The work of Prof. Zamboni has highlighted the well-established involvement of veins in patients with multiple sclerosis but he does not claim that stenoses are involved in causing the disease. The typical venous lesions in the CNS with blood-brain barrier damage and demyelination can, paradoxically, be produced by arterial micro embolism (Lancet 1982;i:380-386).

All the 'auto' immune features of MS are found at the same level after cerebrovascular events like stroke and also after head injuries (Clin Exp Immunol 1992;88:157-162). Auto immunity is involved in repair; it is hypoxia and inflammation that causes the perivenous damage (N Eng J Med 2011;364:656-665)

In the 1980s Mr Gerard Glass a specialist in vein surgery in Belfast observed similar improvement to CCSVI interventions in MS patients when stripping their varicose veins. He researched compressing veins in the legs of MS patients using bandaging finding immediate improvement and he filmed the changes.

Stripping the veins produced longer term improvement. Unfortunately Mr Glass encountered great resistance to publication although was able to publish improvements in migraine patients from varicose vein surgery (Vascular Surgery 1991:25;654-660) He is now 92 and taking a keen interest in the venous debate.

The improvement appears likely to be due to reflex action but it is surprising that the effects often last for months. I am communicating details of this work to Prof. Zamboni.

Philip B James

Emeritus Professor of Medicine

University of Dundee