Chronic cerebral venous dysfunction: view of the problem

The article presents an analytical review of the results of domestic and foreign studies on chronic disorders of cerebral venous circulation, which is given less attention against the arterial system due to blurred manifestations, especially early, anatomical variability of the venous system, even in healthy, difficulty in diagnosis. When the balance of arterial and venous inflow is disturbed and this state exa­cerbates, irreversible changes evolve other structures of the cranial ca­vity — primarily in the brain (consistent with the concept of Monroe-Kelly). Chronic disorders of cerebral venous circulation may have different causes and varying degrees of severity. The equivalent of chronic cerebral venous insufficiency (SCVD), terminologically accepted in our country, in some countries is considered as chronic venous cerebrospinal insufficiency, which emphasizes the pathogenetic link of disorders of cerebral venous blood flow and extracranial veins, which is, in our opinion, is logical and reasonable. Recognition of chronic cerebrospinal venous insufficiency has aroused intense interest for a better understanding of the role of extracranial venous pathology and developmental options. Although the diagnosis was originally based on Doppler sonography, there are currently no diagnostic imaging methods, non-invasive or invasive, that can serve as the gold standard for detecting venous abnormalities indicative of chronic cerebrospinal venous insufficiency. The results of some studies are discussed, in particular, the hypothesis that chronic cerebrospinal venous insufficiency plays a role in the pathoge-nesis of multiple sclerosis or in many concomitant clinical manifestations. The affinity of the pathogenesis of idiopathic intracranial hypertension, Ménière’s disease, spondylotic vertebrobasilar insufficiency syndrome is analyzed. Attention is also focused on the other opinion of scientists when the increase in venous blood supply to the brain and other formations in the head cavity under certain conditions is considered as a compensatory reaction. The anatomical and physiological features of the venous system of the cranial cavity are considered, which substantiate the clinical manifestations of venous dysfunction, methods of diagnosis and treatment of pathology. Summarizing the above, chronic venous blood circulation in the cranial cavity, which is largely associated with problems of extracranial venous blood flow, not only in itself is a very characteristic syndrome complex t that adversely affects neurological functions due to cerebral hypoxia and metabolic changes, deteriorates the quality of life, but also has a negative impact on the course of the disease or has a pathogenetic link with other diseases, in particular, may be accompanied by different levels of blood pressure.

Chronic cerebrospinal venous insufficiency, ten years after. New headlights on a venous disease that enriched the vascular world

Two very recent scientific papers have re-opened a debate on a vascular issue, chronic cerebrospinal venous insufficiency (CCSVI), that apparently was sent in a corner by other trials and some Editorial hasty conclusions. The never-ending debate is still open and, perhaps, a one-year truce helped to calm waters and sort out, as by means of a sandbox, the situation from the vascular point of view. Before discussing why these recent papers have widened the path for CCSVI, some mind refreshing is mandatory, since the opinions are spread in all directions and a concise summary may help for those that are newcomers in this issue...

Inflammatory Biomarkers May Predict Poor Outcome in Patients with Chronic Cerebrospinal Venous Insufficiency.

Background and purpose Chronic cerebrospinal venous insufficiency (CCSVI) related inflammatory process is still unclear. This study aimed to evaluate peripheral inflammatory biomarkers in both intracranial CCSVI and the extracranial CCSVI group, as well as the relationship between the inflammatory state and prognosis of CCSVI.Methods Patients with CCSVI were included from July 2017 to July 2019, divided into three groups by location of stenosis. The inflammatory biomarker assay included neutrophil-to-lymphocyte ratio (NLR), platelet-to-lymphocyte ratio (PLR), red blood cell distribution width (RDW), C-reactive protein (CRP), interleukin- 6 (IL-6)) and neuron-specific enolase (NSE). The clinical outcome was assessed by the modified Rankin Scale (mRS) and Patient Global Impression of Change (PGIC) score. Univariate and multivariate regression analysis was performed to identify significant prognostic factors for poor outcome. Then a nomogram based on multivariate regression analysis was established.Results In total, 248 consecutive patients were enrolled, 102 males and 146 females, with an average age of 57.85 ± 12.28 years. Patients with cerebral venous sinus stenosis (CVSS) were more likely to be younger age and present headaches and severe papilledema. Higher levels of NLR, RDW, and CRP were also observed in the CVSS group. In multivariate analysis, NLR, PLR, and IL-6 became the independent prognostic factors for predicting the poor outcome of CCSVI.Conclusions The clinical presentations and the increased levels of NLR, PLR, and CRP may be more remarkable in the group with CVSS-related CCSVI than that with internal jugular venous stenosis (IJVS)-related CCSVI. The pro-inflammatory state may relate to CCSVI. An elevated level of NLR, PLR, and IL-6 played a negative role in the prognosis of CCSVI.

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

About 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 modality in multiple sclerosis patients. Still, a possibility that some patients may benefit from endovascular treatment cannot be ruled out. This may concern patients at early stage of the disease and presenting with lesions that can easily be managed with balloon angioplasty. Therefore, we need more studies evaluating clinical efficacy of venous angioplasty in selected subgroups of multiple sclerosis patients. Importantly, it has already been demonstrated that venous angioplasty in multiple sclerosis patients is a safe procedure. Thus, also from an ethical point of view, such trials seem justifiable.