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Contents : CIRSE Commentary on the Treatment of Chronic Cerebro Spinal Venous Insufficiency (CCSVI) Chronic Cerebro Spinal Venous Insufficiency or CCSVI is a putative new theory which is suggested by some to have a direct causative relationship with the symptomatology associated with multiple sclerosis (1). The core foundation of this theory is that there is abnormal venous drainage from the brain due to outflow obstruction in the draining jugular vein and/or azygous veins. This abnormal venous drainage characterised by special ultrasound criteria called the Venous Hemodynamic Insufficiency Severity Score (VHISS) is said to cause intra cerebral flow disturbance or outflow problems leading to peri ventricular deposits (2). In the CCSVI theory these deposits have a great similarity to the iron deposits seen around the veins in the legs in patients with chronic DVT. Dr. Zamboni who first described this new theory has promoted balloon dilatation to treat the outflow problems thereby curing CCSVI and by the same token alleviating MS complaints. However this theory does not fit into the existing bulk of scientific data concerning the pathophysiology of MS. Nevertheless there is an increasing acceptance of CCSVI and the associated balloon dilatation treatment worldwide disregarding the fact that there is only low grade scientific evidence mainly coming from one source. The treatment is called the Liberation Treatment and the results from the treatment can also be watched on YouTube. There are well documented testimonies by MS patients who have gained improvement in their personal quality of life after the treatment. There are however no data available from patients who underwent unsuccessful treatments. There are currently several centres actively promoting and performing balloon dilatation with or without stenting for CCSVI. However it must be stated that no randomised trial data are available to back the theory behind the treatment or to support its use. There are also no RCTs currently in progress. Therefore the basis for this treatment rests on anecdotal evidence and successful testimonies by patients. It is for these reasons that CIRSE feels that this is not a sound basis to currently offer this new treatment which has not yet been part of a RCT. -1- The core of this new theory is the CCSVI syndrome or the abnormal venous drainage from the brain. However venous drainage from the head has an impressive anatomic variation which is not very well catalogued in most textbooks. Also valves can be present at a variety of sites in the head and neck veins. Interventional Radiologists who practise para thyroid sampling are well aware of the huge variety in venous anatomy. Besides the huge variation in normal venous anatomy the jugular veins have some natural narrowing at two sites and the azygous vein prominent in the CCSVI theory does not drain the brain at all. The azygous can clearly drain the spinal cord but not solely as there are many intercostal venous collaterals which fulfil the same function. In addition the fact that this imaging is done in the supine position will have a great influence on blood flow and image interpretation. There have recently been randomised studies comparing socalled venous stenoses in patients with and without MS (3 4). Both studies show that there is no difference in the prevalence of venous stenoses between the two groups. This seems to be a very strong argument against the existence of CCSVI. However physicians performing CCSVI treatment point out that these studies were not performed according to the specific Venous Hemodynamic Insufficiency Severity Score (VHISS) criteria. The other part of the theory is that the venous outflow obstruction needs to be treated. However if there is a real haemodynamic venous outflow obstruction there should also be a pressure gradient and this gradient should disappear after successful balloon dilatation. It has been shown and confirmed by those who perform balloon dilatation for CCSVI that over the so called stenosis there is never a measurable pressure gradient. Those who perform this treatment argue that it is not the pressure gradient but the change in outflow pattern caused by this stenosis that is the p

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