Pressure and Shear Stress in MS Lesions

Annotated Sagittal ATECO MR Venogram

Image by Reigh LeBlanc via Flickr

According to Schelling one of the likely causes of MS lesions is venous back jets into the brain. He proposes that one of the possible sources arises from normal cardiorespiratory waves. The other is from trauma. In either case venous blood flows backwards and into the brain.

One route of venous back jets into the brain is through the jugular veins. Schelling proposes that certain people are born with or acquire incompetent valves in the jugulars that fail to check the reverse flows. The other route is through the vertebral veins which have no valves to prevent reverse flows. In the picture above, the jugular veins are the large veins in the front of the neck. The vertebral veins are the smaller veins in the back of the neck. The large veins inside the skull are called dural sinuses.

Typically most, but not all veins have valves to check and prevent back flow. Technically speaking none of the dural sinuses have valves. The alignment of some of the cerebral veins however serves to prevent reverse flows to a limited degree, which I won’t go into here. Disregarding that little piece of not so trivial information, the large veins of the brain basically have no valves.

If you click on the image and enlarge it you will find little boxes with the names of the veins as you mouse over them. Following the veins backwards, upstream and counter current to normal flow, the jugular and vertebral veins next connect to the sigmoid sinus, the S shaped sinus directly above them. The transverse sinus is the short flat sinus that runs from the sigmoid sinus to the back of the skull. At that small circular junction at the back of the skull is another sinus that runs forty-five degrees upward and toward the middle of the brain. It’s called the straight sinus. Going straight up, beyond the junction of the transverse and straight sinus is the largest sinus of the brain that runs up to the top of the brain. It’s called the superior sagittal sinus. The superior cerebral veins attach to it. As an aside, these are the veins mentioned above that attach to the superior sagittal sinus at angles counter current to blood flow. It has been suggested that their angle of attachment may serve as a semi valve-like mechanism.

Now if you follow the straight sinus inward you will see it connects to the Great Vein of Galen, the Basal Vein of Rosenthal and the internal cerebral veins. These veins all drain the core of the brain.  More importantly, regarding this discussion they go to the periventricular areas of the brain. If you click on the picture and enlarge it once more, you will see a large shadow in the middle of the brain. The shadow you see is the lateral ventricle. The ventricles of the brain produce and are filled with cerebrospinal fluid (CSF) which is made mostly of water. CSF cushions, protects and supports the brain. If you look down by the vertebral veins you will see another shadow. That shadow is the spinal cord. Among other things it contains the subarachnoid space surrounding the cord, which is likewise filled with CSF. The subarachnoid space is part of the protective covering of the brain and cord called meninges. The ventricles, subarachnoid space and CSF pathways likewise have no valves. In contrast to being inside the cord, the vertebral veins surround the cord inside the spinal canal.

I would like to put aside cardiorespiratory waves, which I disagree with as a source of injury to the brain, and focus on trauma. In contrast to relatively mild normal cardiorespiratory waves, trauma produces massive uncontrolled forces that can reflux into the brain under significant pressure. In this regard, the vertebral veins contain a large volume of unchecked blood. The subarachnoid spaces at the lumbar cistern of the cord also contain a significant volume of unchecked CSF. Lastly, the valves of the jugular veins have physical limitations which may be easily overwhelmed by massive forces.

According to Schelling venous back jets and massive refluxes from trauma simply follow the course of the dural sinuses. It makes sense then that the lesions in MS tend to show up around the largest veins in the brain and get progressively smaller as you follow the veins upstream counter-current to flow. MS lesions also tend to show up in the periventricular areas, which, as mentioned above, drain into the straight sinus system.  The ventricles are depicted in red in the sketch to the left.

In other words venous blood back jets into the brain and stretches the largest veins of the brain that take the brunt of the crushing force, causing them to balloon out and strain nearby surrounding myelinated nerves. Researchers studying normal pressure hydrocephalus surmized many years ago that stretching from something as simple as edema alone was enough to break myelin. Basically speaking, myelin, is simply no match for the massive forces generated by whiplash and other similar severe type traumas. Trauma can generate significant pressure in the veins of the entire body never mind the brain. What’s more, pressure associated with trauma often causes rapid, acute rises in surrounding tissue pressures.

In contrast to trauma, normal inversion and Valsalva maneuvers cause reverse flows into the brain. Hanging upside down or standing on your head causes inversion flows. A Valsalva maneuver is performed by blowing real hard against maximum resistance. Pilots and scuba divers use Valsalva maneuvers to control pressure in the brain and ears respectively. The famous trumpet player “Satchmo” Louis Armstrong performed Valsalva maneuvers when he played long powerful high sustained notes. His neck and facial veins would buldge and his eyes would literally pop out. Technically speaking, he should have blown his cork before middle age if inversion flows were a problem. Instead he lived a good and long life. Additionally, Olympic style competition weight lifters do Valsalva maneuvers when they lift heavy weights. In this regard, Valsalva maneuvers are beneficial in that they help shore up, stabilize and strengthen the spine.

