From what I’ve heard, I don’t think he regularly stents the IJV, only the upper sinus areas. I also have a likely narrowing in the superior sagittal sinus. I wonder if that can be stetted (if shows proper gradient)…
@KoolDude , do you know if the IJVs are visible on a CTA?
I assume by CTA, you mean the Catheter Angio/venogram. Yes, They can’t get to brain sinuses (sigmoid/transverse/Sagittal sinuses) without going through the IJV first. He just needs to be paying attention to the IJV while doing the CTA so that he can evaluate if there is any stenosis and if there is extrinsic compression.
By CTA, I mean CT angiogram. I’m not sure if it only catches the arteries, or if veins are viewable as well
CTA usually includes venous phase if I recall it but it has to include the neck (Not only head) when it is being performed.
Just had a call with Dr. Yakes office for my case. I also asked about video consultation options. They are providing Zoom meetings but they said that Dr. Hepworth should be contacted first and that they need to have a referral.
They are only providing diagnostics for Dr. Hepworth more or less.
Trouble is, I can’t get into Dr. Hepworth for many months (that’s if I can get in at all).
I found a head/neck CTA done less than 2 years ago, so it could give some clues of pre-surgical anatomy, especially of the IJVs. I took a couple of screenshots. See below and let me know your thoughts. Thanks!
On this screenshot, I feel like I might see a “kink” in the left IJV (red arrow). I’m thinking it’s close to where I have congenital fusion of c2-c3?
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In this second screenshot, I feel like I see significant compression of the left internal jugular vein.
We already know the left great cornu of the hyoid bone runs through the carotid bifurcation and mildly compresses the external carotid artery. In this picture…is the left greater cornu also possibly compressing the left IJV? Let me know your thoughts. Thanks!
@1speechpick So see my comments below for the images you sent.
The first one is vertebral artery (cyan arrow) so this is not your Jugular Vein. It is known to be tortuous in vertebral bones so I would not worry about this.
The circle is also pointing to the first vertebral (C1 atlas) and it is primarily that one that IJV drapes over often and can be potentially compressed by C1 or Styloid or both. I also notice this one is the non-dominant side. The thyroid cartilage and its superior cornu are way below (cyan circles). Hyoid bone Corno is on top of it
There appears to be slight compression on your non-dominant IJV between the carotid artery (cyan arrow) and what appears to be another vessel or tissue (can’t really tell clearly).
Thank you. I still have so much to learn when it comes to picking out structures!
@1speechpick my understanding is that you have recently developed intercranial pressure (post surgery) but before that you had pain possibly caused by neuralgia (caused by cranial nerves trigeminal, … etc) and throat issues related to hyoid bone. If that is the case, I think pursuing IIH signs in imaging prior to the surgery is not worthy it and might deviate you from pursuing a treatment of your current IIH symptoms. I say go for endovascular process to check all your venous systems (from Jugular vein to superior sagittal sinus), then the vascular surgeon can address it. I think that is one way to get the IIH symptoms properly diagnosed and treated.
@KoolDude, thanks for your thoughtful reply. I understand what you’re saying, and completely agree.
Thus far, I’ve done a poor job explaining this newest phase. As I gather further info, I’m learning “cranial venous congestion” is in its infancy and there isn’t a standardized approach in dealing with diagnosis and treatment. In the words of Dr. Hui, there isn’t even an ICD10 code for it yet.
From prior imaging, Dr. Hui sees evidence of “mild venous congestion” and thinks I’ve had “low grade intracranial hypertension” most of my life. He saw probable stenosis in superior sagittal sinus and reduced venous flow in IJVs bilaterally. He said this explains my long history of headaches & pressure. He also said in his research, he’s found venous flow issues can cause cranial nerve neuralgias (which I have). Then after the MVD along came the CVST on 8/20/22, causing a partial blockage in the right venous sinus system, and further compromising an already broken venous system (in terms of venous flow) and causing worse intracranial hypertension symptoms.
So, how to restore venous flow in my case? It would be ideal if they could remove clot and/or stent the right transverse/sigmoid sinus & jugular bulb areas…if my body doesn’t resolve the clot with anticoagulants. It’s a risky surgery. However, per Dr. Hui, even if this is fixed I’m still left with a broken system, especially in terms of the IJV outflow bilaterally. Per Dr. Hui, IJV venous outflow can be impaired by internal vein stenosis or external compression of the IJV (most commonly with C1 or styloid process). My reasoning in wanting to comb through my head/neck CTA images was to see if I could find any evidence of external compression of the right or left IJVs. The fix for each problem is a very different surgery. Internal IJV compression requires a stent while external compression of the IJV requires a “decompression” surgery.
I hope that all makes sense. Let me know your thoughts. As always, thank you so much!
@1speechpick I hear you but the way I would approach this is to have a Catheter Angiogram/Venogram to determine the extent of clot formation in your brain sinuses and if there is any external compression or clotting in your IJV . So this way, the vascular doctor will know what course of action is needed to open up both the brain sinuses and jugular veins if any. That way you can take care of both issues (IJV & Brain sinuses). CTA imaging is not as sensitive as Catheter Angiogram/Venogram (the gold standard in diagnosing venous stenosis). Even if the CTA shows some compression on your jugular vein, still Catheter Angiogram/Venogram will be required to both formally diagnose it and potentially treat it if it happens to be soft tissue compression (bones will require surgery). I am not doctor, this is my personal opinion but I think Dr. P and Dr. Hui both recommended endovascular exploration which I agree as well.
Can the angiogram/venogram determine internal vs external IJV problems?
Yes. It can. They can tell what is causing the narrowing (bone/clot/vessel/muscle/soft tissue…etc). They can even do CTV at the same time as well. They did that in my case. So they can also quantify how much narrowing and measure the pressure gradient.
@KoolDude, Thanks again, for your great information. My procedure with Dr. P isn’t until mid October. Dr. Hui said if I could make it to Hawaii, he would admit me to the hospital and do the procedure immediately. That’s a far fetch. It would be a 12 hour flight. We’re looking into a doctor in North Carolina that I could possibly get into sooner. There’s actually an amazing surgeon in Toronto, too. I reached out to them but did not hear back.
What surgery did you have with him? I just called his office and the receptionist said “he doesn’t deal with veins in the brain”…
Ok, that’s a bit strage. I had cranial angiography and cerebral venogram performed there. And in case of transvers sinus stenosis, I thought, he would have been stenting that… Anyway they said that they are only doing some diagnostics for Dr. Hepworth.
Hmmmm…I talked to the receptionist and she was supposed to send me an email so I could “have my case reviewed”. However, that email never came.
I’m still waiting for an email they wanted to send me yesterday, too. Takes a bit as it seems.
