessels. The other, so-called glymphatic system, is primarily built by astrocytes. The newly discovered lymphatic system of the brain is lik…

Do nonmelanoma skin cancers develop from extra-cutaneous stem cells?

A hypothesis is presented that nonmelanoma skin cancers can develop from extra-cutaneous stem cells, and not exclusively from skin keratinocytes. This idea is supported by recent findings regarding the initiation of cancers in the digestive tract, and by a cancer stem cell model of a neoplasia. It is known that multipotent adult progenitor cells can trans-differentiate into very diverse cellular lineages and can be recruited to areas of profound tissue injury. In these settings, they might also initiate malignant transformation. Some epidemiological data and recent findings regarding mechanisms of wound healing indicate that skin cancers could also originate from bone marrow-derived or othe…

Diagnostic accuracy of current sonographic criteria for the detection of outflow abnormalities in the internal jugular veins

Objectives: This study was aimed at evaluation of the diagnostic value of Doppler sonography for the assessment of abnormalities in the internal jugular veins (IJVs). Method: One hundred and sixteen IJVs were assessed in 58 patients with associated multiple sclerosis. Findings of Doppler sonography were compared with results of the reference test: catheter venography. Results: At least one positive extracranial sonographic criterion suggesting venous abnormality was found in 92.2% of the assessed veins. Yet, sensitivity, specificity, positive and negative predictive values of sonography were low: 93.4%, 12.0%, 79.4% and 33.3% for at least one positive criterion, and for at least two positiv…

Letter regarding article titled ‘Microembolism during foam sclerotherapy of varicose veins’ in the New England Journal of Medicine

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, whi…

Endovascular treatment for chronic cerebrospinal venous insufficiency: is the procedure safe?

Objectives The aim of this report is to assess the safety of endovascular treatment for chronic cerebrospinal venous insufficiency (CCSVI). Although balloon angioplasty and stenting seem to be safe procedures, there are currently no data on the treatment of a large group of patients with this vascular pathology. Methods A total of 564 endovascular procedures (balloon angioplasty or, if this procedure failed, stenting) were performed during 344 interventions in 331 CCSVI patients with associated multiple sclerosis. Results Balloon angioplasty alone was performed in 192 cases (55.8%), whereas the stenting of at least one vein was required in the remaining 152 cases (44.2%). There were no majo…

Revascularization technique for a long occlusive lesion in a case of symptomatic chronic occlusion of the internal carotid artery

Evidence against the role for dural arteriovenous fistulas in the pathogenesis of multiple sclerosis

Chronic cerebrospinal venous insufficiency: current perspectives

This review summarizes the research to date on chronic cerebrospinal venous insufficiency (CCSVI). CCSVI was initially defined as a clinical syndrome comprising stenoses of the internal jugular and/or azygos veins, characterized by collateral venous outflows and reduced cerebral blood flow, and was found primarily in patients with multiple sclerosis. However, the published evidence on CCSVI is very discordant. Catheter venography studies gave a regular picture, with the majority of patients with multiple sclerosis presenting with demonstrable outflow abnormalities in the veins draining the central nervous system. The prevalence of these lesions was over 50%, and even higher (about 90%) when…

Mid-term and late results of endovascular treatment for symptomatic carotid artery stenosis under proximal protection

Introduction: Although filters are still preferred during carotid stenting, proximal protection systems (PPS) are increasingly used during these procedures. PPS seem to be safer than distal systems, especially in symptomatic patients, but evidence supporting their use is limited. Aim: This was a post hoc survey with 30-day mid-term and long-term follow up, which was aimed at assessment of the safety and efficacy of stenting of the internal carotid artery under PPS in symptomatic patients. Material and methods: We analysed the results of stenting in 120 symptomatic patients presenting with at least 60% stenosis. Patients were aged 67.9 ±9.8 years, and 12 patients were older than 80 years. An…

Hypothetical molecular mechanisms by which local iron overload facilitates the development of venous leg ulcers and multiple sclerosis lesions.

