Sunday, February 9, 2014

ISNVD FEB 9,2014

ISNVD Feb 9,2014
Day 2
Nitric Oxide and Vascular Hypothesis in MS
Dr Yulin Ge
Diffuse Inflammatory activities
inhibit mitochondria aerobic respiration and neurovascular coupling tiring out leas to decrease of oxygen consumption
leading to hypoxia
 leading to hypo-perfusion  an d to neuronal/axonal dysfunction and neurodegeneration

apoptotic cell death of oligodendrocytes at later stages of lesion development
measuring NO effects using MRI
effects on oxygen metabolism
effects on oxygen delivery
Facts of oxygen metabolism in brain
brain uses 20% of total oxygen
oxygen delivery..
oxygen consumption in MS is decreased
oxygen metabolic abnormalities in MS measured with TRUST MRI
why is there is less oxygen consumption in MS
it's not only atrophy but it's because of the mitochondria has high levels of NO
CO2 like NO is a  potent vasodilator and can cause increase of CBF
compared to controls MS showed significantly decreased CVR
The CVR defect inMS...impaired vasculaar regulation of blood flow supply or defective neurocoupling mechanism may affect effective oxygen delivery
decreased CMRO2 in MS and decreased CVR inMS
recent accumulating evidence of mitochondrial of/NO hypotheses in neuronal axonal tissure damage
both O2 delivery and O2 uptake impairment can lead to chronic hypoxic condition
NO is not the only mechanism that is responsible to neurodegeneration
the increase in NO may be from the endothelium or microglia( as a result of infection) but either is due to inflammation

Perfusion imaging in stroke
Its current clinical status and its role in treating patients
Dr Larry Latour

there is insufficient evidence to support or refute the value of PWI in diagnosing acute ischemic stroke
what is a mini stroke and being treated with tPA?
15 minutes makes a difference in the treatment of an acute ischemic stroke. It is safe to reat even if it's a mimic of a the treatment can prevent a stroke

Hemodynamic impairment in MS...Imaging techniques and perspectives
Yulin Ge
vascular hypotheses has been around for numerous years
pathology in MS...vascular
perivascular inflammation...Dawson's lesions start around abnormal vessels
first imaging sign of lesion formation
 BBB breakdown and increased permeability
with effective anti inflammatory drugs
first sign is prominent perivenular space using 7T MRI
perfusion MRI
detect abnormality before lesion
increased perfusion in NAWN just before lesion formation
venous dilation in initial inflammatory stage... priminet venules companied with increased perfusion
enhancing lesion with increased perfuion
new or recurred lesion activity that are not seen on conventional MRI
the is hemodynamic impairment in MS
fibrin deposition, small venous thrombosis, intimal hyperplasia
there are lesions with different type of perfusion patterns
significantly reduction of perfusion in deep GM in MS
vascular component is critical in neurological disease
MS patients with cardiovascular problems have increased MS problems

SPECT and PECT perfusion changes after CCSVI restoration
Paolo Zamboni

diffuse hypo-perfusion in MS is a FACT. It cant be explained with autoimmunity but CCSVI is a valuable hypothesis
hypo-perfusion precedes plaque formation approx 2 weeks earlier
chronic plaques were more prevalent in WM regions with lower relative perfusion.  can ccsvi be a strong contributor to hypoperfusion. may outflow restoration restore brain perfusion
the data support a role of ccsvi in cerebral hemodynamic changes, such as a decreases of CBV and CBF regardless of diagnosis of MS
theres is a relationship between brain perfusion and jugular flow
flow reduction in and significant flow increase in collaterals
the collateral veins drain blood respect to ED inflow to the head
are the collateral veins filled by premature intra extra cranial anastomosis?
hypo-perfusion may be consequence of  blood shunting through meningeal arteries
pilot study with 5 ccsvi cases...not only MS
used PET scan.
3 patients who improved with venoplasty of them had Huntington disease had improvement of perfusion
pilot study 2 using SPECT using open angioplasty
8 ccsvi cases
vast majority of patients improved flow
PET and spect both reliably detect change in perfusion in ccsvi
spect demonstrate hypoperfusion in ccsvi
the procedure seems to cause significant improvement

The rest of the morning session was devoted to traumatic brain injury:

Abstract...cerebral hemodynamic changes in mild traumatic brain injury at the acute stage

Abstract...altered IJV hemodynamics and impaired cerebral auto-regulation in patients with panic disorder
PD patients have decreased IJV lumen

Traumatic brain injury and vascular consequences
state of the art understanding the fundamental physiology of TBI...from research to treatment

Dr Ramon Diaz Arrastia
single most common cause of death and permanent disability in young people under 45
10%-15% of pts with TBI have micro blood vessel injuries
there is also diffuse meningeal injury
 chronic mild tB of retired professional boxers
cerebral blood flow is normal but the reactivity of the blood vessels is impaired
Sildenafil,erythropoietin, statins, G-CSF, VEGF, pioglitazone, exercise , enriched endothelia progenitor cells, from cord blood or bone marrow, low level laser light therapy, Infrared can penetrate the skull.
It has anti inflammatory properties and promotes angiogenesis and releases NO
people who have had TBI in early life have an increased risk of dementia in later life.