In light of inversion flows and Valsalva maneuvers, I decided decades ago to study bats, whales and giraffes because of the extreme inversion flows they face during head inversion and deep dives. It turned out to be a great idea. As I expected, these mammals appear to have developed compensatory mechanisms. Based on my studies, it is my opinion that giraffes use the extra large spaces inside their skull called diploe as a drip pan to catch blood that has been rerouted during head inversion. I discussed the diploe in humans and their role in brain cooling in previous posts.

This extra large rather handsome looking giraffe with the beautiful bedroom eyes and full sensous lips, also has a particularly distguished prominent bump over the paranasal bones of the nose. I believe that large giraffes use these extra special, strategically located bumps, called accessory horns, to further increase the capacity of the accessory drainage system of the diploe during head inversion. The challenge for humans is just the opposite. Humans developed compensatory mechanisms to contend with upright posture. Interestingly, the valveless veins of the skull and spine appear to play similar roles in all the mammals mentioned above. What is even more fascinating is that humans and whales use the vertebral veins to stabilize intracranial pressure (ICP) and fluid mechanics in the brain but in completely opposite ways. In brief, moderate inversion flows don’t appear to be the problem. On the other hand, acute venous back jets are an entirely different story.

Unfortunately, back jets don’t explain the full story behind the lesions you find in the cord. Again, that’s where Schelling’s theory makes the most sense. I will discuss cord lesions in MS in my next post. In contrast to massive pressure from venous back jets that stretch nearby myelin in the brain, according to Schelling the myelin in the cord simply snaps due to shear forces acting on attachment points inside the cord itself. Those shear forces are amplified by a Tsunami of CSF waves flowing backwards through the subarchnoid space of the cord.

For additional information on this and related topics visit my website at


About uprightdoctor

I am a sixty year old retired chiropractor with considerable expertise in the unique designs of the human skull, spine and circulatory system of the brain due to upright posture, and their potential role in neurodegenerative diseases of the brain and cord. I have been writing about the subject for well over two decades now. My interests are in practical issues related to upright posture and human health.
This entry was posted in ccsvi, demyelination, ms lesions, multiple sclerosis, Uncategorized. Bookmark the permalink.

9 Responses to Pressure and Shear Stress in MS Lesions

  1. Pat Lawson says:

    Hi Dr. Flanagan,

    Another terrific piece of writing! Another cause of violent venous back-jets is jugular valve ablation by venoplasty. Rici, who lives in Poland and is a member of TIMS, was the first Polish MS patient Dr. Simka performed the liberation procedure on, and his inverted valves were venoplastied — but his right jugular became widely distended which, in combination with his valve having been ablated, made him suffer debilitating violent venous back-jets which cannot happen with the left jugular vein because its route to the heart is shorter.

    Rici was in close contact with Dr. Schelling afterward, and they named Rici’s new MS type “Turbo MS” due to all the strong symptoms he was experiencing. Venous pressure and/or blood traveled through his cerebral veins and adversely affected his hypothalamus which caused a 104 degree Fahrenheit fever — he was rushed to the emergency department where his life was saved.

    Rici was able to secure the correct surgeon to perform open-neck surgery using his Saphenous vein to replace his “ruined” jugular vein and to perform a valve reconstruction, but he ran into trouble finding a country that would allow the operation. Now, many months later, it seems as if Rici will be soon giving us some new information about his case. Dr. Schelling approached Dr. Simka about his worries, but Dr. Simka is still doing valve ablations.

    Here are some links that will give you much information about this concept if you’re interested. The first link is to Rici’s original thread on TIMS which is ten pages, but it’s fast reading. The second link is to Rici’s website. The third link is to a video of Rici’s blood traveling through his right jugular (this link is on his website but is hard to find). The fourth link is of a TV interview with Dr. Schelling. The last link is to a thread on TIMS in which Rici alludes to new information coming “soon.”

    I had my inverted valves ablated thinking that since I’ve lived 50 years with the valves inverted (95% blockage in both right and left IJVs), I want to try my next 20 years with jugulars that work properly. So far, two months out, I have not noticed anything unusual, so hopefully my right jugular vein did not widely distend like Rici’s did. Why Rici did not elect to have jugular ligation, I don’t know. My thought process is that the jugular wasn’t properly draining anyway prior to venoplasty so if the worst is ligation, with no drainage, it is basically the same thing as an inverted valve, with no drainage.