Summary This paper presents a hypothetical model of role for iron in the development of venous leg ulcers and multiple sclerosis. Elevated concentrations of iron were found in the skin affected by venous hypertension and also in the areas of brain with multiple sclerosis lesions. Individuals with hemochromatosis gene (HFE) mutations: C282Y and H63D, which result in a less efficient transport of iron by macrophages, are characterized by an increased risk for venous leg ulcer and multiple sclerosis. Multiple sclerosis is a T cell-mediated disease, and T cells probably participate in the development of venous ulcers. This deleterious role of ferric ions could be related to the regulation of T …

Baseline factors affecting closure of venous leg ulcers

Objective: The objective of this study was to characterize factors associated with closure of venous leg ulcers (VLUs) in a pooled analysis of subjects from three randomized clinical trials. Methods: Closure of VLUs after treatment with HP802-247, an allogeneic living cell therapy consisting of growth-arrested human keratinocytes and fibroblasts, vs standard therapy with compression bandaging was evaluated in three phase 3 clinical trials of similar design. Two trials enrolled subjects with VLUs ranging from 2 cm2 to 12 cm2 in area with 12-week treatment periods; the third trial enrolled subjects with VLUs between >12 cm2 and #36 cm2 with a 16-week treatment period. The first trial went to …

Results of Numerical Modeling of Blood Flow in the Internal Jugular Vein Exhibiting Different Types of Strictures

The clinical relevance of nozzle-like strictures in upper parts of the internal jugular veins remains unclear. This study was aimed at understanding flow disturbances caused by such stenoses. Computational fluid dynamics software, COMSOL Multiphysics, was used. Two-dimensional computational domain involved stenosis at the beginning of modeled veins, and a flexible valve downstream. The material of the venous valve was considered to be hyperelastic. In the vein models with symmetric 2-leaflets valve without upstream stenosis or with minor 30% stenosis, the flow was undisturbed. In the case of major 60% and 75% upstream stenosis, centerline velocity was positioned asymmetrically, and areas of…

Intraluminal thrombus in abdominal aortic aneurysm: a friend or a foe?

A potential role of interferon-gamma in the pathogenesis of venous leg ulcers.

Venous leg ulcer is the most severe expression of chronic venous insufficiency. Venous ulcerations are always associated with venous ambulatory hypertension, but the exact mechanism leading from pathological hemodynamics in venous circulation to the necrotic lesions in the skin still remains undiscovered. It has been shown that tissue injury in venous ulcer patients was induced by leukocytes. However, though infiltrating leukocytes have at their disposal a powerfully cytotoxic arsenal, it has not been discovered which molecular mechanisms may contribute to the skin damage. The search for this hypothetical factor responsible for the development of ulceration should be focused on mechanisms l…

Biophysics of venous return from the brain from the perspective of the pathophysiology of chronic cerebrospinal venous insufficiency

This article discusses the biophysical aspects of venous outflow from the brain in healthy individuals and in patients with chronic cerebrospinal venous insufficiency. Blood flows out of the brain differently, depending on body position. In the supine position it flows out mainly through internal jugular veins, while in the upright position it uses the vertebral veins. This phenomenon is probably not due to the active regulation of the flow but instead results from the collapse of jugular veins when the head is elevated. Such a collapse is associated with a significant increase in flow resistance, which leads to redirection of the flow towards the vertebral pathway. Theoretical calculations…

Optimal interventional treatment in a patient with occlusion of the brachiocephalic trunk and left subclavian artery with “double” steal syndrome

Subclavian steal syndrome, which comprises reversal of flow in the ipsilateral vertebral artery with stenosis or occlusion of the subclavian artery (SA) or brachiocephalic trunk (BCT), was first described by Contorni in 1960 [1]. This clinical syndrome manifests with the signs and symptoms of vertebrobasilar insufficiency, but can also be asymptomatic. This paper describes a step-by-step technique of complex endovascular treatment for a double steal syndrome caused by occlusions of the BCT and the left SA, associated with stenosis of the left internal carotid artery (ICA) and reversed flow in the left external carotid artery (ECA).

Mechanical rotational thrombectomy with Rotarex system augmented with drug-eluting balloon angioplasty vs. stenting for the treatment of acute thrombotic and critical limb ischaemia in the femoropopliteal segment

Introduction Mechanical thrombectomy is an alternative to local thrombolysis for the treatment of severe ischaemia in the femoropopliteal segment, but stent implantation is usually required after this procedure. The use of drug-eluting balloons (DEBs) may overcome long-term problems associated with stents, but it remains unclear how often such a treatment is technically feasible and efficient. Aim This post hoc single-centre study was aimed at assessment of the feasibility, safety and efficacy of mechanical thrombectomy followed by application of DEBs. Material and methods Fifty-one patients, aged 69.1 ±11.6 years, were managed for acute thrombotic or chronic critical ischaemia in the femor…

Endovascular embolectomy of the superior mesenteric artery using the Rotarex® system for the treatment of acute mesenteric ischemia.

