Get an angiogram if you think your jugular veins are 'compressed'

General
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Was told my jugular veins were compressed by my styloids. Had two styloidectomies that didnt help my symptoms. The ‘compression’ of the jugulars looks the same on CT scan before and after the procedures so I was told to get an angiogram to check the pressure in the veins. Had an angiogram after the surgeries which showed normal flow in the veins. Wish I had that done before the surgeries because I believe that it would have came back normal in which case I wouldn’t of had the surgeries. So they aren’t really compressed and I had surgery for no reason! Let that be a lesson for anyone.

Of course, since the angiogram showed normal flow I can see why people might think the styloidectomy
helped but none of my symptoms changed so I don’t believe it was the problem.

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@Nolan,

It’s great news that your IJVs are not compressed & blood flow looks good. Please forgive me for asking, but when did you have your styloidectomies, & if you don’t mind sharing, which doctor did them? I apologize as you’ve likely posted this info, but w/ all the posts I read, I lose track of who did what & when, sometimes.

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Thanks for the report! I would be interested to know if you saw any dilated vertebral (‘collateral’) veins on the CTA that people often point to as evidence of a pathological compression. I’d love to see an image if your scans if you have them available and would be willing to share! I’m about a month away from styloidectomies for the same reason.

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@Isaiah_40_31 Don’t worry, he’s already on the list :grin:. Last one was about 4 months ago.

@coldbear No collateralizing was noted

I should be clear about the test I had. It was a cerebral angiogram with manometry, meaning that they test the pressure of the veins in real time. The area of concern was ‘compression’ by the c1 transverse process so they measure the pressure in the veins below and above that spot and in the brain. There was no pressure gradient across any of the veins meaning that what looks like ‘compression’ is not actually obstructing anything; thats just how the anatomy appears.

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Yup I got it! I agree that DSA with manometry, while not diagnostic, should really be the gold standard of deciding whether to operate or not. Unfortunately, this is not an option in the stingy socialized healthcare system where I live. I’m left to go only off the CTA findings and my symptoms. But I do have some collateral flow on the CT, and the symptoms can be provoked to an extent in certain head positions, so I plan to roll the dice with a styloidectomy and hope for the best.

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@Nolan,

By four months out from surgery people usually notice some improvement in symptoms, so I’m sorry you’re not seeing some positive momentum in that direction. We (I include myself here) do have instances where it’s 6 mos or more before resolution of some symptoms begins to be apparent. I had a few that took 9 mos to really resolve & the First Bite Syndrome I got from my first ES surgery is continuing to decrease 7.5 yrs post op. Who knew nerves could recover that far out from injury?!

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@nolan I am bit concerned and confused about the statement below. You really do not know what the pressure gradient would have been prior to the Styloidectomy assuming that it was compressing your IJV to begin with. The reason is Veins in general and Jugular Vein in particular are elastic, collapsible and have thin wall. What this means is, they expand and collapse depending on the pressures exerted on them. Inside pressure ( intramural pressure) cause it to expand and pressure outside ( extramural pressure) causes them to collapse and the difference between the 2 pressures or pressure gradient across the wall of the vein is called ( transmural pressure). So without going too deep in the fluid dynamics here, what you need to understand is that if we assume that your Styloid was compressing the vein against C1, there would have been external pressure exerted on the vein and pressure inside the vein would not be enough to overcome the external pressure so the vein would remain narrowed/collapsed hence pressure gradient differences would have been found before and after the narrowed segment. Now, let us examine when the compression by Styloid was removed. Then when blood flow is increased the Vein would be able to expand as the inside pressure increases hence there would not be a significant pressure gradient difference. So in a nutshell, by removing the pressure inducing bone, it will allow the IJV to expand/dilate with more blood flow reducing any pressure gradient. So seeing a collapsed vein in CT does not necessarily mean, it won’t expand when the flow increases. So we would only know if the pressure was measured pre & post but now the jury is out for this.

BTW it is well documented that IJV does collapse when upright and expand when lying doing due to hydrostatic pressure.

