REPORT FROM THE 26TH CONGRESS OF THE EUROPEAN COMMITTEE FOR TREATMENT AND RESEARCH IN MS (ECTRIMS), GOTHENBURG, SWEDEN, OCTOBER 13-16, 2010 - “We should not be using any interventions to treat CCSVI (chronic cerebrospinal venous insufficiency) until we can demonstrate that it has a pathological role,” stated Dr. Giancarlo Comi, Milan, Italy, at a special symposium organized by the European Charcot Foundation. “CCSVI is not a cause of MS,” he said, “and what is the evidence that it influences the MS disease process?”

“Surgery is not recommended at this stage” Dr. Paulo Zamboni, Ferrara, Italy, said during his presentation. However, he did not endorse the call to end endovascular surgery altogether, stating that it was justified if performed in the context of a clinical trial. Indeed, Zamboni and colleagues have already reported results from a phase I study (Zamboni et al. J Vasc Surg 2009; 1348-1358), and the Endovascular Treatment (EVT) pilot study (Zamboni et al. ECTRIMS 2010; abstract P508). The Prospective Randomized Endovascular Treatment in MS (PREMISE) trial plans to further investigate the clinical effects of surgical intervention.

Prof. Zamboni did not support the “medical tourism” that has seen patients travel to eastern Europe or India for CCSVI surgery, and has criticized the use of stenting, which has been associated with fatal complications.

The Charcot symposium brought together proponents and critics of CCSVI. Dr. Robert Zivadinov, Buffalo, stated that Doppler ultrasonography is more reliable than other techniques (e.g. MR venography. Lopez-Soriano et al. ECTRIMS 2010; abstract P773). This was the method used to assess patients in the Combined Transcranial and Extracranial Venous Doppler Evaluation (CTEVD) study. According to the most recent results from the first 499 consecutive subjects, CCSVI was found in 56-62% of MS patients compared to 44-46% of patients with other neurological disorders and 22-25% of healthy controls. In a new analysis presented at ECTRIMS, there was no significant difference between subjects with and without CCSVI with respect to number or volume of T1 lesions; T2 lesion number and volume were greater in subjects with CCSVI (Zivadinov et al. ECTRIMS 2010; abstract P318). Zivadinov et al. also reported increased iron concentrations, as assessed by susceptibility-weighted imaging (SWI), in deep-grey matter (DGM) with an associated decrease in DGM volumes in MS patients versus healthy controls (ECTRIMS 2010; abstract P772), as well as a correlation between iron concentrations and CCSVI (ECTRIMS 2010; abstract P774).

Other speakers at the Charcot symposium noted that the Zamboni criteria for CCSVI (Zamboni et al. J Neurol Neurosurg Psychiatry 2009; 80: 392-399; free full text at www.ncbi.nlm.nih.gov/pmc/articles/PMC2647682/?tool=pubmed) have not been independently validated. “If CCSVI exists,” said Dr. Omar Khan, Detroit, “is it pathological or simply an anatomical variant?” He added that methods of quantifying iron concentrations have produced highly inconsistent results.