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Efficacy and safety of venous angioplasty of the extracranial veins for multiple sclerosis. Brave dreams study (brain venous drainage exploited against multiple sclerosis): study protocol for a randomized controlled trial

Paolo Zamboni1*, Antonio Bertolotto2, Paolo Boldrini3, Patrizia Cenni4, Roberto D’Alessandro5, Roberto D’Amico6, Massimo Del Sette7, Roberto Galeotti8, Stefania Galimberti9, Alessandro Liberati10, Luca Massacesi11, Donato Papini10, Fabrizio Salvi12, Silvana Simi13, Andrea Stella14, Luigi Tesio15, Maria Grazia Valsecchi9, Graziella Filippini1617* and Chair of the Steering Committee

Author Affiliations

1 Vascular Diseases Center, University of Ferrara, Giovecca 203, 44100, Ferrara, Italy

2 Neurology 2nd Unit–CRESM, AOU San Luigi, Orbassano, Italy

3 Rehabilitation, Motta di Livenza Hospital, Treviso, Italy

4 Neuroradiology, Ravenna Hospital, Ravenna, Italy

5 Neurology, University of Bologna, Bologna, Italy

6 Statistics Institute, University of Modena and Reggio Emilia, Reggio Emilia, Italy

7 Neurology, La Spezia Hospital, La Spezia, Italy

8 Interventional Radiology, University of Ferrara, Ferrara, Italy

9 Center of Biostatistics for Clinical Epidemiology, University of Milano-Bicocca, Milan, Italy

10 Regional Agency for Health and Social Care, Regione Emilia Romagna, Bologna, Italy

11 Neurology, University of Firenze, Florence, Italy

12 Neurology, Bellaria Hospital, Bologna, Italy

13 International MS Cochrane Group, Milan, Italy

14 Vascular Surgery, University of Bologna, Bologna, Italy

15 Università degli Studi and the Istituto Auxologico Italiano, IRCCS, Milan, Italy

16 Unit of Neuroepidemiology, Foundation C Besta Institute of Neurology, IRCCS, Milan, Italy

17 Istituto Neurologico Besta Milano, Milan, Italy

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Trials 2012, 13:183  doi:10.1186/1745-6215-13-183

Published: 3 October 2012



Multiple sclerosis (MS) is a chronic inflammatory demyelinating disease of the central nervous system with a disabling progressive course. Chronic cerebrospinal venous insufficiency (CCSVI) has recently been described as a vascular condition characterized by restricted venous outflow from the brain, mainly due to blockages of the internal jugular and azygos veins. Despite a wide variability among studies, it has been found to be associated with MS. Data from a few small case series suggest possible improvement of the clinical course and quality of life by performing percutaneous balloon angioplasty (PTA) of the stenotic veins.

Study design and methods

This is a multicenter, randomized, parallel group, blinded, sham-controlled trial to assess the efficacy and safety of PTA. Participants with relapsing remitting MS or secondary progressive MS and a sonographic diagnosis of CCSVI will be enrolled after providing their informed consent. Each participant will be centrally randomized to receive catheter venography and PTA or catheter venography and sham PTA. Two primary end points with respect to efficacy at 12 months are (1) a combined end point obtained through the integration of five functional indicators, walking, balance, manual dexterity, bladder control, and visual acuity, objectively measured by instruments; and (2) number of new brain lesions measured by T2-weighted MRI sequences. Secondary end points include annual relapse rate, change in Expanded Disability Status Scale score, proportion of patients with zero, one or two, or more than two relapses; fatigue; anxiety and depression; general cognitive state; memory/attention/calculus; impact of bladder incontinence; and adverse events. Six hundred seventy-nine patients will be recruited. The follow-up is scheduled at 12 months. Patients, treating neurologists, trained outcome assessors, and the statistician in charge of data analysis will be masked to the assigned treatment.


The study will provide an answer regarding the efficacy of PTA on patients’ functional disability in balance, motor, sensory, visual and bladder function, cognitive status, and emotional status, which are meaningful clinical outcomes, beyond investigating the effects on inflammation. In fact, an important part of patients’ expectations, sustained and amplified by anecdotal data, has to do precisely with these functional aspects.

Trial registration NCT01371760

Multiple sclerosis; Chronic cerebrospinal venous insufficiency; Percutaneous transluminal angioplasty; Functional disability