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Geez that’s hard to hear. My neurosurgeon told me the angiogram is arterial phase and since it’s not a pressurized system the ijv will often look flat. Mine definitely look compressed by the c1. He also mentioned it being a timing issue. I never believed him but maybe what you’re saying is what he was talking about

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Sorry KD, but I think I respectfully disagree here. If there had been a pressure gradient prior to the operation, wouldn’t one expect some change in the vessel caliber post-op due precisely to the reasons you describe?

Say pre-op, only 5 units of blood could pass through the stenosis per unit time, creating an input/output mismatch and subsequent pressure gradient. And post-op the normal 10 units can pass. Presumably both scans were done in the supine position when IJV flow should be maximized. With blood as an incompressible fluid, wouldn’t you then expect an increase in IJV cross-sectional area at the same level?

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@coldbear Yes, I would expect a gain of cross-sectional area (CSA) but the question is how much gain is enough to lower the pressure gradient. We know from previous studies and many cases of post-styloidectomies that a few millimeters gain such as 1.5 mm to 2 mm gain was associated with pressure gradient reduction with or without relief of symptoms. I agree we are assuming a lot here since we did not have a quantified measurements pre/post (which I agree might be difficulty as the blood flow is by no means uniform and depends on many physiological processes which are beyond the discussion here) but I would assume/argue those gains of CSA might not be differentiable from that pre-styloidectomy imaging due to the size of CSA gain but nevertheless I expect the vein to expand a bit with an increase of blood flow due less external pressure now that the bone is removed.

Now, it is too common to see the narrowing of the IJV remain after the osseous compression has been removed due to many factors such as swelling, fibrosis, scars tissue, etc. It might not be a few months before one can see a noticeable gain in terms of CSA while others do not see a noticeable gain for various reasons but what is known is that the resistance induced by the bone compression is not there so the vein is somewhat more elastic than when the bone was present. That is why interventions like ballooning are entertained after the external compression is removed. Now this whole thing is based on, if there was a considerable compression coming from the Styloid to begin with but if there was small compression coming from the Styloid to begin with, then yes, removal of it will not render any meaningful change in the pressure gradient or symptoms for that matter.

I read somewhere though that @nolan described that he experienced some improvement after surgery but also said lightheadedness, swallowing, brain fog is not relieved. the first 2 of these symptoms are not the primary symptoms of Jugular compression but more on the classic ES so one has to question whether these symptoms was attributable to the IJV compression to begin with. Brain fog can be attributed to raised intercranial pressure so it is plausible but can be caused by many other etiologies as well.

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Sure - I agree with most of this. But if after my styloidectomy, my veins looked qualitatively identical and no gradient was measured during an angiogram, I would feel pretty safe assuming the pressures had been similar pre-op. That’s why the morphometrics of the vein are used as the main readout in ~80% (my estimate) of published studies on jugular ES…if it were so common for visually undetectable differences to cause/relieve pressure gradients, then I think we would need to be a lot more reliant on DSA for diagnosis. As far as I know, only a handful of ES specialists routinely measure pressures before diagnosing/treating.

Regardless, I think @nolan 's main message is on point. Angiography with manometry before surgery might save a few unnecessary procedures and is worth considering.

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Well in the absence of any measurements, one is safe to assume anything. I do not disagree with @nolan regarding blood flow assessment prior to surgical intervention which I advocated numerous times here but more on his conclusion that the pressure gradient was the same since the vein compression remained the same visibly (subtle improvements are hard to visualize specially when it is time averaged) I do not want to open up discussions about what affects pressure gradients and its significance when other factors affect its accuracy. Suffice it to say that it is not always the ONLY determining factor but important factor if measured in accurate setting.

My pressure gradient was found to be insignificant and the difference between above C1 and below C1 was ( 9 mmHg - 6 mmHg = 3 mmHg ) based my hand calculation. I do have all the signs of IIH such as partial empty sella, optic nerve sheath enlargement and tortuous optic nerve as well as numerous IJVS symptoms. I shared my Angiogram with Manometry finding below.

