Dr. Jack Burks

Multiple sclerosis patients and endovascular interventionalists were elated when Italian researchers reported in 2009 that they had found evidence of chronic cerebrospinal venous insufficiency in nearly every MS patient they had studied and that in many cases, balloon angioplasty and sometimes stent placement of central thoracic veins reduced or eliminated signs of the disease. Neurologists, on the other hand, suggested that hope might be eclipsing reason in the rush to advocate the vascular procedure, given the single-center study’s small sample size and nonrandomized, uncontrolled design.

The opposing perspectives incited an apparent turf war within the MS community fueled by a firestorm of accusations, with both sides going for the jugular, according to Dr. Jack Burks, chief medical officer of the Multiple Sclerosis Association of America. At issue, he said, is the validity not only of the study results but also of the underlying hypothesis that toxic iron overload in the brain due to chronic cerebrospinal venous insufficiency (CCSVI) might have a primary role in the pathogenesis of MS – a hypothesis that contradicts the compelling body of evidence suggesting that MS is primarily an autoimmune condition.

On one side of the debate are the MS patients and endovascular interventionalists, dubbed the "liberators" by Dr. Burks because of their unflappable advocacy for what has become known as the liberation procedure – the endovascular surgery designed to open the lesions causing the venous insufficiency, he said. On the other side are the neurologists and MS societies, whom he lightheartedly calls the CCSVI nihilists because of their outspoken criticism of the surgery in the absence of more robust, conclusive scientific evidence.

"Neurologists believe the interventionalists are overstating the possible value of CCSVI and that commercial interests are overriding scientific inquiry," according to Dr. Burks, a neurologist and clinical professor of medicine at the University of Nevada, Reno. Patients, armed with anecdotal evidence downloaded from the Internet, are certain that CCSVI surgery is the miracle they’ve been waiting for and perceive the hesitancy of U.S. and Canadian neurologists to embrace the treatment as evidence of a possible conspiracy with pharmaceutical companies who stand to lose billions of dollars if the surgery becomes a first-line treatment, he said. Further, he noted, advocates of CCSVI claim that neurologists who refuse patients’ demands for diagnostic testing and surgical referral for CCSVI are jeopardizing the safety of those patients, who are traveling to foreign countries such as Poland, Bulgaria, Mexico, Costa Rica, and India to get the care that they cannot receive in North America.

Both camps point to the much publicized case of a Canadian MS patient who traveled to Costa Rica for jugular vein angioplasty and died from a ruptured vessel as evidence that supports their respective positions, said Dr. Burks.

To date, the majority of the evidence regarding CCSVI diagnosis and treatment in MS is inconsistent, and can be confusing, Dr. Burks noted. In the initial study, Dr. Paolo Zamboni of the University of Ferrara in Italy, and colleagues, used Doppler ultrasound to examine venous drainage of the brain and spinal cord in 65 patients with different types of MS and 235 controls without MS and observed abnormal venous flow in all of the MS patients and none of the controls. The patterns of venous obstruction differed depending on MS stage and course, although there was no apparent relationship between disease severity and extent of venous obstruction, and MS treatment status did not influence the signs of CCSVI in any of the patients, the authors wrote (J. Neurol. Neurosurg. Psychiatry 2009;80:392-9).

The researchers went on to conduct an open pilot study to determine whether percutaneous transluminal angioplasty could safely and effectively treat the narrowing of the extracranial cerebrospinal veins in the 65 MS patients in which the condition was observed – 35 with relapsing-remitting MS, 20 with secondary progressive MS, and 10 with primary progressive MS. They reported significant improvements in MS clinical outcome measures, significant reductions in new brain lesions on MRI, and significant reductions in the number of relapses experienced by some of the patients.

The findings were limited, however, not only by the study design, but also by the fact that patients remained on their disease-modifying antirheumatic drug therapy during the study period and the timing and type of MRI scans varied among the patients, according to the authors. They also noted that restenosis of the internal jugular veins occurred in nearly half of the patients (J. Vasc. Surg. 2009;50:1348-58).

Since the initial paper, a number of CCSVI studies of various designs have been undertaken, with contradictory results. Following are some of the investigations reported within the past year:

• Researchers at the University of Buffalo found that up to 62% of the 280 patients with MS enrolled in the Combined Transcranial and Extracranial Venous Doppler Evaluation study – the first randomized clinical trial to evaluate MS patients for CCSVI – had the characteristic narrowing of the extracranial veins compared with approximately 22% of 220 healthy controls. While the results, which were reported at the annual meeting of the American Academy of Neurology, did not establish causation, they showed "that narrowing of the extracranial veins, at the very least, is an important association in multiple sclerosis," principal investigator Dr. Robert Zivadinov said in a statement. He acknowledged that the finding of vascular narrowing in nearly a quarter of the healthy controls warranted additional investigation.

• In an open-label study of extracranial Doppler criteria of CCSVI in 70 MS patients in Poland – 49 with relapsing-remitting MS, 5 with primary progressive MS, and 16 with secondary progressive MS – investigators detected at least two of four extracranial criteria in 90% of the patients. They concluded that, while the extracranial abnormalities could exist in various combinations, "the most common pathology in our patients was the presence of an inverted valve or another pathologic structure [like membranaceous or netlike septum] in the area of junction of the [internal jugular vein] with the brachiocephalic vein (Int. Angiol. 2010;29:109-14).

• A comparison of the internal jugular vein hemodynamics and morphology in 25 patients with MS and 25 controls identified abnormal findings in 92% of the MS patients and 24% of the controls, and evidence of CCSVI in 84% of the MS patients and none of the controls, leading the investigators to conclude that both hemodynamic abnormalities and morphologic changes in the internal jugular vein "are strongly associated with MS" (Int. Angiol. 2010;29:115-20).