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

AbstractAbout 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 modal…

What Could Be a Primary Cause of Multiple Sclerosis: Is It an Autoimmunity Triggered by Chronic Protozoan Infection?

The generally accepted paradigm of multiple sclerosis is the autoimmune one; still, a body of evidence suggests that this disease may actually be triggered by an infectious factor. In this paper, it is hypothesized that multiple sclerosis may actually be a rare complication of a protozoan infection, which is usually asymptomatic but in some susceptible individuals is accompanied by autoimmune attack against the nervous tissue. If multiple sclerosis were actually caused by such an infection, then a microorganism responsible should exhibit several properties: it (i) is transmitted by an arthropod vector; (ii) is characterized by specific metabolism of the lipids; (iii) should be dependent on …

Prognostic factors for delayed healing of venous leg ulcers

The use of a proximal protection system, a reperfusion catheter, and new-generation mesh stents in combined endovascular therapy for a long, symptomatic dissection of the right internal carotid artery.

Blood flow in the internal jugular veins during the spaceflight - Is it actually bidirectional?

Recently intriguing results of the research performed on astronauts of the International Space Station have been published. Unexpectedly, in some crew members a stagnant and bidirectional flow in the internal jugular vein was found, and in one of the astronauts this vein seemed to be totally thrombosed. If it actually were the case that in the settings of weightlessness there is a substantial risk of jugular vein thrombosis, any long-term human space missions would be extremely dangerous. Yet, we interpret these findings differently. In our opinion, what has been explained as bidirectional flow, actually represented the flow separation, and what has been described as occluded vein was rathe…

Liposuction and diabetes type 2 development risk reduction – A commentary

Mechanical thrombectomy for rescue treatment of severe thrombosis of the superior sagittal sinus with the use of Penumbra and AngioJet catheters

Delayed healing of chronic leg ulcers can result from impaired trafficking of bone marrow-derived precursors of keratinocytes to the skin

In this paper, it is hypothesized that in chronic wounds the process of homing of bone marrow-derived precursors of keratinocytes is disturbed, and that the interaction between cutaneous T-cell attracting chemokine (CTACK/CCL27) and soluble P-selectin glycoprotein ligand-1 (PSGL-1) can be the cause of this impairment. Several studies have revealed that bone marrow-derived cells (BMDC) trans-differentiate into various cellular lineages, and probably they participate also in healing of wounded skin. Recent studies have demonstrated that BMDC can engraft into the epidermis, and probably they do not engraft into epidermis as keratinocyte stem cells, but rather as transient amplifying cells. So,…

Early results of endovascular treatment of patients with bilateral stenoses of the internal carotid arteries using proximal protection systems at 30-day follow-up

Abstract Background Although surgical endarterectomy remains the treatment of choice for carotid artery stenosis, carotid artery stenting (CAS) with use of proximal protection systems (PPS) plays an very important role as alternative treatment modality, especially in patients with critical, symptomatic lesions. This study was single-centre study to evaluate the technical and clinical success of proximal protection devices as the first choice for embolic protection in symptomatic and asymptomatic carotid stenosis in patients with bilateral, advanced lesions of carotid arteries (bilateral stenoses or stenosis and occlusion). Methods This was a post hoc analysis, with 30-day follow up. We anal…

Retinal abnormalities in multiple sclerosis patients with associated chronic cerebrospinal venous insufficiency

Optical coherence tomography (OCT) is a non-invasive method for the assessment of optic nerve fibers and retinal ganglion cells. This study was aimed at the assessment of retinal abnormalities in multiple sclerosis patients in the context of chronic cerebrospinal venous insufficiency using OCT of the retina and the optic nerve. We examined 239 multiple sclerosis (MS) patients, including 220 patients with associated chronic cerebrospinal venous insufficiency and 19 MS patients without venous pathology. The following OCT parameters were assessed: average ganglion cell complex thickness, global loss volume, focal loss volume and average retinal nerve fibre layer thickness. Abnormalities in the…

Cerebral venous outflow in the prone position

Diagnostic accuracy of Doppler sonography and magnetic resonance venography for the assessmentv of impaired outflow from the internal jugular vein in patients with multiple sclerosis