The following observations are made:

  • On the right common carotid artery injection and left vertebral injection,
    the left transverse sinus is the dominant sinus but there is also nondominant
    flow into the right transverse sinus. Right transverse sinus is not
    hypoplastic but only nondominant. Bilateral prominent condylar veins are
    seen, left more than the right.
  • The left common carotid artery angiogram shows that the left hemisphere is
    draining almost exclusively through the left transverse sinus.
  • There is compression of internal jugular vein at the level of C1
    transverse process-styloid process bilaterally.
  • On provocative testing with head turned to the right and left
    respectively, an interesting observation is made: When head is turned to the
    right, the left condylar vein is no longer opacified. With the head in
    neutral position or turned to the left, the left condylar vein is prominently
    seen. This suggests that with head turned to the right, there is improvement
    of the venous outflow, by relief of the compression at the level of styloid
    process-C1 transverse process with a better downstream flow towards the heart
    with consequent reduction of venous reflux into the left condylar vein. This
    may explain his left-sided pulsatile tinnitus.
  • There is no evidence of dural arteriovenous fistula.
  • On venous manometry, there is no significant pressure gradient within the
    venous system. The pressure values at various points are as follows:
  1. Right atrium-3 mmHg
  2. Right superior vena cava - 4 mmHg
  3. Left brachiocephalic vein - 5 mmHg
  4. Left internal jugular vein in the chest - 5 mmHg
  5. Left internal jugular vein below C1 level-6 mmHg
  6. Left internal jugular vein above C1 level-9 mmHg
  7. Left jugular bulb 9 mmHg
  8. Left sigmoid sinus-9 mmHg
  9. Left transverse sigmoid junction-9 mmHg
  10. Left transverse sinus laterally-9 mmHg
  11. Left transverse sinus medially-10 mmHg
  12. Torcula-10 mmHg
  13. Superior sagittal sinus 10 mmHg

There were no complications during the procedure.
The catheters were removed. Hemostasis at right common femoral vein access
was achieved with manual compression. Left common femoral artery was closed
using Angio-Seal device after confirmation with a groin angiogram.

Patient was transferred to surgical daycare with stable vital signs and at
neurological baseline.

IMPRESSION:
Eagle syndrome, with prominent venous reflux into left condylar vein - this
is the most likely cause of his left-sided pulsatile tinnitus. This venous
reflux improves with head turned to the right. See detailed explanation above.

Dominant left transverse sinus.

Plan:
Further plans for management will be discussed with the patient in the clinic
with Dr. Pereira.

KISLAY KISHORE M.D.
VITOR MENDES PEREIRA M.D. (Staff)

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I find what you’re saying (@KoolDude) extremely interesting. One of my NIR who was the one who found my bilateral IJVS said that from my cerebral angiogram / balloon angioplasty alone, along with my symptoms and CT and MRV imaging, a pressure reading would be an unnecessary step.

He mentioned something about it not being so accurate and something about blood flow turbulence effecting the results. He told me he can spend the time to explain it to me when I’m better and we have time and that if I really wanted it, we can do it but he didn’t think it was necessary for my case and wouldn’t change the plan or results.

I know many Drs would disagree with him, but I’m curious what he / you meant by the turbulence effecting the results.

I’m currently scheduled for bilateral styloidectomy with Dr Hackman.

Here are the angiogram procedure notes, apologies because it’s quite long.

