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In 2009, this journal published a manuscript by Zamboni et al that proposed a major paradigm shift in the pathophysiology and consequently the treatment of multiple sclerosis (MS).1 Using extracranial colour Doppler and transcranial colour coded Doppler sonography, Zamboni et al reported 100% of their MS patients and none of the healthy controls having impaired venous drainage from the CNS that fulfilled specific criteria for abnormal extracranial venous return, also proposed by Singh and Zamboni.2 This extracranial colour Doppler and transcranial colour coded Doppler sonography based phenomenon was described as chronic cerebrospinal venous insufficiency (CCSVI). The pathological consequences of CCSVI have been hypothesised to emanate from chronic venous reflux and hypertension leading to increased iron deposition in the brain and subsequent MS pathology, including inflammation and neurodegeneration.1 Since the initial publication in this journal, the debate on CCSVI and its relevance to MS …