Objectives: This prospective study was aimed at evaluation of diagnostic value of Doppler sonography and magnetic resonance (MR) venography in the internal jugular vein territory. Material and methods: There were assessed 126 patients (252 internal jugular veins). The patients were initially diagnosed using Doppler sonography and MR venography, and then catheter venography of the veins was performed. For the purpose of this study catheter venography was regarded the reference test. We interpreted sonographic findings in the context of criteria proposed by Zamboni and criteria by International Society for Neurovascular Disease (ISNVD). We applied MR protocols aimed at flow assessment in the …

Anatomy of nerves of the lower extremities in the context of the treatment for varicose veins

Injury of nerves of the lower extremity is the most prevalent complication associated with invasive treatment of varicose veins. These adverse events are particularly frequent after traditional surgical stripping and thermal ablative procedures. The most frequently injured nerves comprise the saphenous nerve, the sural nerve, and the anterior cutaneous branch of the femoral nerve. The high rate of injury to these nerves is primarily related to their close anatomical relationship with major trunks of the superficial venous system. The great saphenous vein is accompanied by two groups of sensory nerves. In its proximal part it runs along the anterior cutaneous branch of the femoral nerve. In …

Obstructive Malformations of the Internal Jugular Vein

Obstructive malformations of the internal jugular veins represent a relatively new clinical problem, which as of yet has not been fully understood. In normal subjects, the internal jugular vein is valveless, except for a single valve, situated just above the junction of this vein with the brachiocephalic vein. Usually, normal jugular valves exhibit a two-leaflet structure. Stenotic lesions of these veins were described for the first time in 2009 in a group of multiple sclerosis patients. The most common obstructive malformation of the internal jugular vein is a stenotic valve. There are several morphological types of such aberrant valves, comprising annular stenoses, valves with fused, reve…

Anti-metastatic activity of heparin is probably associated with modulation of SDF-1-CXCR4 axis

Numerical modeling of blood flow in the internal jugular vein with the use of computational fluid mechanics software.

ObjectivesTo determine the site and nature of altered hemodynamics in pathological internal jugular veins.MethodWith the use of computational fluid mechanics software we simulated blood flow in 3 D models of the internal jugular veins that exhibited different morphologies, including nozzle-like strictures in their upper parts and valves in the lower parts.ResultsIn a majority of models with nozzle-like strictures, especially those positioned asymmetrically, abnormal flow pattern was revealed, with significant flow separation and regions with reversed flow. Abnormal valves had no significant impact on flow in a case of already altered flow evoked by stricture in upper part of the vein.Conclu…

The effect of the calibre and length of needle on the stability of sclerosing foam.

Objectives Little is known how calibre and length of needles affect the stability of sclerosing foam. Methods Foams were made of 0.5%, 1%, 2% and 3% polidocanol, and 0.2%, 0.5%, 1% and 3% sodium tetradecyl sulfate (STS), which were mixed with air in the proportion of 4:1. These foams were ejected through needles with the length of: 4 mm, 6 mm and 13 mm, and diameter of: 0.26 mm, 0.3 mm and 0.4 mm. Results Foams made of more concentrated polidocanol were more stable. Regarding STS an opposite relationship was revealed. Foams made of polidocanol were more stable if ejected through a longer needle, while the length of needle did not significantly affect stability of STS foams. Foams ejected th…

Endovascular management of carotid artery dissections with the use of new generation stents and protection systems

Dissection of the internal carotid artery (ICA) is a rare disease, but in young patients is responsible for about 20% of cerebral events. We presented three different cases of ICA dissection, including one iatrogenic and two spontaneous ones, which were successfully managed endovascularly, with the use of different techniques, different protection devices and stents. In this article, the clinical management and details of procedures were described.

Clinical meaning of incompetent perforators in the setting of post-thrombotic syndrome commentary

In this issue of Phlebological Review Zolotukhin et al. [1] present the results of their study on recurrence of venous leg ulcers in post-thrombotic patients after endovenous laser ablation of incompetent lower leg perforators. They have found that not only the recurrence rate of these perforators was very high, but also that the procedure did not reduce the ulcer recurrence. This lack of clinical efficacy in terms of recurrence was different from the results of the well-known ESCHAR study [2]. In the ESCHAR study surgical ablation of incompetent superficial veins resulted in less frequent recurrences. From a hemodynamic and pathophysiological point of view a thermal ablation (such as laser…

Internal jugular vein entrapment in a multiple sclerosis patient.

