CCSVI Database Program Application

Thank you for your interest in our research projects which are designed to explore the link between MS and chronic cerebrospinal venous insufficiency (CCSVI). CCSVI is an ongoing problem when blood from the brain has difficulty flowing properly to the heart due to blockages or stenoses (narrowing of the veins).

 

You have an opportunity to self refer to our center for testing of CCSVI. The testing is presented as a complete regimen which includes:

 

MRI of the brain and neck: This MRI is designed to collected special pictures of your brain and neck. The MRI will last 60-90 minutes.

 

Doppler ultrasound: A non-invasive test that uses reflected sound waves to evaluate blood as it flows through a blood vessel. It helps doctors evaluate blood flow through the major arteries and veins of the arms, legs, neck and more recently with the new instruments also the flow trough the brain. It can show blocked, reduced or reversed blood flow through the major vessels of the neck and head. This exam will last about 45 minutes.

 

Clinical visit with a neurologist: You will have a physical examination which will include blood pressure, pulse, and functioning. You will be asked questions regarding your medical history as well as what medication you currently take and have taken in the past. There will also be questions about your MS diagnosis, symptoms, and relapse issues.  The tests will evaluate disability associated with MS, leg, arm and cognitive function, and fatigue. The visit will last approximately 60 minutes.

 

Neuropsychological evaluation: You will complete a group of tests which are designed to assess memory, cognitive functioning, hearing, verbal learning, motor function and mood. This testing takes about 2 hours.

 

Blood sample: You will be asked to contribute 2 tablespoons of blood for evaluation of specific genetic factors related to higher MS disease susceptibility and severity.


Optical Coherence Tomography: The OCT test measures the retinal nerve fiber layer thickness and macula.  This test provides us detailed information about the health of your retina.  The test will take approximately 15 minutes.



At this time, there isn’t any health insurance reimbursement for any testing component. The total cost of testing and reports is $4500.00. We kindly ask that 50% of this is paid prior to scheduling.

 

Research evaluating CCSVI and MS is not complete and is, in fact, only in its initial stage.  By signing up for testing, you will also agree to allow our team to use your test results to create a large patient database which will allow us to carefully evaluate the value of these procedures, according to the approved IRB protocol, in further understanding MS and any possible treatment that could follow.

 

You understand that you are voluntarily agreeing to undergo the tests. Any information you gain from these tests is purely informational and educational and will not be able to be used by you or any other person to diagnose, cure, treat, mitigate, or prevent your MS.

Once the team evaluates the information you provided in the below application, you will be contacted to:

a) complete the screening and safety evaluation process

b) discuss schedule of procedures and payments

c) receive, review and sign consent agreements for testing, payment, results  interpretations and use of your data for research purposes

d) organize your testing schedule

 

PLEASE SUBMIT ONLY ONE application per person. Any incomplete or duplicate applications will only delay the application process. This information is required for all applicants. Thank you for taking the time to complete this application.



1) Please tell us how you learned about this study











2) Personal Information:
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Format: YYYY-MM-DD
("M" for Male, "F" for Female)
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3) Contact Information:

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4) Do you have a primary care physician?




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