Typical vascular lesions of TBI and their evolution
Dr Gunjan Parikh
brain micro vascular tree
the first thing hit is the dura and cortex
prospective study of acute TBI in the ED with blood on clinical CT or on MR
256 subjects had indications of hemorrhage
all were considered mild TBI

The clinical spectrum and natural history of TBI Sequelae
Dr Karen Tung

role of perfusion and SWI in TBI
how TBI and how it relates to the micro vasculature of the brain
neurovascular unit NVU
TBI damages the vessel wall or causes impaired perfusion and cause tissue ischemia
BBB dysfunction results in edema and may affect protein clearance and accelerate brain aging or disease pathology

State of the Art...the role of imaging and venous abnormalities in TBI
Dr Zhifeng Kou

Abstract...Hemorrhagic lesions based on venous and arterial damage and its clinical correlation in Traumatic Brain Injury
Hardik Doshi

Abstract...Thalamic Shape and Cognitive performance in amnesic mild cognitive impairment
Hyun-kook Lim

It is my understanding that the ISNVD will provide summaries of each of the presentations in a few weeks.

Saturday, February 8, 2014

ISNVD Feb 8,2014

ISNVD Feb 8, 2014
Session I. A multi-Modality Approach to Extra Cranial Venous Disease
Dr Zivadinov session chairperson
1. The Current Status of Ultra sound Imaging for the Screening of CCSVI...Dr Marcello Mancini...Univ. Naples
ccsvi can be non invasively diagnosed by combined transcranial and extracranial echo doppler
CCSVI more frequent in MS than in normal controls
Italian study 1800 subjects
the assessment of CCSVI was highly operator dependent... the echo color doppler is an ideal tool for assessing cerebral venous return

What is the Normal Jugular Vein Valve Function?....Dr Erica Menegatti
using echo doppler they were able to see the motility of the IJV valve leaflets in healthy volunteers
findings 50% showed absent valve on 1 side
in healthy subjects in IJV leaflets are always mobile and open in up right position
62% of HC with valve absence at least of one side suggests a progressive loss of motility.

Prevalence of Extracranial Venous Narrowing on Catheter Venography in pwMS
Dr.Lindsay Machan
CCSVI more prevalent in pwMS?
BC Saskatchewan study...published in Lancet
evaluate the frequency of venous stenosis in pwMS vs controls, and siblings of MS patients.
ultrasound trained in Ferrara and used the Zamboni criteria
the subjects were blinded
the venography protocol was developed with Gary Siskin, MD and an SIR discussion group
standardized upright and supine venography measures
no significant differences in each group but MS patients felt moderately better.
Dr Zamboni challenged this study!!!!

Identifying CCSVI with Cervical Plethysmography
Paolo Zamboni
measured in normal controls
hydrostatic gradient in cerebral venous outflow
upright there is negative hydrostatic pressure
zero hydrostatic pressure in supine
posture shows restricted venous outflow in ccsvi vs normal when the system is stressed through change in position
the system fills up quicker because the outlet pathways are restricted in CCSVI

Diagnostic Contributions of Catheter Venography for Screening of CCSVI
Dr Hector Ferral
limitations of catheter venography is radiation exposure contrast media and may miss subtle issues.
review the Venographic protocols of CCSVI
reviewed 8 papers.
R femoral vein is the easiest access
power injection most popular
Delayed emptying is an important criteria...greater than 6 sec is severe
patients with severe stenosis had emptying between 6 and 27 sec
r femoral vein( Dr Zamboni said in PPMS the L entrance is better)
catheter straight multi-perforated
contrast depends on IVUS availability
injection...Power injector
position of pt is supine
multimodal approach is important

What Additional information Can Intravascular ultrasound Provide?
Adnan Siddiqui
looked at azygos and IJV
blinded evaluations
IVUS  is the best evaluation tool and was compared to catheter venography