    Dr. Sclafani’s first CCSVI procedure resulted in a situation in which the patient lost her jugular vein, and she is doing well sans her IJV as she waits for Dr. Sclafani to find a solution for her — this occurrence did not stop him from taking on more patients which reinforces my thinking that the removal of a jugular equals an inverted jugular, but I know I could be wrong. Also, this woman is one of his strongest allies on TIMS, and she continues to stand by him.

    Again, you’ve written a terrific piece, and I’m looking forward to your next installment.

  2. Tony says:

    Good day Dr. Flanagan,
    Thanks for shared information and ideas. Your blog is one of a king, glad we have it around now.
    Few remarks though.
    I would like to disagree with the statement “snap or break myelin”. Myelin shield is quite elastic and virtually unbreakable unless if you apply a force which could destroy the whole brain tissue.
    Also, there is a great deal of variations in IJV, some people have only one, some have 3, some got valves only in one some have no valves at all, etc., most important these are findings from healthy people. This fact must be kept in mind when you try to figure out “the disturbances of blood flow” in one of jugs.
    Also, while blood flow through vertebral veins is always bidirectional, the flow in jugs is not strictly mono-directional; Jugs have the build-in mechanism to reverse it in a case of necessity. In other words, it’s OK to have a reverse flow (of various degrees) though jugs from time to time. The combination of different flows though both jugs exist more often in healthy population than layman usually thinks.
    Venous blood “back jets” sounds scary for layman, they do not realize that there are not truly “jets”, the venous blood back flow is slow.

    The list could go up, but it is not my main point.
    If you read the famous “Consensus Document” of Phlebotomists, it contains the following:
    Quote: “…Furthermore, surgical resection may often require a vascular surgeon, a hand and/or plastic surgeon, or other specialists.

    The multidisciplinary team often includes medical and allied health teams: Vascular Surgery, Pediatric Surgery, Plastic and Reconstructive Surgery, Orthopedic Surgery, Neurosurgery, Anesthesiology, Pathology, Physical Medicine and Rehabilitation, Oral-Maxillofacial Surgery, Head and Neck Surgery, Cardiovascular Medicine, Psychiatry, Dermatology, Interventional Radiology, Diagnostic Radiology, Nuclear Medicine, General Medicine, Neurology, Hematology, Genetics, General pediatrics, Occupational therapy, and many other health care practitioners.

    The multidisciplinary team approach is also mandatory for proper selection/combination of the treatment modalities. All the decision related to the management should be based on the consensus among this multidisciplinary team approach as well as life-time follow up on the natural course and treatment outcomes.” /end of quote.
    Unless IRs start follow their main document and start forming a real team with others who understand more, the results of CCSVI fix will be unpredictable and even harmful for some.
    Check out the story of second patient from Katowice, name Erika, her “party” seems is coming to end also. Of course, the Rici case was (and still is) horrible, but everyone has downplayed it and every possible connection with “CCSVI fix” was consciously ignored.

  3. Karri Weber says:

    Hello Dr. Flanagan,
    I am a 26 year-old female yoga/fitness instructor who is at the start of my educational journey to become a D.O.. This piece you have written is of great interest to me because I am in desperate need of more information on a problem I have developed that has to do with venous back-flow during inversions. You see, I have spent a significant amount of time in inversions over the past few years (particularly head/hand stands). Well, recently I have had to abruptly stop due to swelling in all superficial veins at my face and neck (presumably at my scalp also but due to my extremely thick long hair, it’s hard to tell!); this swelling is particularly severe at my temple. The swelling can only be seen WHILE I’m in ANY sort of inversion whatsoever. I am very concerned as to the danger of my veins having stretched to such extremes and am having a difficult time finding information pertaining to the subject.
    Thank you so much for your time and I would GREATLY appreciate any insight you have into my unusual situation!
    Karri Weber

  4. Hello Karri, I started doing yoga over forty years ago and have several black belts in martial arts and a CFT. Needless to say I know a great deal and I am a fan of both yoga and martial arts. That said, I think some yoga asanas pose far more risks than benefits, especially the headstand. Inversion flows aren’t so much the problem unless taken to extremes. The far greater risk is to the cervical spine, especially the upper cervical spine. The human neck is small and not meant to bear such compressive loads. What’s more, even slight wobbling can strain and misalign the spine in this critical area. I would avoid it and don’t go to extreme in plow (halasana) poses. Make sure to fully exahale to reduce venous back pressure. The same is true for the shoulder stand. Be moderate. You are only 26 so your veins should return to normal but you might want to get you spine checked.

  5. I usually don’t post in Blogs but your blog forced me to, amazing work.. beautiful …

  6. Quite a beautiful website. I recently built mine and i was looking for some ideas and your website gave me some. May i ask you whether you developed the website by youself?


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