We describe a multiple sclerosis patient presenting with compression of the internal jugular vein caused by aberrant omohyoid muscle. Previously this patient underwent balloon angioplasty of the same internal jugular vein. Ten months after this endovascular procedure, Doppler sonography revealed totally collapsed middle part of the treated vein with no outflow detected. Still, the vein widened and the flow was restored when the patient’s mouth opened. Thus, the abnormality was likely to be caused by muscular compression. Surgical exploration confirmed that an atypical omohyoid muscle was squeezing the vein. Consequently, pathological muscle was transected. Sonographic control three weeks af…

Activation of the glymphatic system during sleep – is the cerebral venous outflow a missing piece of the puzzle?

Until recently, mechanisms responsible for an activation of the glymphatic system of the brain, the system which is responsible for cleansing of this organ of waste products, were unclear. A recently published paper has finally shed some light on this problem. It has been demonstrated that there is a temporary decrease of the arterial cerebral blood flow during the deep phase of sleep, which is followed by an influx of the cerebrospinal fluid into the cranial cavity, and that this phenomenon is probably responsible for the activation of the glymphatic system. Although, of as yet, this issue has not been studied, it is likely that such a mechanism is not effective in the settings of disturbe…

Chronic cerebrospinal venous insufficiency and multiple sclerosis: A commentary

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

Simka, Marian, Paweł Latacz, and Joanna Czaja. Possible role of glymphatic system of the brain in the pathogenesis of high-altitude cerebral edema. High Alt Med Biol. 19:394–397, 2018.—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 increa…

Endovascular therapy of symptomatic high-grade stenosis of left internal carotid artery in C6 segment using Elutax “3” Neuro pDEB

Possible Pathomechanisms Responsible for Injury to the Central Nervous System in the Settings of Chronic Cerebrospinal Venous Insufficiency

The discovery of stenoses in the azygous and internal jugular veins, the so-called chronic cerebrospinal venous insufficiency that accompanies multiple sclerosis, has enabled the reinterpretation of knowledge about this neurologic dis- ease. Pathologic venous outflow from the central nervous system appears to lead to two main problems. Firstly, it disas- sembles the blood-brain barrier and may allow the penetration of nervous parenchyma by glutamate and leukocytes. Sec- ondly, it may result in significant hypoperfusion of the brain and spinal cord. These two overlapping pathologies are likely to trigger plaques through caspase-1-driven pyroptosis of oligodendrocytes and to evoke neurodegene…

Endovascular management of carotid and vertebral artery dissections with new generation double-mesh stent and protection systems – single-center early and midterm results

Introduction Symptomatic dissections (SD) of cervical arteries are still a therapeutic problem. Although endovascular management (EM) is currently a preferred method of treatment of SD, complications associated with this method of treatment in published reports are quite frequent (3-16%). Aim In this retrospective study we analyzed the results of EM with novel, double-mesh stent and protection systems (PS) for SD of the internal carotid (IC) or vertebral arteries (VA) that coexisted with hemodynamically significant stenosis or aneurysmatic dilatation of the dissected artery. Material and methods We evaluated the results of EM in 19 patients (men 15, median age: 55, range: 25-83), presenting…

What is the relationship between chronic cerebrospinal venous insufficiency and multiple sclerosis?

Abstract Although most of the research on multiple sclerosis was focused on its autoimmune aspects, researchers were also considering the roles of other factors, including vascular background of the disease. The idea that multiple sclerosis might be caused by stenoses of the veins draining the brain and spinal cord (the so-called chronic cerebrospinal venous insufficiency), is currently hotly debated by scientific community. Despite conflicting reports, chronic cerebrospinal venous insufficiency seems to be a real clinical phenomenon. However, it remains uncertain how it should be defined and which tests should be used for its detection. Probably this vascular abnormality should be primaril…

Blood Brain Barrier Compromise with Endothelial Inflammation may Lead to Autoimmune Loss of Myelin during Multiple Sclerosis

Multiple sclerosis is an autoimmune disease characterized by multifocal areas of inflammation and demyelination within the central nervous system. The mechanism that triggers the disease remains elusive. However, recent findings may indicate that multiple sclerosis, at its source, could be a hemodynamic disorder. It has been found that multiple sclerosis patients exhibit significant stenoses in extracranial veins draining the central nervous system (in azygous and internal jugular veins), which are associated with significant pressure gradients measured across strictures. Such anatomic venous abnormalities were not found in the control group of healthy subjects. In this review, it is hypoth…

Collapsibility of the internal jugular veins in the lateral decubitus body position: A potential protective role of the cerebral venous outflow against neurodegeneration.