Molecular Markers of Abnormal CNS Hemodynamics
Dr. Steven Alexander PhD
endothelial cells are important they create the bBB
abnormal pressure patterns.. links to neurodegenerative disease.Vascular stress is related to neurodegenerative disease. intra abdominal hypertension disturbs BBB
endothelial cells under shear or stress release micro-particles can affect distant gene expression
APP is associated with neurovascular disease and is a precursor to amyloid
oscillating shear causes increased APP which is released into the brain.
altered pressure can rapidly and reversibly modulate BBB
Different shear patterns alter brain endothelial transcription factors
Some transcription factors and microRNA's between cells as a novel form of distant site epigenetic modification
APP is released by brain endothelial cells and is packaged into micro-particles
Differential transfer of APP laden micro-particles may contribute to several forms of neurovascular degeneration

State of the Art1: Why we need a multi-modality diagnostic approach for CCSVI
MR, catheter venography, ultra sound, and IVUS all have positive aspects.
PREMISE study used a multi-modality approach
ISNVD has a position statement for the screening for diagnosis of CCSVI
Two abstracts were presented:
Abstract 1: Extracranial brain draining veins in a mouse: Assessment by high resolution ultrasound and MR angiography of the neck
Brain drains from the external jugular in the mouse and in humans it is IJV's

Abstract 2:  Inverse relationship between IJV narrowing and increased brain volumes in healthy individuals
IJV narrowing has been implicated in CNS pathologies
Similarly brain volume reduction...atrophy...has also been linked to CNS pathologies
However, IJV narrowing and atrophy have never previously been linked
Assessment of the relationship between IJV CSA and atrophy in healthy individuals
the hypothesis is increased narrowing...stenosis...would correlate with increased atrophy...reduced brain volume
Secondary outcome is assessment of age effects and cervical location on these potential associations
IJV narrowing was not associated with brain atrophy...mechanism unknown
Dr Ziv Haskal Moderator
Designing an endovascular trial...What elements are essential and why CCSVI trials might differ from Disease Modifying trials
Dr Kottil W. Rammohan...Neurologist Univ. Miami(director of MS center)
what is the short term effect of the procedure
Long term a stand alone or adjunct to a disease modifying treatment (DMT)
any trial has to be blinded
no trials have been done that meets the test of Cochran Review .
Essential elements of all clinical trials.
evidence, population, intervention. comparison, outcome , time (EPICOT)
Defining CCSVI is the biggest problem
Should use ambulation as an evaluation tool
"having an open label trial is unconscionable"

State of the Art :Current results of safety and efficacy of CCSVI therapy in MS patients
Gary Siskin (Dr Dake presented)
studies have demonstrated very low adverse events with venoplasty. It is a very safe procedure
improvement in a majority of patients but not all. Patients with severe delayed flow did not do as well as those with moderately delayed flow
EDSS at one month and one year significantly improved
cutting balloons are safe for those patients who had failed venoplasties.

Procedural Endpoints.  How to Best measure Meaningful Flow Impairment, Inter and Post Procedural Therapy
Hector Ferral
 IVUS Driven Intervention..provides accurate information of vascular pathology shows, webs, valves, dissection, intramural problems.
Optimizing Pure Venographic Therapy :  there is no validated approach

Intervention Studies in 2014
The Time is Ripe for Primary and Replicative Therapy Trials in MS
Ziv Haskal
science is not linear, often not in types of therapeutics
what happened in MS and CCSVI?
the venoplasty is less dangerous than present treatment (DND's)
it's time for more research

Therapy Trials Need to Wait. The Landscape has changes
Dr Kottil W. Rammohan
Are we ready to do a randomized controlled trial? Dr Zamboni's trial was replicated by Dr Troulbasse and could not reproduce the same results in Vancouver.
Dr Hubbard and challenges Dr Rammohan and says MS has not been proven to be immune modulated.

Abstract 3...A report of 4 cases of anterior cranial fossa dural arteriovenous fistula: surgical consideration and technique using intraoperative indocyamine green angiography.
Kuhyun Yang,MD

Abstract 4...Classification of venous outflow in the extracranial vessels in a large cohort of MS patients.
Sean Sethi...with Dr Haacke's research group
4th study  showing abnormal flow in the IJV
used MRi and assessed the the IJV
MS subjects wer classified as stenotic or non stenotic
did flow quantification at c2/c3 and c5/6
61% of the MS were stenotic

CCSVI and Parkinson's
Mark Haacke
In MS patients, iron deposition occurs in both the basal ganglia and midbrain similar to what is seen in idiopathic Parkinson's Disease.
23 PD patients and 23 Normal Controls
there are abnormal structural and flow findings in PD patients.

