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Catheter based treatment of the chronic cerebrospinal insufficiency in patients with multiple sclerosis, a single center experience.

Rafael Moguel, Virginia Samaniego, Agustin Vela

Introduction: Multiple sclerosis is a chronic neurological disease that manifests clinically in many different ways, causing varying degrees of disability. This disease has been addressed for years as the result of an autoimmune disorder that causes demyelination with multifactorial etiology involving genetic and environmental factors on three basic clinical forms of behavior: Relapsing-remitting, secondary progressive and primary progressive. Classical descriptions in the nineteenth century considered the possibility of a vascular connection, due to the constant presence of blood vessels in the center of the histopathological lesions. Contemporary researchers later emphasized this concept, based on the presence of blood elements surrounding a vascular area in the characteristic lesion; these elements include iron and blood cells, suggesting damage to the blood-brain barrier. Recently Paolo Zamboni described the findings of brain venous flow in patients with “multiple sclerosis”, obtained by ultrasound and invasive angiography that showed abnormalities by obstructions of the internal jugulars and azygous veins. On that publication, he treated sixty-five patients with multiple sclerosis of the three types with balloon angioplasty in stenosis of the internal jugular and azygos veins. It showed a reduction in disease progression by counting MRI lesions, improved functional status and quality of life. Materials and Methods: We present the data from our first 390 patients with multiple sclerosis; everyone received neurological evaluation before and after treatment, based on the disability scale (SDSS: Expanded Disability Status Scale), the multiple sclerosis functional composite (MSFC: Multiple Sclerosis Functional Composite) and otoneurological assessment, pre and post treatment. Results: This experience showed average age of 51 ± 11 years old, 68.4% were female; 29.9% had relapsing-remitting, 24.1% primary progressive and 46% secondary progressive types; the left jugular was treated in 93.5%, the right one in 96.4% and the azygous in 20.4%. Objective clinical improvement was seen in 91.2% of patients, (pre and post EDSS scale 5.46 vs. 5.06), MSFC scale (0.07 vs. 0.15), instability (60 vs. 2%), hypoacusis (31.8 vs. 16.1%) and tinnitus (35 vs. 5.5%); all of them showed statistical significance (p<0.01). Fourteen self-expanding stents were implanted to improve results. The severe complications rate was 1.4%, including thrombosis of jugular or azygous veins, femoral artery pseudo-aneurysm and balloon rupture, none of them caused neurological worsening. Conclusion: Based on old publications and the histopathological characteristics, it is probable the vascular origin of multiple sclerosis, with evidence of vein congestion due to mechanical obstruction of the internal jugular and azygous veins; the recent demonstration of delayed flow in these veins, the chronic cerebrospinal venous insufficiency, supports this probability. The publication by Paolo Zamboni showed the improvement of the first ever patients treated by angioplasty as shown in this experience, with minimal complication rate that may even decrease with the progress of the learning curve. This concept opens a new therapeutic approach for the patients with multiple sclerosis.