Recent research has revealed that patients with neurodegenerative disease sleep longer in the supine position, while healthy controls prefer sleeping in the lateral decubitus position. Thus, sleeping in the lateral position seems to be protective against neurodegeneration. It has also been suggested that a protective role of this body position could be associated with better cerebral venous drainage in this body position, which results in more active glymphatic system of the brain (the system responsible for clearance of the cerebral tissue from waste products, e.g. amyloid-β). Since no published evidence exists regarding venous outflow from the cranial cavity in the lateral decubitus posit…

Factor V Leiden distribution – could it shed some light on the pre-history of Europe and the Near East?

Polymorphism of clotting factor V, comprising Arg506Gln substitution in the factor V molecule, commonly known as Factor V Leiden, represents the most common heritable risk factor for thrombotic events in Indo-Europeans and some Semitic nations. Although it is suggested that this mutation is associated with a survival advantage that has facilitated the spread of this polymorphism in the human population, in this paper we argue against such a Darwinian evolutionary mechanism responsible for the high prevalence of FV Leiden in some countries. Instead, we propose that cultural, climatic, and geographic factors played a role. Taking into account the current distribution of FV Leiden polymorphism…

Patient- and lesion-tailored algorithm of endovascular treatment for arterial occlusive disease of extracranial arteries supplying the brain: safety of the treatment at 30-day follow-up

Introduction: Although surgical endarterectomy remains the treatment of choice for carotid artery stenosis, stenting plays an important role as an alternative treatment modality, especially in high-risk patients. The actual safety profile associated with stenting procedures is probably better than that reported by randomized controlled trials. Aim : To assess the safety of stent implantations in extracranial arteries supplying the brain, and also to identify risk factors associated with this procedure. Material and methods: This was a post hoc analysis, with 30-day follow-up. We analyzed the results of treatment of 372 patients who underwent 408 procedures, 197 such procedures in asymptomat…

Endothelin-1 concentrations in the internal jugular and azygous veins in multiple sclerosis patients: the results of a pilot study

Objectives: In this pilot study we examined the potent vasoconstrictor, endothelin-1, in the blood of multiple sclerosis patients in the context of chronic cerebrospinal venous insufficiency hypothesis. For this purpose we measured endothelin-1 concentrations in blood samples that were obtained during selective catheterisation of the main veins draining the central nervous system: the internal jugular veins and the azygous vein. Material and methods: We measured endothelin-1 concentrations in peripheral blood in nine multiple sclerosis patients and five healthy controls. In multiple sclerosis patients this peptide was also evaluated in blood samples obtained from the internal jugular veins …

How to skip the ‘‘false, trivial, obvious’’ paradigm?

Abnormal jugular valves are not the sole explanation of an impaired outflow from the cranial cavity through the internal jugular veins: results of in silico studies

Background. Currently, pathological jugular valves are thought to be the main cause of altered hemodynamics in the internal jugular veins, the so-called chronic cerebrospinal venous insufficiency. The alternative interpretation of flow disturbances in these veins is that the main source of abnormal outflow are nozzle-like strictures in their upper parts, at the level or just below the jugular foramen, for example, caused by an enlarged transverse process of the atlas and/or styloid process of the temporal bone.1 These in silico studies were aimed at validation of this hypothesis.
 Methods. With the use of computational fluid mechanics software: the Flowsquare+ and the COMSOL multiphysi…

Adenoviral vector-based COVID-19 vaccines-associated cerebral venous sinus thromboses: Are those adverse events related to the formation of neutrophil extracellular traps?

