What Liberation Treatment is all about?

This is a whole new approach for treating the patients with Multiple Sclerosis. In recent days it has become a new hope for millions of Multiple Sclerosis patients across the world. Dr Paolo Zamboni, a former vascular surgeon and professor at the University of Ferrara in northern Italy developed this procedure while he was trying to understand the underlying causes for the condition which his wife was into a, Multiple Sclerosis (MS).

What is Multiple Sclerosis (MS)?

First diagnosed in the year 1849, Multiple sclerosis (MS) is a nervous system disease that affects brain and the spinal cord. It is also known as disseminated sclerosis or encephalomyelitis disseminata. The disease affects an estimated 2.5 million people around the world, causing physical and mental disabilities that can gradually destroy a patient's quality of life. It damages the myelin sheath, the material that surrounds and protects your nerve cells. This damage slows down or blocks messages between your brain and your body, leading to the symptoms of MS like visual disturbances, muscle weakness, trouble with coordination and balance, sensations such as numbness, prickling, thinking and memory problems etc. Multiple sclerosis affects women more than men.

It often begins between the ages of 20 and 40. Usually, the disease is mild, but some people lose the ability to write, speak or walk. MS is five times more prevalent in temperate climates-such as those found in the northern United States, Canada, and Europe-than in tropical regions.

What is CSSVI all about?

CCSVI stands for Chronic cerebrospinal venous insufficiency is a chronic problem where blood from the brain and spine has trouble getting back to the heart. It’s caused by stenosis (a narrowing) in the veins that drain the spine and brain. Blood takes longer to get back to the heart, and it can reflux back into the brain and spine or cause edema and leakage of red blood cells and fluids into the delicate tissue of the brain and spine. Blood that stays in the brain for too long creates “slowed perfusion” and a delay in deoxygenated blood leaving the head. This can cause a lack of oxygen (hypoxia) in the brain.

1. Relation between CCSVI and MS : -

Dr Zamboni’s finding:
It all started with the Dr Paolo Zamboni’s search to find out the root cause of debilitating condition of his wife who was suffering with Multiple Sclerosis. After studying many patients suffering from the same condition, he found that that almost all of them had a abnormal narrowing, twisting or outright blockage of the veins that are supposed to flush blood from the brain. Further Dr Paolo Zamboni found that whichever patient had this condition, had a high level of deposition of Iron in the veins. Lack of free flow of the blood to the brain possibly explains the symptoms of MS.

2. The Liberation Procedure : -

Dr Zamboni’s Invention Now the idea was to open up such blocks and allow the free flow of blood through veins to brain. This is the reason why this procedure is called as Liberation Procedure or Liberation Treatment. This is done in the similar way as it is done in Coronary Balloon procedure. The patient may have single blockage or multiple blockages. Accordingly the treatment is decided.

3. How is this connected to Multiple Sclerosis?

Reflux flow mapping in the cerebral venous system found in CCSVI-MS. Map of venous reflux flow in MS and in healthy controls. In the diagram, areas investigated by means of high resolutions vascular ultrasounds. Legends: Yellow arrows normal flow direction, red arrows reflux flow; SSS (superior sagittal sinus), CS (confluence sinus), TS (transverse sinus), SS (straight sinus), DCVs (deep cerebral veins including Galen vein (GV), internal cerebral veins (ICVs), Rosenthal vein (RV)), IPS (inferior petrous sinus), IJVs (internal jugular veins). A Area: reflux rate in the extracranial main pathways, IJVs and azygous vein; B Area: reflux rate in the TS; C Area: reflux rate in the DCVs; D Area: reflux rate in the veins connecting the subcortical gray matter with the DCVs.

4. Collateral Circulation of intracranial &extracranial veins

Main collateral circles activated in the course of CCSVI-MS. Substitute circles frequently activated in the course of chronic obstruction of the IJVs. (A) The superior and the middle thyroid veins drain into the IJVs, whereas the inferior thyroid vein drains into the brachiocephalic trunk, permitting to bypass the obstacle. (B) The pterygoid plexus (PTER. PLEX.) is one of the preferential intra–extra cranial venous anastomoses? (C) The three condylar veins, connected, respectively, with the thyroid veins and with the vertebral plexus.

5. Venography in MS (CCVSI)

Extracranial venous stenosis associated to MS (CCSVI). Selective venography in the course of CCSVI associated to MS. Left: proximal stenosis of the left IJV (arrow) with agenesis more distally (A). Intra–extra cranial collateral circle (CC1) represented by condylar veins shunts the double block, whereas the agenesis is bypassed by extracranial collateral (CC). Right: Twisting of the descending segment of the AZ just below the arch communicating with the superior vena cava (SVC).

6. Physiology of cerebral venous return

Physiology of cerebral venous return: The blood leaves the brain by using the back propulsion of the residual arterial pressure (Vis a tergo), much more important in the cerebral veins, complemented by antegrade postural and respiratory mechanisms (Vis a fronte), which has a major function in the dural sinuses and in the jugular and azygous vein (IJV-AZ). In fact, the blood flow velocity is higher close to the chest, due to the negative thoracic pressure gradient, increased by inspiration. According to the Bernoulli law, by increasing the blood flow velocity there is a corresponding reduction of the lateral pressure resulting in a natural aspiration of the deep cerebral veins (DCVs) into the sinuses, and finally into the main outflow extracranial pathways, IJV-AZ.

7. Autoimmunitary attack to myelin

Autoimmunitary attack to myelin: The role of major cells from immune cascade those attack and damage to the myelin sheath under autoimmune modulation across cerebrospinal region, triggered by iron overload and oxidative stress (IL, interleukin; Th, T-helper cells; MMP, matrix metallo proteinase; MHC, major histocompatibility complex; TNF-, tumor necrosis factor-; IFN-, interferon-).

8. Histology of brain section in MS patient

Histology of a brain MS plaque (hematoxylin-eosin 50). The figure depicts a streak of blood (arrows) encircling the wall of a vein (V) at the center of an MS brain plaque. Heme iron triggers macrophages infiltration, demonstrated by the presence of iron-laden phagocyte (M).

It is believed that due to CCVSI, iron builds up in the brain, blocking and damaging crucial blood vessels. This causes the vessels to rupture, which allows both the iron and immune cells from the bloodstream, to cross the blood-brain barrier into the cerebro-spinal fluid. Once the immune cells have direct access to the immune system, they begin to attack the myelin sheathing of the cerebral nerves, and result in the development of Multiple Sclerosis.