Does the evidence support angioplasty for CCSVI as an effective treatment for MS?
Response from Randall T. Schapiro, MD
Clinical Professor of Neurology, University of Minnesota, Minneapolis, Minnesota
If we are to believe the press reports of yesteryear and the blogs of today, we have cured multiple sclerosis (MS) hundreds of times. Surprisingly, MS is still here. In the 1970s, the cure was pregnant cow's milk (colostrum); in the 1980s, it was cobra venom and hyperbaric oxygen, and then mercury amalgams, bee stings, vertebral stenosis with surgery, goat serum, and all sorts of vitamins. Some of these treatments had no science behind them, but many were backed by "pseudo" science. That is, assorted facts that could be put together to tell a story. Unfortunately, the story was fiction.
As long as no clear, concise answer to MS is found, interesting but phony hypotheses will continue to be brought forth. Although we do not know the answer to MS, we do know a lot about it:
- MS is a disease that occurs mainly in women and predominantly white women.
- MS is a disease of the central nervous system (brain and spinal cord).
- MS is a disease of young adults living away from the equator.
- MS is a disease that involves the immune system and that can be modulated by immune system modifiers.
- MS is a disease of inflammation and degeneration of myelin and axons.
- MS is a disease with some genetic characteristics.
Whatever ideas we come up with to understand and treat MS must take into account each of these factors.
The correction of chronic cerebrospinal venous insufficiency (CCSVI) to cure MS is the brain child of a vascular surgeon whose wife happens to have MS. It was apparently serendipity that led to his discovery that the large veins that drain her head and neck had what appeared to be stenotic areas. Of note, he noted these changes in a substantial series of other patients with MS but not in those without MS.
 Other studies appeared to confirm that stenosis of these veins is common in MS but also in people who do not have MS.
 When surgery is performed and stents are placed, the results do mimic bee stings, colostrum, and other treatments that have no basis in fact but have significant placebo effects.
Does venous stenosis occur more often in young adult women of northern descent? Could this lead to immune system dysfunction that involves myelin and axons and little else? Do white patients have more venous abnormalities? Although we do not necessarily know the answer to all these questions, it would appear to defy logic and reason to think these possibilities are reasonable. Furthermore, the venous drainage of the spinal cord is very different from the brain, and yet we see disease there, as well.
In situations where these veins are tied off or damaged for various reasons (including cancer surgery and radiation), no undue problems have resulted. Although the circle of Willis is similar in all individuals, venous drainage is often different. Veins are low pressure but can maintain significant changes in pressure without structural damage to the brain. When damaged, they often regrow and reroute.
We live in an era of evidence-based medicine, but the evidence should make some sense and not be randomly pulled together. The political answer to the question, "Is correction of CCSVI a viable therapy for MS?" is "We do not know, so we should spend hundreds of thousands of dollars to find out." I think that is malarkey. Before a dollar more is spent, let us see a randomized, controlled study with sham surgery and surgeons who perform the procedure and then do not influence the patient after that. This is what we need, not organizations that promote reckless procedures -- albeit in good faith -- almost like a religion.