Etiologies of jugular venous abnormalities in transient monocular blindness
Dr Chun-Yu Cheng
sudden painless transient visual loss
there is venous outflow resistance in the IJV
IJV stenosis is found in in transient monocular blindness

Age Related White Matter Changes, Alzheimer's Disease and Jugular Venous Reflux
Dr Clive Beggs
Pilot study and IJV reflux.
JVR is associated with age related white matter changes, particularly in posterior brain regions.
12 pts with AD 17 healthy controls 24 mild cognitive impairment
dirty appearing white matter is a region of intermediate signal intensity between that of T2 lesions which may develop into lesions later on.
AD patients had significantly reduction of dirty white matter, and increased lesion formation

JVR and brain atrophy
increased brain volume in grey and white matter...
venous blood pooling is a possiblity

Cerebral venous drainage impairment in idiopathic intracranial hypertension
Dr Noam Alperin
venous drainage in supine and upright postures
in the upright posture, venous drainage shifts from the jugular to secondary veins and is significantly less pulsatile

Headache and venous abnormalities
Dr Wei-Ta Chen
vein related cerebrovascular disorders with headache
cerebral venoos thrombosis
arteriovenous malformation
dural arteriovenous fistula
carotid cavernous fistula
Headache disorders with venous abnormalities
idiopathic intracranial hypertension
spontaneous intracranial hypotension
IIH is not benign...they may lose vision
treatment IIH
endovascular stenting is one tx option
spontaneous intracranial hypotension=
orthostatic headache, neck tightness, subjective hearing symptoms
evidence of CSF leakage on imaging
TX of SIH:
bed rest, hydration, epidural blood patch
unilateral, throbbing,associated symptoms are nausea, photophobia and phonophobia, duration 4-72 hrs
aura...visual, sensory, aphasia,motor
if you compress bilat IJV it can make migraine worse.
IJV volume increases during attack
decreased in IJV compliance in migraine
venous hypertension occurs during a migraine

venous abnormalities involve in high altitude associated neurological disorders
Dr Mark Wilson
what happens when you are gradually exposed to increased altitude?
can get a headache, mountain sickness or
high altitude cerebral edema
those with HA's had large  venous sinuses
being in space is not good for your eyes due to venous hypertension

Cerebral venous drainage impairment and cerebral small vessel disorders
Dr Han-Hwa Hu
CVDI linked to small artery disease
association with impaired cerebral auto-regulation
association with lacuna stroke
association with white matter diseases

There were a couple of presentations that followed but because of my "brain overload" I decided to take a break.
Will post again tomorrow!

ISNVD 2014 Keynote

ISNVD 2/14 Conference
Day I
Meeting and greeting so many remarkable people is such an inspiration. The energy in the room has been palpable. I think there will be a lot of excellent science presented at this conference if the keynote address is any indication.
I'm posting this as the notes I took at the presentation. I apologize for abbreviations, poor sentence structure etc but I wanted to share ASAP.
Keynote speaker...Dr. Paula Grammas PhD

The Role of Blood Vessels and Inflammation in the Pathogenesis of Neurological Disorders.
Texas Alzheimer's research and care Consortium...Director

brain endothelial cells
bbb function
synthetic/metabolic capabilities...brain has more vasculature than any other part of the body

the tight junctions of the bbb are very important
the brain endothelial cells are very important metabolically
endothelial cells actively regulates the neruonal micro environment
neurpathological and neuroimaging studies indicate that 1/3 AD cases are complicated by vascular problems

AD and CVD...inflammation, oxidative stress and apoE4 expression common to both AD and CVD...
endothelial cells are widely recognized as key players in development of neurologic disease
brain endothelium produces toxins in brain in AD
blood vessels in AD...?
NO can be toxic to neurons in high doses.  NO is made by endothelial cells and in small amts. is fine. in AD these cells become abnormal
AD vessels an over expression of iNOS and is usually not present in endothelial cells. this iNOS is very toxic in large amounts....caused by stress and inflammation
micro vessels in AD are inflamed
something is making the endothelial cells make inflammatory proteins
Thrombin is an inflammatory protein and is found in the AD brain in the micro vessels and CSF...inflammation in the vessels has been found in AD
vascular activation and angiogenesis have been documented in the AD brain
no new blood vessels in the AD brain...what does that mean?
vascular activation as a target for AD therapeutics
animal studies are being done now...
animals have been given a Pfizer drug (Sunitinib)  causing angiogenesis have improved the animals cognitive abilities
in vitro Sunitinib improves the function of the endothelium
possible trigger for vascular activation is hypoxia
a key mediator in both angiogenesis and hypoxia is Thrombin
 Thrombin inhibitors improve the function of the mice
"what's good for the heart is good for the brain"
While waiting for the cure of AD take care of any causes of inflammation (ie Diabetes) with diet and exercise.
Hypoxia stimulates the endothelial cells to create a host of inflammatory messengers designed to cause angiogenesis (creation of new blood vessels). So why is there hypoxia? Is the hypoxia chronic or intermittent? These are some questions that need to be answered!
Looking forward to the first full day of learning!