• An extended extra- and transcranial color-coded sonography study in 56 MS patients and 20 controls detected no internal jugular vein stenosis and normal blood flow direction in all but 1 patient. There were no between-group differences in intracranial veins and during Valsalva maneuver, and none of the patients fulfilled more than one CCSVI criterion, according to the authors. They concluded that their findings "challenge the hypothesis that cerebral venous congestion plays a significant role in the pathogenesis of MS" (Ann. Neurol. 2010;68:173-83).

• Swedish investigators used phase-contrast MRI to study 21 relapsing-remitting MS patients and 20 healthy controls and found no differences in internal jugular venous outflow, aqueductal cerebrospinal fluid flow, or the presence of internal jugular blood reflux between the two groups. Although contrast-enhanced MR angiography showed internal jugular vein stenosis in 3 of the 21 MS patients, the authors stated they found no evidence "confirming the suggested vascular multiple sclerosis hypothesis" (Ann. Neurol. 2010;68:255-9).

• The authors of an MR venography and flow quantification study in The Netherlands compared the intracranial and extracranial venous anatomy and the intracerebral venous flow profiles of 20 MS patients and 20 age- and gender-matched controls, with image analysis performed by blinded interventional neuroradiologists. They identified venous system anomalies in 50% of the MS patients and 40% of the healthy controls and no venous backflow in either group. "Given the normal intracranial venous flow quantification results, it is likely that these findings reflect anatomical variants of venous drainage rather than clinically relevant venous outflow obstructions," the authors wrote (J. Neurol. Neurosurg. Psychiatry 2010 Oct. 27 [doi: 10.1136/jnnp.2010.223479]).

• Italian researchers investigating the occurrence of CCSVI in 50 consecutive patients with clinically isolated syndromes suggestive of MS reviewed the patients’ extracranial and transcranial venous echo-color Doppler sonographs and compared the findings to those of 50 age- and gender matched healthy controls as well as those of 60 patients with transient global amnesia (TGA) and 60 healthy controls matched to the TGA patients. They found extracranial Doppler sonographic abnormalities in 52% of patients with possible MS, 68.3% of patients with TGA, and 31.8% of the healthy controls. While eight of the patients with possible MS fulfilled the CCSVI criteria, selective phlebography showed no venous anomalies in seven of them. The authors concluded that there was no evidence of CCSVI at MS onset but recommended further studies to "clarify whether CCSVI is associated with later disease stages and characterizes the progressive forms of MS" (Ann. Neurol. 2011;69:90-99).

Not only do the findings of this study challenge the hypothesis that CCSVI plays a role in the pathogenesis of MS, they suggest that some patients may be getting unnecessary surgery, according to lead author Dr. Claudio Baracchini of the University of Padua, Italy. "The few patients [in this study] with venous anomalies suggesting a CCSVI pattern had normal cerebral venous hemodynamics and all of the patients who underwent selective venography had predominantly normal findings," he said in an interview. For such patients, the surgery is "unjustified and associated with unnecessary risk," he stressed.

Despite the media focus on the professional divide sparked by the CCSVI controversy, most in the scientific community agree that more research is needed before interventional surgery for CCSVI can be routinely recommended.

In a position statement, the Society of Interventional Radiology stated that at present, the published literature is "inconclusive on whether CCSVI is a clinically important factor in the development and/or progression of MS, and on whether balloon angioplasty and/or stent placement are clinically effective in patients with MS" (J. Vasc. Interv. Radiol. 2010;21:1335-7).

Additionally, in a commentary on the treatment of CCSVI, representatives of the Cardiovascular and Interventional Radiological Society of Europe acknowledged that although several centers worldwide are promoting and performing balloon dilatation, with or without stenting for CCSVI, "no trial data are available, and there is currently no randomized controlled trial [RCT] in progress." Further, anecdotal evidence and patient testimonies on the Internet are not a sound basis to offer a new treatment "which could have possible procedure-related complications to an often desperate patient population," they wrote. "We believe that until real scientific data are available for CCSVI and balloon dilatation, this treatment should not be offered to MS patients outside of a well designed clinical trial" (Cardiovasc. Intervent. Radiol. 2011;34:1-2).

Toward that end, the National Multiple Sclerosis Society of the United States and the MS Society of Canada have pledged $2.4 million in support of seven CCSVI research studies, including projects designed to evaluate venous abnormalities in children and teens with MS, patients with early and late stage MS, and those at risk for MS. An international review panel comprising radiologists, vascular surgeons, and neurologists evaluated research applications via an expedited review process and chose those that "combined the strongest science with the research goals necessary to most quickly determine the scope and meaning or reported abnormalities in blood drainage from the brain and spinal cord in MS," according to the societies. "It is hoped these findings will provide clarity regarding the need for next-step therapeutic trials to correct such blockages as MS societies around the world pursue this CCSVI lead."

In a presentation at the annual International Symposium of Endovascular Therapy in January, Dr. Burks outlined the critical issues related to crafting a united CCSVI message with multidisciplinary support, which include the best CCSVI diagnostic tests and outcomes; treatment standards and successful outcomes; diagnostic criteria; standards for qualified CCSVI specialists and treatment centers; uniform institutional review board requirements; standards, by discipline, for follow-up care; and criteria for retreatment and procedural standards.

Additionally, "we need to establish a CCSVI patient registry that documents outcomes and adverse events, as well as other relevant data, and disseminate that document widely to all groups," Dr. Burks said. Doing so will go far toward mending the fractious community and directing energy toward optimal patient care, he stated.

Dr. Burks disclosed financial relationships with Acorda, Allergan, Avanir, Bayer, Biogen Idec, Novartis, and Serono. Dr. Baracchini disclosed having no relevant financial relationships.

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