Impact of Extracranial Veins Endovascular Procedures on the Quality of Life in Patients with Multiple Sclerosis - Follow Up After 1 Year

Research Article

Austin J Mult Scler & Neuroimmunol. 2014;1(1): 5.

Impact of Extracranial Veins Endovascular Procedures on the Quality of Life in Patients with Multiple Sclerosis - Follow Up After 1 Year

Denislic M1,2*, Zorc M1,2, Ravnik J2,6, Milosevic Z3, Tiric Campara M4, Al-Hashel JY5, Zorc Pleskovic R1 and Ravnik D1

1University of Ljubljana, Slovenia

2MC Medicor, Slovenia

3University Clinical Centre Ljubljana, Slovenia

4Neurološka Klinika, BIH

5Neurology Department Ibn Sina, Kuwait

6Mathematics and Physics, University of Ljubljana, Slovenia

*Corresponding author: Denislic M, University of Ljubljana, Korytkova 2, SI-1000 Ljubljana, Slovenia

Received: September 30, 2014; Accepted: December 02, 2014; Published: December 05, 2014


Background: Chronic cerebrospinal venous insufficiency is a new term which highlights the role of extracranial venous anomalies. Stenoses of the jugular and the azygous veins hinder venous drainage and may influence brain perfusion and cerebrospinal fluid flow.

Materials and Methods: In patients with relapsing-remitting and progressive course of multiple sclerosis with a proven obstruction of neck veins percutaneous transluminal angioplasty was performed. We evaluated the clinical disability and quality of life in terms of fatigue, cognitive, psychosocial and bladder dysfunction one year after angioplasty.

Results: In the relapsing-remitting group of patients an improvement of disability was observed, whereas in patients with the progressive course of the disease a stable clinical status was noticed. Both patient groups showed a significant improvement of fatigue. Cognitive and psychosocial impact on the quality of life showed better outcome in patients with advanced course of the disease than in less affected patients. Important amelioration of bladder dysfunction was achieved in both groups.

Conclusion: Endovascular procedures of extracranial venous anomalies demonstrated an encouraging effect in patients with relapsing-remitting and progressive course of the disease. It seems that the removal of vein obstructions improves many non-motor symptoms which importantly contribute to the quality of life in MS patients.

Keywords: Chronic cerebrospinal venous insufficiency; Percutaneous transluminal angioplasty; Clinical disability; Fatigue; Cognitive function; Micturition disturbance


Chronic cerebrospinal venous insufficiency (CCSVI) is a new paradigm which provides at present still controversial insight into the vascular role of multiple sclerosis (MS). By contrast, numerous studies are endeavoring to elucidate the role of CCSVI and its influence on the course of MS [1-5]. CCSVI is a syndrome characterized by stenoses or obstructions of the internal jugular (IJV) and/or azygous (AZ) veins. Venous narrowings are related to intraluminal defects such as webs, fixed valve leaflet, membrane, inverted valve position or congenital segmental hypoplasia [6,7]. The relationship between global hypoperfusion of the brain and deficient blood drainage due to venous anomalies in MS patients is discussed [8]. Due to venous occlusions, the amount of toxic radicals in the central nervous system (CNS) accumulates and enhances the process of inflammation.

MS is a chronic inflammatory progressive immune-mediated demyelinating disease of CNS characterized by inflammation, demyelination, diffuse axonal damage and neuronal loss. The cause and pathogenesis of MS are still unknown. Most of the patients have a relapsing-remitting (RR) course of the disease. About 15% of patients start with a primary progressive form of the disease (PP). After 10-15 years, a large proportion of RR patients develop a secondary progressive (SP) course of the disease [9]. An interaction between genetic and environmental factors is considered as a determinant of susceptibility, whereas immune mechanisms are implicated as the effector of inflammatory demyelination and neurodegeneration. Hypothesis that MS has an autoimmune pathogenesis is based on inflammatory changes, intrathecal immunoglobulin production, and T-cell - mediated immunopathology and autoimmune-initiated demyelination [10-12]. The variable clinical course and heterogeneity of active demyelinating lesions support the view that MS is not a single entity [9,10]. The most common of four immunohistopathological - pattern II demyelination in MS lesion suggests antibody-dependent and complement-dependent pathogenicity [10]. The absence of a MS specific biomarker makes therapeutic trial difficult. The target antigen of MS remains still elusive [13]. Although the role of vascular impact on the course of MS is denied by many authors [14-16], there are several studies reporting a marked symptomatic improvement after endovascular procedures [17-19].

