Mid-term sustained relief from headaches after balloon angioplasty of the internal jugular veins in patients with multiple sclerosis

Abstract

ObjectivesMultiple sclerosis (MS) patients frequently suffer from headaches and fatigue, and many reports have linked headaches with intracranial and/or extracranial venous obstruction. We therefore designed a study involving MS patients diagnosed with obstructive disease of internal jugular veins (IJVs), with the aim of evaluating the impact of percutaneous transluminal angioplasty (PTA) on headache and fatigue indicators.Methods286 MS patients (175 relapsing remitting (RR), 75 secondary progressive (SP), and 36 primary progressive (PP)), diagnosed with obstructive disease of IJVs, underwent PTA of IJVs during the period 2011–2015. This included 113 headache positive patients (82 RR, 22 SP, and 9 PP) and 277 fatigue positive patients (167 RR, 74 SP, and 36 PP). Migraine Disability Assessment (MIDAS), and the Fatigue Severity Scale (FSS) were evaluated: before PTA; 3-months after PTA; and at final follow-up in 2017. Patients were evaluated with Doppler sonography of the IJVs at 1, 6 and 12 months after PTA and yearly thereafter. Non-parametric statistical analysis was performed using a combination of the Friedman test and Spearman correlation analysis.ResultsWith the exception of the PP patients there were significant reductions (all p < 0.001) in the MIDAS and FSS scores in the 3-month following PTA. The improvement in MIDAS score following PTA was maintained throughout the follow-up period in both the RR (p < 0.001; mean of 3.55 years) and SP (p = 0.002; mean of 3.52 years) MS cohorts. With FSS, significant improvement was only observed at 2017 follow-up in the RR patients (p < 0.001; mean of 3.37 years). In the headache-positive patients, post-PTA MIDAS score was significantly negatively correlated with the change in the blood flow score in the left (r = -0.238, p = 0.031) and right (r = -0.250, p = 0.023) IJVs in the RR patients and left IJV (r = -0.727, p = 0.026) in the PP patients. In the fatigue-positive cohort, post-PTA FSS score was also significantly negatively correlated with the change in blood flow in the right IJV in the PP patients (r = -0.423, p = 0.010). In addition, the pre and post-PTA FSS scores were significantly positively correlated in the fatigue-positive RR (r = 0.249, p = 0.001) and SP patients (r = 0.272, p = 0.019).ConclusionsThe intervention of PTA was associated with a large and sustained (>3 years) reduction in MIDAS score in both RR and SP MS patients. While a similar initial post-PTA reduction in FSS score was also observed, this was not maintained in the SP and PP patients, although it remained significant at follow-up (>3 years) in the RR MS patients. This suggests that venoplasty might be a useful intervention for treating patients with persistent headaches and selected concomitant obstructive disease of the IJVs.

Chronic cerebrospinal venous insufficiency theory after the Brave Dreams study

“…This year the results of another study were published, which are contradictory to the previous ones. In this study the authors demonstrated improvement after endovascular angioplasty of IJVs in MS patients in terms of relief from headaches and chronic fatigue accompanying MS [24]. Similarly to the Brave Dreams study, this improvement occurred only in a subgroup of patients.…”

Percutaneous Venous Angioplasty in Patients with Multiple Sclerosis and Chronic Cerebrospinal Venous Insufficiency: A Randomized Wait List Control Study

“…Defined negative aspects include inadequate disability improvement 8 . vPTA might be a useful intervention for treating patients with persistent headaches 10 . These changes cannot be detected with the commonly used EDSS score system for disability.…”

“…Only a few randomized sham-controlled intervention studies have been published [7][8] . Furthermore, improvement has been reported relating to subjective symptoms such as headache, fatigue and depression, which could not be detected with the commonly used expanded disability status scale (EDSS) [9][10][11][12] . Following the resolution issued by the Italian Superior Health Council in February 2011 and spurred by public opinion, the Directorate of tertiary referral center activated a care pathway aimed at clarifying the clinical effectiveness of venous Percutaneous Transluminal Angioplasty (vPTA) in patients with MS and CCSVI.…”

An overview of randomized controlled trials on endovascular treatment for chronic cerebrospinal venous insufficiency in multiple sclerosis patients

“…Therefore, it was hoped that venous angioplasty for abnormal extracranial veins will be a much awaited and efficient treatment for MS. Yet, although open-label studies demonstrated clinical improvements [7][8][9][10][11][12], a majority of randomized clinical trials with sham arms did not reveal efficacy of endovascular repair of such pathological veins. However, a detailed analysis of these trials suggests that they were poorly designed, underpowered and endovascular techniques used were often far from being optimal [13].…”