In 2007¹ and then in 2009² Dr. Paulo Zamboni published his best known articles about the association of chronic brain venous obstruction and MS. Zamboni is not a neuroradiologist, a neurosurgeon, or a neurologist but a vascular surgeon who no longer practices as such, as he is afflicted by multifocal motor neuropathy.

It is to be noted that his explorations of venous hemodynamics were initially done using Doppler sonography and that his initial observations have not been exactly reproduced. Also in 2009, Zamboni published another article describing increased brain iron in patients with MS.³ (Here, one must remember that brain iron is increased in many chronic neurodegenerative disorders.) Because his wife is significantly affected by MS, he sought out new explanations for the disease. Linking abnormal blood to MS is not new: in the mid-19th century Charcot postulated some connection between both, and we now know that cerebral perfusion is affected in this disease.⁴ Knowing this, it does not take long to link brain iron overload with venous insufficiency. Zamboni initially treated 65 patients with venous balloon angioplasty, and the rest is history. Many patients come to us asking for this type of treatment and, at least at my institution, we do not offer or perform it.

The benefits of this treatment are controversial, minimal at best, and probably placebo-related. Complications such as venous perforations and thrombosis are not uncommon and lead to further invasive therapies. The US National MS Society has begun a large-scale study devoted to chronic cerebrospinal venous insufficiency. One huge problem with Zamboni's explanation is that it discards decades of research on the role that inflammation plays in MS. Many articles (some of them are featured here) do not support the hypothesis of venous insufficiency as a cause of MS. I consider it critically important for us, clinical neuroradiologists, to be familiar with how this controversy started and what can we offer our patients. The lay press is replete with articles regarding this issue (one of the best recent ones can be found in the New York Times).

As you will see by the articles chosen for this issue of AJNR Digest, the same groups and same authors have published articles in favor of and against chronic venous insufficiency and MS. But before jumping to conclusions, start by reading those articles here!

References

1. Zamboni P, Menegatti E, Bartolomei I, et al. Intracranial venous hemodynamic in multiple sclerosis. Cur Neurovasc Research 2007;7:252-58
2. Zamboni P, Galeotti R, Menegatti E, et al. Chronic cerebrovascular venous insufficiency in patients with multiple sclerosis. J Neurol Neurosurg Psychiatry 2009;80:392-99
3. Singh AV, Zamboni P. Anomalous venous blood flow and iron deposition in multiple sclerosis. J Cereb Blood Flow Metab 2009;29:1867-78
4. Ge V, Law M, Johnson G, et al. Dynamic susceptibility contrast perfusion MR imaging of multiple sclerosis lesions: characterizing hemodynamic impairment and inflammatory activity. AJNR Am J Neuroradiol 2005;26:1539-54

 

Image modified from: Dolic K, Marr K, Valnarov V, et al. Intra- and Extraluminal Structural and Functional Venous Anomalies in Multiple Sclerosis, as Evidenced by 2 Noninvasive Imaging Techniques.