Chronic cerebrospinal venous insufficiency, commonly known as CCSVI, is a new theory for the cause of multiple sclerosis proposed by vascular surgeon Dr. Paulo Zamboni, of Ferrara, Italy. He attributes the cause to venous malformations and stenosis in the jugular or azygous veins.

The role of venous drainage problems in the brain causing neurodegenerative diseases such as mutliple sclerosis, however, is not new. Other’s considered it long ago. Moreover, the term is very similar to a term I use to describe a potential cause of Alzheimer’s disease, Parkinson’s disease and multiple sclerosis. I call my theory chronic craniocervical venous back pressure or CCVBP.

I began my research into venous drainage problems sometime in the early 1980’s for entirely different reasons. I was looking into the cause of normal pressure hydrocephalus (NPH) in adults when I stumbled on an old, outdated neurology book. In the section on NPH it stated that researchers had suspected that blockage of the dural sinuses (large veins of the brain) could result in tension hydrocephalus (NPH). The problem is that blockages of the dural sinuses were never found. But they were looking for the blockages inside the skull, so I began to look outside the skull. Interestingly, NPH is almost identical to Alzheimer’s disease in signs and symptoms.

Aside from sharing similar theories regarding the role of venous drainage problems in the brain causing multiple sclerosis, the theory of CCSVI is considerably different from my theory of CCVBP.

The theory of chronic cerebrospinal venous insufficiency attributes the cause of venous drainage problems to structural problems in the jugular, azygous, abdominal and iliac veins. Other problems include abnormal valves, septums, or flaps inside the veins that restrict blood flow. Typically, valves in the jugular veins prevent venous blood from flowing backwards toward the brain. Faulty valves allow blood to flow backwards which is called reflux or inversion flows. Septums are sheets of tissue inside the veins that divide the opening. Flaps similarly invade the inside space but without dividing it.

Atresia, hypoplasia and agenesis are also terms applied to chronic cerebrospinal venous insufficiency. The theory of CCSVI indicates partially closed, underdeveloped or missing veins.

With regards to the CCVBP theory, the term refers to partially closed, underdeveloped and missing venous outlets (holes called foramen) in the base of the skull. This theory is discussed in depth in my book The Downside of Upright Posture – The Anatomical Causes of Alzheimer’s, Parkinson’s and Multiple Sclerosis.

Chronic cerebrospinal venous insufficiency is diagnosed according to strict criteria utilizing specialzied imaging equipment and techniques. One method used is CT venography. The other uses MR venography. CT venography uses x-rays to create the image. The MRV uses magnetic fields bombarded with radio waves. In both cases the veins are injected with a dye to make them more visible. Both methods are considered unreliable at detecting abnormal valves, septums and flaps. The biggest problem with both, however, is that they fail to detect faulty blood flow due to upright posture. Blood flow is dynamic and changes from the supine to the upright position.

 

 

Specialized MR scans, such as magnetic resonance flow quantification and magnetic resonance imaging susceptibility weighting are good at detecting venous blood flow. MRFQ detects both flow rate and direction so it can be used to check for reflux (inversions flows) as well. Unfortunately, current CCSVI testing does not make use of newer upright MRI scanners which would add important information to their determinations.

Another method used for determining blood flow dynamics in CCSVI is called duplex ultrasonography. Ultrasound works like sonar and radar equipment that send and receive radio sound waves bounced off of objects to create an image.

Conventional ultrasound uses ultra high frequency sound waves bounced off of stationary objects. Doppler ultrasound bounces ultra high frequency sound waves off of moving objects such as red blood cells to determine speed and direction of blood flow. Duplex ultrasound combines both conventional and doppler ultrasound. color coded doppler creates a picture of the blood vessels, as well as the direction of blood flow. It thus provides information about the anatomical structure of the blood vessel, such as plagues and stenosis, as well as dynamics of blood flow.

CCSVI testing uses color coded ultrasound to examine blood vessels outside the cranial vault called extracranial vessels. It also uses a special transcranial probe to examine blood vessels inside the cranial vault. The accuracy of the information obtained is highly dependent upon the operator in gathering and interpreting the images.

The last means of examining the blood vessels and blood flow is called a catheter venogram. In a catheter venogram a thin wire is run through the blood vessels up to the area to be examined. When the area is reached a dye is injected and x-rays are taken of the blood vessels. Ultrasound can also be added for use in imaging the inside of the blood vessel. Lastly, a manometer can be added for detecting pressure and blood flow.

The catheterization process usually incorporates treatment as well when certain specific criteria and conditions set forth by Zamboni’s protocols are met for determining CCSVI. The suspect vessel is dilated with balloon venoplasty. Some physicians prefer to use more durable stents. Both procedures have problems. Venoplastly is subject to failure to dilate and early restenosis. Stents have problems with forming clots.

 

 

What makes CCSVI so remarkable is the oftentimes stunning improvements in signs and symptoms following treatment. No previous treatments have ever achieved such success even if only short lived.

While some people get little or no improvement and some even get worse, the biggest problem lies in the duration of the improvement following treatment. About one-third of the patients suffer restenosis and their signs and symptoms returns shortly after treatment.

Nonetheless, despite the drawbacks, CCSVI has turned multiple sclerosis research on its head as formerly held beliefs about its causes come crumbling down and so do the dangerous, sometime life threatening drugs currently used to treat it. A whole new world of possibilities for future treatment has opened up.

CCSVI is just the beginning. Now its time to recognize the role of CCVBP in the cause of neurodegenerative diseases. In fact, the theory of CCVBP makes as much if not more sense. So does the cure.

The Weaknesses in the Theory of CCSVI

One of the problems with the theory of CCSVI is that it fails to explain the unusual epidemiological demographics associated with multiple sclerosis. For one, classic MS doesn’t affect everyone equally. People living in northern climates have a higher incidence of MS than people living in more southern latitudes and MS incidence is very low in the tropics.

The theory of CCSVI also fails to explain significant racial differences in that Asians appear to have a much lower incidence of MS than European cultures throughout the world. What’s more, Eskimos, who are of Asian descent, and live in extreme northern climates, have almost no incidence of MS. Even more interesting, is that the incidence of MS appears to be equally low in Africa.

While the incidence of classic MS is low, Asians do get a variant form of MS called Devic’s disease, also known as neuromyelitis optica (NMO). More recently, it was shown that African-Americans tend to fall into the NMO category similar to Asians. Design differences in the skull of Europeans and Asians may explain the different manifestations of these diseases in races. In this regard, African skulls are more similar to Asian skulls.

CCSVI has opened a whole new door in the treatment of neurodegenerative diseases of the brain and cord. The journey has just begun. There is much more to be learned. MR brain images, especially upright MRI, will shed much more light on the complexities of the drainage system and fluid mechanics of the brain and cord.