Looking side on, the jugular is so faint it is barely there, but it does not necessarily look like it is in contact with the c1 or styloid.
Looking at the base of the skull, it seems compressed coming out of the skull, like there isn’t enough room for it.
Can anyone help me interpret this? I will have a follow up with Dr. Constantino, but who else should I talk to about this?
@dwg176 the best way to assess vascular compression is in the axial view.
I’m one of the main members who helps others with their imaging. What members typically do is put their CT files into a folder on google drive and then send me a private message of the link to the drive. Then I go in and download the files and thoroughly go through the entirety of the imaging to see what’s going on. Is this something you’d be interested in? You’d no longer be anonymous to me, but I would not be sharing any of your personal information. Let me know your thoughts.
Hi, I DMed you the link. Greatly appreciate any guidance you can give. Feel free to respond with your analysis here if it might give others reading this thread any insight.
I’m not confident enough to comment on your scans, I hope that @TML can help you work it out!
@dwg176 see attached annotated imaging (4 here, and 2 3D constructions in a following post).
On your right side you have one continuous elongated styloid. On your left side, you have a normal length styloid, but followed by two pockets of calcified stylohyoid ligament.
At the upper end of C1 both styloids make immediate contact with your IJVs. It’s easy to tell that there is compression of your left IJV by the styloid because it is your dominant (bigger) IJV.
At the mid-section of C1, your left IJV becomes compressed between what I believe is your left stylohyoid muscle and C1. On your right side, your tiny IJV is pushed against C1.
A bit further down, at the level of C2, both IJVs are being compressed by your posterior digastric muscles. On your left side, the calcified stylohyoid ligament is also contributing to the compression.
Lastly, your right greater horn of your hyoid sits much higher than your left greater horn. And, the superior horns of your thyroid cartilage are quite prominant. Fortunately, neither of your greater horns nor superior horns are causing any vascular compression. But I wanted to point this out incase they are causing nerve irritation and pain.
Reminder that I am not a doctor nor radiologist. I hope this helps!
Thank you so much for your time. I guess I should have added some description of my symptoms. In order of severity:
So, my symptoms are very focused on the right side. I see that the left IJV is also compressed, but it seems to have so much more blood flow in comaprison.
My concern is I don’t see how much improvement can really be had on the right side since that IJV is already so much smaller to begin with.
Anyway, I have a follow up appointment with Constantino next week. Is there anyone else I should be trying to schedule with, or is this well within his scope of specialty?
In the third image, your right styloid is very close to your right ICA. It is possible that with head movements, the styloid is striking or compressing the ICA, which would cause pain to radiate down the right side of the neck. Any styloid less than 3mm from an ICA is increased risk for stroke, ans I’m thinking you have maybe 1mm of clearance. I’m getting my left styloid removed in a couple weeks because of this (and because of IJV compression).
I wonder if a IJV stent could help increase the diameter of the right IJV? Not really sure how that works.
Dr Costantino is a very experienced VES doctor, so hopefully you can discuss the issues @TML has noticed (thank you again @TML !). As far as we’re aware, Dr Costantino doesn’t trim the hyoid processes though. Other VES doctors if you wanted to get another opinion, Dr Cognetti in PA, Dr Hepworth in CO or Dr Nakaji in AZ are the ones other members have seen, & also one of our members has seen Dr Babu Welch in Texas for VES as well. If you are concerned about the hyoid bone, Dr Dewan in Louisiana does this surgery, or Dr Marshall Smith in Utah has done a thyroid cartilage surgery, I think there are other doctors who do hyoid surgery, but I can’t remember!
Here’s a link to the Doctors List if you want to look up any doctors:
Doctor Lists – no discussion - Symptoms and Treatments / Doctor Information - Living with Eagle
Hi,
I am new to forum. How do people get these great 3D scans in the first place? I saw a famous doctor in Denver (Hepworth) and the CTV scan just looks like layers of an X-ray and doesn’t show this detail and not sure why even when I asked another vascular doctor for 3D it was never done. Can your program take the scan and see 3D? What should I be asking for if I get another scan?
