Endovascular therapy for chronic cerebrospinal venous insufficiency in multiple sclerosis

• ¹ Department of Neurology, Froedtert Hospital and Medical College of Wisconsin, Milwaukee, WI, USA


• ² Department of Neurosurgery, Froedtert Hospital and Medical College of Wisconsin, Milwaukee, WI, USA


• ³ Department of Radiology, Froedtert Hospital and Medical College of Wisconsin, Milwaukee, WI, USA


• ⁴ Department of Neurology, Delray Medical Center, Delray Beach, FL, USA

Recent reports have emerged suggesting that multiple sclerosis (MS) may be due to abnormal venous outflow from the central nervous system, termed chronic cerebrospinal venous insufficiency (CCSVI). These reports have generated strong interest and controversy over the prospect of a treatable cause of this chronic debilitating disease. This review aims to describe the proposed association between CCSVI and MS, summarize the current data, and discuss the role of endovascular therapy and the need for rigorous randomized clinical trials to evaluate this association and treatment.

Introduction

Multiple sclerosis (MS) is a neurodegenerative disorder that affects approximately 350,000 people in the United States and possibly up to 2.5 million people worldwide (Anderson et al., 1992), making it the most common non-traumatic cause of disability among young and middle-aged people in the developed world (Koch-Henriksen and Sorensen, 2010). The pathogenesis is complex with varying associations and is primarily thought to be autoimmune, but a unifying hypothesis has yet to be identified. Compelling reports have recently emerged proposing a link between a recently defined entity named “chronic cerebrospinal venous insufficiency” (CCSVI) and MS.

The Cerebrospinal Venous System in Relation to CCSVI

A brief overview of the cerebrospinal venous system anatomy and physiology is important to understand the potential role of a vascular model in the pathogenesis of MS.

Anatomy

The cerebrospinal venous system is a large interconnected network of venous drainage that spans the length of the neuraxis (Figure 1). The primary intracranial venous drainage can be simplistically divided into deep and superficial systems, while additional drainage occurs through emissary veins. The deep system involves tributaries to the vein of Galen from the internal cerebral veins and the basal veins of Rosenthal. The vein of Galen in turn drains into the straight sinus, confluence of sinuses, and into the transverse sinuses. The superficial system provides cortical drainage into the superior sagittal sinus as well as several large channels that provide lateral cortical drainage. The cortical drainage ultimately passes into the dural sinuses before leaving the head through the transverse sinuses. The two systems communicate by shared outflow through the transverse sinuses.

See remainder of article at http://www.frontiersin.org/endovascular_and_interventional_neurology/10.3389/fneur.2011.00044/full