„Chronische zerebrospinale venöse Insuffizienz” bei Multipler Sklerose – Ist die Multiple Sklerose eine Erkrankung des zerebrospinalen venösen Abflusssystems?

Zusammenfassung

Das pathogenetische Konzept der Multiplen Sklerose (MS) beruht auf einer multifaktorellen autoimmunen Entzündungsreaktion. Seit Kurzem wird vor allem durch die Arbeitsgruppe um Paolo Zamboni postuliert, dass eine chronische Behinderung des venösen Blutflusses aus dem zentralen Nervensystem (ZNS) die wesentliche Ursache der MS sei. Dies hat den Begriff der „chronischen zerebrospinalen venösen Insuffizienz” (chronic cerebrospinal venous insufficiency, CCSVI) bei MS geprägt. Das Konzept der „CCSVI” basiert auf duplexsonografischen Untersuchungen, die zeigten, dass eine Behinderung des venösen Blutflusses mit pathologischem Reflux nahezu ausschließlich bei MS-Patienten und nicht bei gesunden Personen vorhanden ist. Das diesen Befunden zugrunde liegende pathophysiologische Konzept beinhaltet, dass eine chronische Behinderung des Abflusses mit konsekutiver Druckerhöhung im venösen System sekundär zu einer pathologischen Eisenablagerung im ZNS führt, welches in der Folge eine chronische Entzündungsreaktion sowie neurodegenerative Prozesse induziert bzw. unterhält. Diese Theorie des „CCSVI” bei MS hat sehr schnell eine große Aufmerksamkeit der Medien sowie Patienten aber auch in neurowissenschaftlichen Kreisen auf sich gezogen. Insbesondere mögliche therapeutische Konsequenzen mit einem transvenösen interventionellen Behandlungsansatz werden gegenwärtig diskutiert. Ergebnisse neuerer Studien, welche auch andere bildgebende Methoden berücksichtigen, stellen jedoch das „CCSVI-Konzept” substanziell infrage. In dieser Übersichtsarbeit wird das Konzept der „CCSVI” bei der MS methodenkritisch analysiert und im Kontext der MS-Pathophysiologie sowie der aktuellen Literatur diskutiert. Zusammenfassend ergibt sich derzeit auf der Grundlage der aktuell verfügbaren Daten keine Indikation zu einer interventionellen Behandlung vermeintlicher venöser Anomalien.

Abstract

Chronic impaired venous outflow from the central nervous system has recently been claimed to be associated with multiple sclerosis (MS) pathology. This resulted in the term chronic cerebrospinal venous insufficiency (CCSVI) in MS. The concept of CCSVI is based on sonography studies showing that impaired venous outflow leading to pathological reflux is almost exclusively present in MS patients but not in healthy controls. Based on these findings, a new pathophysiological concept has been introduced suggesting that chronic venous outflow obstruction and venous reflux in the CNS result in pathological iron depositions leading to inflammation and neurodegeneration. The theory of CCSVI in MS has rapidly generated tremendous interest in the media and among patients and the scientific community. In particular, the potential shift in treatment concepts possibly leading to an interventional treatment approach including balloon angioplasty and venous stent placement is currently being debated. However, results from recent studies involving several imaging modalities have raised substantial concerns regarding the CCSVI concept in MS. In this review article, we explain the concept of CCSVI in MS and discuss this hypothesis in the context of MS pathophysiology and imaging studies which have tried to reproduce or refute this theory. In addition, we draw some major conclusions focusing in particular on the crucial question as to whether interventional treatment options are expedient. In conclusion, the present conclusive data confuting the theory of CCSVI in MS should lead to reluctance with respect to the interventional treatment of possible venous anomalies in MS patients.

brain - CNS - head/neck - ultrasound color Doppler - MR imaging - inflammation

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