Hepworth says he won’t fully know what’s choking the jugular until he’s “in there” after he’s cut into my neck, which to me is unsettling. I had another doc at a spine place do X-rays after he told me my jugular ultrasound test came back at almost zero flow and my left jugular has big round lumps on it from the pressure of the back flow. He said my osteophytes at top of my neck are the biggest he has ever seen and I wonder if those can be pressing on my jugular instead of C1 & C2 or styloids. Would love another opinion and need visual that would settle this mystery. My neck is very offset from my spine and bends crooked back to my skull. After 60 years of this, it’s now compressed enough to be causing pressure and pulsatile tinnitus. I would consider traveling to get better assessment in 3D. Hepworth was strange about my questions needing to see in 3D and seemed like I needed to just jump into surgery. He’s so busy and his office is so notoriously screwed up, I feel like a number. Any insight of how to really see what’s in there would be great.
Thanks
Flo
Hi Flo & welcome!
I understand your concerns, as nobody undertakes the surgery lightly & obviously you need to ensure that you’re making the right decision! Dr Hepworth is very experienced and has done lots of successful surgeries for members, but it’s always a good idea to get a second opinion if you can…
I’m not great with tech, but there are several programs that members have used to convert their scans, on computers with Windows OS, one of the most user-friendly software is RadiANT DICOM Viewer: DICOM Viewer - RadiAnt | Products | RadiAnt DICOM Viewer. For Mac users Bee Dicom Viewer App is a good resource: Bee DICOM Viewer on the Mac App Store. Horos (Horos Mobile - Horos Project), OsiriX viewers work on various Apple products.
Here’s links to a couple of tutorials:
Making Your Own 3D Images from CT Scan- 3D Slicer Tutorial - Living with Eagle
RadiANT DICOM Viewer tutorial - General - Living with Eagle
And @TML did this tutorial if you do manage to convert your images into what to look for:
Axial CT tutorial - General - Living with Eagle
It’s hard with Dr Hepworth especially dealing with his office, we have heard that about other doctors too! And when it’s a major surgery you definitely don’t want to feel like your just a number! If you decide to get a second opinion, then Dr Costantino in NY, Dr Cognetti in PA & Dr Nakaji in AZ are experienced, but you should be able to get your images converted so you shouldn’t need another scan- and feel free to put on here what you do have in the mean time, we can have a look, just make sure that you take your name & details off any imaging…
Thank you for the advice. I have a follow up with Dr. Hepworth in a few weeks where I will ask again for 3D imaging. Hopefully no resistance!
My neck is so bent that I am also worried that it will just keep compressing further even after surgery. So I am trying to find solutions for that as well.
Thanks again!
@FlurryFlo if you want, I can turn your CTV into a 3D model. You’d have to put your CT files into a google drive folder and send me a link to the folder. You would no longer be anonymous to me, but I wouldn’t be sharing any of your personal information.
@FlurryFlo - As @Jules mentioned, you or a friend/relative can make the CT images you already have into 3D. Your other option is to take your scans to the radiology clinic where they were done & ask if they can provide you w/ 3D images of your neck w/ styloids & vasculature or ask Dr. Hepworth, if he orders an additional scan, to please request that some of your significant images be provided in 3D. There is no special type of imaging that creates 3D images. All CT scans can be “put together” into 3D images by “stacking” the slices to form 3D images.
I can try to put into google drive. I will then send, but where to?
@FlurryFlo I just sent you a private message. Reply to me there!
@FlurryFlo - To send a private message to @TML, click on his screen name as it appears above the his post or even in this message I’m sending. That will take you to a page w/ a link in the upper right that says MESSAGE. Just click on that & you’ll be off & running w/ a PM to him. To upload your Google Drive folder, click on the underlined up arrow in the menu at the top of the text box where you send your reply to him, or you can drag it from your computer desk top & drop it in the text box. Either way works.