In March and April 2021 several countries temporarily suspended vaccinations with adenoviral vector-based COVID-19 vaccines. Concerns of national regulators particularly regarded very rare cases of cerebral venous sinus thrombosis after immunization with this type of vaccine. Until now, these adverse events were interpreted as standard hypercoagulable events, but their clinical characteristics suggest that they may actually represent unique thrombotic disorders referred to as immunothrombosis. In this paper it is speculated that it is possible that immunothrombosis after this type of vaccine results from formation of neutrophil extracellular traps (NETs) in veins affected by stagnant blood …

Calf muscle pump impairment and delayed healing of venous leg ulcers: Air plethysmographic findings

There is a need for a diagnostic tool to predict clinical outcome of venous leg ulcer patients, as the prognosis of healing based on clinical data alone has not appeared to be satisfactory. Air plethysmographic assessment of calf muscle pump was performed in the supine and upright position in 129 patients with active ulcers on their legs. All patients were managed in a specialized leg ulcer clinic. Results of air plethysmography were compared to clinical data and time of healing of ulcers. Muscle pump failure was found in 42.6% of extremities (supine position, 33.3%; upright, 22.5%; both, 12.4%). Patients with insufficient pump were older, and their ulcers were larger. Failure of pump was f…

Treatment of high- and intermediate-risk pulmonary embolism using the AngioJet percutaneous mechanical thrombectomy system in patients with contraindications for thrombolytic treatment – a pilot study

Introduction Intravenous thrombolysis is the treatment of choice in patients presenting with high- and intermediate-risk pulmonary embolism. The role of percutaneous mechanical pulmonary thrombectomy (PMPT) is not fully established, although selected patients can be managed with this method. Aim This open-label single-centre prospective pilot study was aimed at assessing the feasibility of PMPT for the treatment of severe pulmonary embolism in a Polish hospital. We also evaluated the safety and efficacy of such management. Material and methods We managed 7 patients, aged 52.7 ±16.6 years, presenting with high- and intermediate-risk pulmonary embolism (4 patients with class 5 and one patient…

Safety and efficacy of endovascular treatment for carotid artery stenoses using proximal protection systems : 30-day follow-up

Introduction. Although surgical endarterectomy remains the treatment of choice for carotid artery stenosis, carotid artery stenting (CAS) with use of proximal protection systems (PPS) plays an important role as alternative treatment modality, especially in high risk patients. This study was aimed at the assessment of safety of CAS with use of the PPS and also at identification of risk factors associated with this procedure. Material and methods. This was a post hoc analysis, with 30-day follow-up. We analysed results of treatment of 94 patients who underwent 97 CAS with PPS, 47 such procedures in asymptomatic, and 50 in symptomatic individuals. Results. There were 0 strokes during 30-day fo…

Chronic cerebrospinal venous insufficiency theory after the Brave Dreams study

Endovascular thrombectomy with the AngioJet System for the treatment of intermediate-risk acute pulmonary embolism: a case report of two patients

Acute pulmonary embolism (PE) is one of the leading causes of death and ranks third, after myocardial infarction and cerebral stroke, among fatal hospital-related cardiovascular events [1–3]. Mortality associated with PE can be lowered by early treatments aimed at restoring patency of occluded pulmonary arteries (PAs). Although systemic thrombolysis remains the recommended management of PE [4], recent advances in endovascular techniques, especially of rheolytic thrombectomy, suggest that the endovascular approach can represent an alternative therapeutic strategy [5–9]. Here we describe endovascular treatment of two patients with acute PE. We used the AngioJet (Boston Scientific, Natick, MA,…

Principles and Technique of Foam Sclerotherapy and Its Specific Use in the Treatment of Venous Leg Ulcers

Invention of foam sclerotherapy has significantly changed the current phlebological practice. Compared with liquid sclerosants, obliterating foam is more efficient, especially for the closure of larger veins. This review discusses clinical aspects of foam sclerotherapy with a focus on its use for the treatment of venous leg ulceration, including the rationale for its use in the treatment of these chronic wounds, physicochemical mechanisms responsible for stability and disintegration of sclerosant foam, pathomechanism of neurologic adverse events seen after foam sclerotherapy, and techniques that can increase efficacy of this procedure and lower frequency of adverse events.

Reinterpreting the Magnetic Resonance Signs of Hemodynamic Impairment in the Brains of Multiple Sclerosis Patients From the Perspective of a Recent Discovery of Outflow Block in the Extracranial Veins

Multiple sclerosis patients examined with perfusion magnetic resonance (MR) imaging techniques have been found to have patterns of abnormal blood flow. These include prolonged mean transit time, a trend toward decreased cerebral blood flow in the area of plaques, and decreased cerebral blood flow and prolonged mean transit time within normal-appearing white matter. In-creased cerebral blood flow and volume and decreased mean transit time (compared with the baseline values before the relapse) were found to precede the development of plaques. In addition, susceptibility-weighted imaging utilizing deoxyhemoglobin as the contrast has revealed that venous blood in cerebral veins of multiple scle…

