The pyramidal pathway is frequently affected early on in multiple sclerosis (MS) 
and impaired motor performance is a major cause of disability. Pyramidal tract 
function can be assessed using transcranial magnetic stimulation (TMS). TMS 
supports the diagnosis of MS, detecting corticospinal tract involvement and 
monitoring its course with or without treatment. It has been never investigated 
whether any relationship exists between the TMS outcome measure and minimally 
invasive treatment of multiple severe extracranial stenosis, affecting the 
principal ce rebrospinal venous segments in MS patients. We report the clinical 
and transcranial magnetic stimulation follow-up of a patient during a relapse in 
relapsing-remitting MS. She underwent percutaneous balloon angioplasty of the 
associated chronic cerebrospinal venous insufficiency (CCSVI), due to membranous 
obstruction of the proximal azygous vein, with severe stenosis of the left 
internal jugular vein. Treatment of the associated CCSVI made a parallel 
improvement in both clinical and neurophysiological parameters, allowing us to 
avoid high dose steroid therapy. The relationship between the clinical and 
neurophysiological course on the one hand, and haemodynamic correction of the 
associated CCSVI on the other, calls for further exploration on a wider number 
of patients. The impact of CCSVI on the different neuro-physiological parameters 
has not been fully estimated, but the intriguing case here reported suggests 
that it may be greater than previously assumed. The demonstration of a 
modification of the cerebrovenous function with both clinical manifestation and 
via TMS suggests that the hampered cerebral venous return may contribute to the 
clinical course of MS.