The purpose of the study was to evaluate the effect of percutaneous transluminal angioplasty (PTA) on the clinical disability and quality of life (QoL) in MS patients 1year after the procedure.

Materials and Methods

MS patients included in our study trial were diagnosed by revised McDonald criteria [20]. The disability was assessed by the Expanded Disability Status Scale - EDSS [21]. Disability between 1.0 and 3.0 is considered as mild, 3.0 to 6.0 as moderate and more than 6.0 as severe requiring intermittent/unilateral constant assistance to walk ~ 100m. The condition for performing a catheter venography (CV) was the fulfilling of two or more of 5 proposed criteria obtained by Doppler sonography required for CCSVI [1,2,22]. Informed consent was obtained from the participating subjects and the study was approved by the National Medical Ethics Committee.

All patients recruited in the study underwent PTA. Before CV, the MS patients received low-molecular-weight heparin subcutaneously (Heparin 5000 IE). Coronary catheter was introduced into the right femoral vein under local anaesthesia and mild sedation. The catheter was first placed into the AZV and positioned at the junction with the hemiazygous vein. After examination of the AZV and lumbar veins, the catheter was placed into the right and then into the left IJV. The exact procedure of CV has been described in our previous article [19]. A luminal diameter reduction of 50% is used as a threshold for angioplasty.

Fatigue was assessed by the Fatigue Severity Scale (FSS). FSS is a unidimensional scale [23], has a physical impact and consists of 9 items on a seven-point scale (range 1-7) and is scored by computing the average ratings [24]. A lower score indicates less fatigue. Three items are related to physical status, three items to the psychosocial environment and three are more generic [25]. The FSS was scored on the day preceding vascular procedure, and at 3, 6 and 12 months after angioplasty. An FSS score ≤4 was considered as status of "non-fatigue", scores between 4.1 and 4.9 as "doubtful fatigue" and scores ≥5 as status of fatigue [26,27].

At the same time as the FSS, an assessment of Modified Fatigue Impact Scale (MFIS) was performed, as recommended by the Multiple Sclerosis Council for Clinical Practice Guidelines [28]. It consists of 21 items assessing impact on: physical status (nine items, pMFIS); cognitive status (ten items, cMFIS); and psychosocial functional status (two items, psMFIS). Finally, the total- global score is calculated (gMFIS). The maximal score is 84 [29]. MS patients with depression and major illnesses which can influence fatigue were excluded.

QoL was evaluated by a simple Visual Analogue Scale (VAS) by pointing the filling on a vertical 100 mm scale (range 0-100). The patient is asked to label on the line the point that best indicates her/ his feeling. A higher score is compatible with better life performance. Additionally, QoL was assessed by Multiple Sclerosis Impact Scale 29 - MSIS-29 scale [30]. The MSIS-29 contains 29 items on 2 subscales: physical impact (PHY, 20 items) and psychological impact (PSY, 9 items).

The bladder dysfunction was assessed by Overactive Bladder Self-Administered Questionnaire (OAB-V8). The 8-item validated questionnaire (Pfizer) reflects micturition function (Table 1). How bothered the patients are by bladder problems is calculated on a 6-point scale ranging from 0 (not at all) to 5 (a very great deal). Patients add 2 points if they are male.