Brain Slump Caused by Jugular Venous Stenoses Treated by Stenting: A Hypothesis to Link Spontaneous Intracranial Hypotension with Idiopathic Intracranial Hypertension

Here comes another interesting study By Higgins et.al about Jugular Vein Stenting that resolved Both IIH and CSF Leak.

Abstract

Spontaneous intracranial hypotension, of which brain slump is an extreme expression, is caused by a cerebrospinal fluid leak. The reason the leak develops in the first place, however, is unknown, and some cases can be very difficult to manage. We describe a patient with severe symptoms of spontaneous intracranial hypotension and brain slump documented by magnetic resonance imaging whose clinical syndrome and structural brain anomaly resolved completely after treatment directed exclusively at improving cranial venous outflow. Diagnostics included computed tomography (CT) venography, catheter venography, and jugular venoplasty. CT venography showed narrowing of both internal jugular veins below the skull base. Catheter venography confirmed that these were associated with pressure gradients. Jugular venoplasty performed on two separate occasions as a clinical test gave temporary respite. Lasting remission (2 years of follow-up) was achieved by stenting the dominant internal jugular vein. These findings and this outcome suggest a mechanism for the development of spontaneous intracranial hypotension that would link it to idiopathic intracranial hypertension and have cranial venous outflow obstruction as the underlying cause.

Keywords: spontaneous intracranial hypotension, idiopathic intracranial hypertension, brain slump, cranial venous outflow obstruction, jugular venoplasty, jugular stenting

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Interesting paper. Thanks for sharing. I am hoping might get nHS diagnostic help from Nick Higgins after first NHS telephone consult soon but to date has proved impossible to get to see him. Told he is the leading neurological radiologist in UK. Spoke to him in Jan 2022 and seemed very nice but first step of lumbar puncture postponed due to C1 op and then all attempts to reschedule failed. If I ever get to see him will let you know if helpful in update. D

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I can imagine how busy a guy like Higgins is. Hope you find a time to see him.

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Thanks for posting this, a really useful research paper!

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@KoolDude - Interesting that there is was no mention of trying to decompress the jugular by removing the styloid. Perhaps the styloid & C-1 weren’t the problem though it seems unlikely.

I’ve seen an image of a stent that was bent to almost a 90° angle by an invading C-1 transverse process. Without dealing w/ the cause of compression, stents aren’t necessarily the best solution.

In the article above, if I understood the approach correctly, the stenting regimen used a longer, more robust stent to house two smaller stents to protect them from collapsing due to external pressure.

When vascular decompression isn’t attempted this approach to stenting makes more sense.

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@Isaiah_40_31 you are spot on but even this was not complications free. There was a number of stent failure before they finally worked for the 55 year old in this case. I really do not like having an stent in my IJV but my fear is that my IJV turns out to be fibrotic due to the longer period that it was under Styloid compression. This necessitates stenting if Styloidectomy that I went through 4 weeks ago fails.

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@KoolDude you still should try to balloon it first, I’d say, and see if it holds, before getting the stent…

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@vdm I really do not want stent at all but all the studies I read point to a temporary resolution of symptoms with ballooning. This is because the veins lack the thick, muscular walls of arteries and once fibrotic, the jugular vein will need a stent to remain open. I am hoping to avoid this at all cost but options are limited if my dominant vein remains collapsed.

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How did you go about getting a telephone consult with Higgins on the NHS?

Well, this is encouraging. I’m scheduled for a jugular stent with Dr. Fargen in January. Perhaps it will cure my brain slump!!

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My case seems to bear that out. My jugular was ballooned during my styloidectomy. Didn’t hold. Next stop, stent.

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To answer the Higgins question I did not ever find a way to get time to talk with him on NHS or privately. Axon had asked him to see me fir diagnostics. When I called his secretary Ruth about this he came on the phone to talk with me. A nice medic & a welcome change. But Very hard to get to see him. D

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@Bopper Not surprising because the IJV has thin wall and would usually collapse back particularly when done just after the bony compression removal (My assumption - swelled muscles can collapse right back) . If ballooning had any chance of working, it is better done 3 or more months after surgery so that the stretching of the vein has no extrinsic force to collapse back (even then it typically collapses back if it is fibrotic). This is my assumption based on the limited number of research papers I have read.

Hope the stenting goes smoothly for you. You are in good hands. Dr Fargen is world renown. I will follow up your case closely, please keep us posted on how things turn out.

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This was a case of fibrotic IJV and it was stented after Styloidectomy did not open up the vein. It was shared by our friend @coldbear (missing in action lately - we needed his insight into this). See the link below.

https://www.instagram.com/p/Cb1RGmFs6C7/

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That’s a long stent! In the pics I’ve seen, they’ve been much shorter. I bet a longer one might work better.

@coldbear, we miss you!!

Thank you, I will!!

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