Endovascular mechanical thrombectomy of the inferior vena cava and iliac veins with the use of Aspirex®S device in a paediatric patient

Phlegmasia cerulea dolens, which is the most severe clinical presentation of deep venous thrombosis and results from an almost complete occlusion of the major and collateral venous outflow routes from the extremity, is very rarely seen in children. Here we describe the treatment of an 11-year-old boy with Down syndrome who presented with thrombotic occlusion of the inferior vena cava and both iliac veins. We present a step-by-step technique of endovascular mechanical thrombectomy of these veins with the use of the Aspirex®S thrombectomy device. Endovascular treatment was followed by local intravenous thrombolysis. Because of recurrent thrombosis, which occurred 4 days later, endovascular th…

More new ischemic cerebral lesions revealed by diffusion-weighted imaging magnetic resonance imaging after carotid eversion endarterectomy in comparison with carotid stenting under proximal protection: the results of randomized prospective trial

Multiple sclerosis, an unlikely cause of chronic cerebrospinal venous insufficiency: retrospective analysis of catheter venography.

Objectives It is unknown if a relationship exists between multiple sclerosis and chronic cerebrospinal venous insufficiency and if this venous pathology is a causal factor for multiple sclerosis or is a product of a neurological disease. Even so, one should expect that if multiple sclerosis were the cause for venous lesions, then patients with an extended history of the disease would present with a more severe venous pathology. Design Retrospective analysis of catheter venography of the azygous and internal jugularveins, and duration of clinical history of the disease in multiple sclerosis patients. Setting Mono-profile specialist hospital. Participants 353 multiple sclerosis patients, with…

Recommendations for Multimodal Noninvasive and Invasive Screening for Detection of Extracranial Venous Abnormalities Indicative of Chronic Cerebrospinal Venous Insufficiency: A Position Statement of the International Society for Neurovascular Disease

Under the auspices of the International Society for Neurovascular Disease (ISNVD), four expert panel committees were created from the ISNVD membership between 2011 and 2012 to determine and standardize noninvasive and invasive imaging protocols for detection of extracranial venous abnormalities indicative of chronic cerebrospinal venous insufficiency (CCSVI). The committees created working groups on color Doppler ultrasound (US), magnetic resonance (MR) imaging, catheter venography (CV), and intravascular US. Each group organized a workshop focused on its assigned imaging modality. Non-ISNVD members from other societies were invited to contribute to the various workshops. More than 60 neuro…

Seasonal variations in the onset and healing rates of venous leg ulcers

Objectives As many vascular pathologies exhibit circannual fluctuation, the aim of this study was to assess the chronobiological features of venous ulcers. Methods Based on a retrospective survey of the case histories of 391 venous ulcer patients, the rates of ulcer onset and healing in each month were analysed statistically; a time series was constructed to evaluate the seasonality. Results There was a significantly higher frequency of ulcer onset during the warmer part of the year (April–October), and onset showed strong seasonality. Healing rates were also unequally and statistically significantly distributed throughout the year: ulcers that appeared or that were treated with specialized…

Catheter venography for the assessment of internal jugular veins and azygous vein: position statement by expert panel of the International Society for Neurovascular Disease.

This document by an expert panel of the International Society for Neurovascular Disease is aimed at presenting current technique and interpretation of catheter venography of the internal jugular veins, azygous vein and other veins draining the central nervous system. Although interventionalists agree on general rules, significant differences exist in terms of details of venographic technique and interpretations of angiographic pictures. It is also suggested that debatable findings should be investigated using multimodal diagnostics. Finally, the authors recommend that any publication on chronic cerebrospinal venous insufficiency should include detailed description of venographic technique u…

Administration of low molecular weight heparins for prolonging the survival of patients with cancer

Thromboembolism represents one of the most common causes of mortality and morbidity in cancer patients, and thromboembolic events occur more often in patients with biologically more aggressive malignant disease. Therefore, low molecular weight heparins (LMWHs) are routinely administered to cancer patients. Importantly, in addition to the prophylactic activity against thromboembolism, LMWHs seem to decrease mortality in these patients. Improved clinical prognosis is independent of the antithrombotic efficacy, since vitamin K antagonists do not improve patient survival, and non-anticoagulant heparins exhibit a similar anti-cancer effect. This protective effect is primarily related to the prev…