CCSVI IN MULTIPLE SCLEROSIS ROLE FOR JUGULAR SURGICAL RECONSTRUCTION
Posted on 02/15/2012
" The Hernandez's Procedure " Also know as Surgical Jugular Reconstruction via patch/bypass
Multiple sclerosis (MS) is believed to be an autoimmune disease, characterized by inflammation, selective demyelination of the central, but not peripheral nervous system and ultimately gliosis of brain cells. Approximately 350,000 people suffer from M S in the U S, with an onset between the ages of 20 and 40 years of age. Additionally, M S is more common among women than men. Acute and chronic symptoms are the hallmark of Multiple Sclerosis, and once established usually leads to considerable disability and impairment of quality of life.
There have been identified four major clinical subtypes of M S. Beginning with: Relapsing Remitting M S (RRMS) 85 % of cases, Secondary Progressive MS (SPMS), Primary Progressive M S (PPMS) 10 % of cases, and Progressive Relapsing M S (PRMS) comprising 5 % off all cases.
Etiologic Factors:
There have been many etiologic factors implicated in this disease that include: genetic factors, infectious etiologies, in particular Epstein Barr virus 1 and 2, smoking, either primary or exposed to second hand smoke, iron toxicity and vitamin D deficiency. Most recently however, it has been introduced the concept of Chronic Cerebral Spinal Venous Insufficiency (CCSVI) as another possible etiologic factor responsible for the development of M S.
This theory put forth by Dr. Zamboni from Italy, proposes that somehow there is progressive damage to the venous system draining the blood from the brain, on route to the heart, causing narrowing or strictures of these structures. This in turn, will cause congestion or engorgement of the veins, with increase in the venous pressure in the brain and ultimately, this physiologic abnormality will lead to disruption of the blood brain barrier with leakage of red cells into the brain substance proper. The red cells in turn, once degenerated, free the iron content in them allowing this substance to come in contact with the brain tissue, inducing the toxic and destructive effects on the axons adjacent to it, initiating the inflammatory response that has been found in recent imaging research. This theory has created a great deal of controversy in the Neurologic community, has not been accepted as a cause of this disease and in fact, several studies suggest that this venous abnormality (CCSVI), is present in patients with MS as frequently as it is present in normal controls.
All this is well and good, but, it is irrefutablethat patients with MS that are found to have CCSVI and have Angioplasty of these vessels, either with balloon technology or stenting, obtain a remarkable improvement in their symptoms and in some cases, their disability disappears completely.
We will like to present a case in point:
Mrs. D. C. is a 47 yr. old patient, with symptoms of Multiple Sclerosis since the age of 17 and finally diagnosed at age 35. Her clinical picture initiated with parenthesis, weakness of the right lower extremity and cognitive changes. In time the disease progressed to the point that she became markedly disabled, at times requiring assistance to walk and do most of her chores. Finally, last year she became incontinent of urine and months later of feces as well.
All of the above took place in spite of taking a number of medications directed to alter the course of her disease. She finally inquired regarding CCSVI and decided to be evaluated for the Liberation Treatment for CCSVI and came to Excel Medical Center in Tijuana, Mexico.
The neurologist and internist, confirming the diagnosis of MS, requesting an Angio-TAC of the cerebral circulation as well as the jugular veins to assess the anatomy, evaluated patient. This study showed evidence of bilateral stenosis of the jugular veins, the left more severe than the right. It was decided to perform Angioplasty with balloon technology with excellent results. Patency of the veins was 100 %.
A day after the procedure, the majority of her symptoms abated almost completely and continued to improve over the ensuing months. Months later her symptoms returned progressively, in particular, the sphincter incontinence; so she decided to return to Excel Medical Center to be re-evaluated. In January of this year 2012, she was re-admitted to the hospital and once again evaluated clinically and by Angio-TAC. The latter found that the left jugular vein was severely constricted, with a great deal of stagnation of flow. The right side had several occlusions in the medium and distal third of the vein.
With this information, the patient accepted to undergo angioplasty once again the following day. The initial veno-gram on the left side showed severe stenosis of the medium third that occluded the vessel by about 98 % and extended for 12 to 15 mm. The occlusions on the right side were dilated with a 14 mm balloon with excellent results. While the patient was on the cath lab table, she noted an improvement in her vision; the fogginess in her head had disappeared. There was some improvement in her motor deficit, but not completely.
It was at that point that we suggested to her to consider undergoing a “Surgical Jugular Reconstruction via patch/ bypass)“ of the left jugular vein, in view of the incomplete results obtained from the previous procedure. The patient accepted and the Surgical Jugular Reconstruction was performed two days later.
The results of this procedure were apparent immediately post op, with a progressive reduction in her motor deficit, disappearance of the so called, “bear hug”, two days later the sphincter incontinence disappeared COMPLETELY. Two weeks after she left the hospital, she was walking on high heels, and just two days ago, we were informed that the patient went jogging without any limitations whatsoever. Now, we must remember, that this patient was incapacitated severely and had not walked without assistance in months, and now was performing activities that had not even considered in years. That is an astounding effect of the Liberation Procedure. We don’t know the exact mechanism by which this procedure reverses the clinical picture present in patients with Multiple Sclerosis. It is possible that there may be low-pressure hydrocephalus responsible for the symptoms, especially when the venous stagnation is severe like in patient D. C. We don t know, BUT what we do know is that patients that have a diagnosis of MS and is at an early stage of the disease, all these patients should be evaluated for CCSVI and if present, to consider the Liberation Treatment at the earliest time possible, because it is at this stage, that we see the most remarkable results. And patient D. C. is the GREAT EXAMPLE of what can be obtained with this procedure when done properly and at the right time.
Dr. Ernesto L. R. Osuna, F.A.C.C.
Interventional Cardiologist Tijuana, Baja Calif., Mexico