Pre Operative diagnosis: Severe Intractable headaches that are worsened by straining without relief and worsening over the past two months and preventing the patient from working

Post Operative Diagnosis:

  1. Occlusion of the left internal jugular vein with severe stenosis of the right internal jugular vein which is worsened by neck extensison status post venous angioplasty with some improvement in venous congestion but persistent occlusion of the left internal jugular vein between the left styloid process and the left C1 transverse process.
    Procedure :
  2. Diagnostic cerebral angiogram
  3. Diagnostic Venogram
  4. Venous Angioplasty
  5. Intravascular ultrasound

Anesthesia : General Anesthesia
Preoperative Medications : None
Introduction : A timeout procedure was documented, the patient’s name date of birth and medical record number as well as the procedures to be performed was confirmed by the entire team, after everyone in the room agreed, the procedure continued. After the patient was placed under anesthesia, both groins were prepped and draped in the usual sterile fashion.Using sterile Seldinger technique the right common femoral vein was punctured using a micropuncture kit. Over a 3mm J wire a Neuron max sheath was introduced into the vein and then hooked up to a continuous heparinized flush system.

Using sterile Seldinger technique the left common femoral artery was punctured using a micropuncture kit. Over a 3mm J wire a 5 French sheath was introduced into the artery and then hooked up to a continuous heparinized flush system.Via the sheath a 5 French diagnostic Catheter was introduced over a 0.35 Terumo glide wire, into the abdominal aorta, the catheter was then double flushed. The following vessels were than sequentially selected, and digital angiographic acquisitions were than obtained.

Vessels Selected :
The right common carotid artery was selected and injected with cervical views.
The right internal carotid artery was selected and injected with cranial views.

The right vertebral artery was selected and injected with cranial views.

The left common carotid artery was selected and injected with cervical views.
The left internal carotid artery was selected and injected with cranial views.

The left vertebral artery was selected and injected with cranial views.

Follow up angiograms were obtained
3D dyna CT was performed
Diagnostic Imaging Findings :
The right common carotid artery was selected and injected with cervical views.
The right common carotid artery appears normal without any areas of irregularity or stenosis.
The right external carotid artery appears normal without any areas of irregularity or stenosis.
The right internal carotid artery appears normal without any areas of irregularity or stenosis.
The right internal jugular vein appears larger with stenosis at the level of the right C1 transverse process.
There is prominence of the right external jugular vein.
The left IJV is not clearly visualized.

The right internal carotid artery was selected and injected with cranial views.
The right internal carotid artery appears normal without any areas of irregularity or stenosis.
The right middle cerebral artery appears normal without any areas of irregularity or stenosis.
The right anterior cerebral artery appears normal without any areas of irregularity or stenosis.
There is filling of the posterior circulation via the pcom.
There appears to be some venous congestion.
There is a severe stenosis of the right internal jugular vein at the level of the C1 transverse process.

The right vertebral artery was selected and injected with cranial views.
The right vertebral artery appears normal without any areas of irregularity or stenosis.
The right PICA appears normal without any areas of irregularity or stenosis.
The basilar artery is faintly visualized due to its connection with a proximal PICA branch.
There is flash filling of the PCA’s
There is venous congestion with delayed emptying via the dural sinuses.

The left common carotid artery was selected and injected with cervical views.
The left common carotid artery appears normal without any areas of irregularity or stenosis.
The left external carotid artery appears normal without any areas of irregularity or stenosis.
The left internal carotid artery appears normal without any areas of irregularity or stenosis.
The right internal jugular vein appears larger with stenosis at the level of the right C1 transverse process.
There is prominence of the right external jugular vein.
The left IJV is occluded at the level of the left C1 transverse process. Venous collaterals are noted in the same area.
There is prominence of the left external jugular vein.

The left internal carotid artery was selected and injected with cranial views.
The left internal carotid artery appears normal without any areas of irregularity or stenosis.
The left middle cerebral artery appears normal without any areas of irregularity or stenosis.
The left anterior cerebral artery appears normal without any areas of irregularity or stenosis.
There is filling of the posterior circulation via the PCOM.
There again appears to be some venous congestion.

The left vertebral artery was selected and injected with cranial views.
The left vertebral artery appears normal without any areas of irregularity or stenosis.
The basilar artery appears normal without any areas of irregularity or stenosis.
The left PICA appears normal without any areas of irregularity or stenosis.
The right PCA is visualized and appears normal.
There appears to be some venous congestion.

INTERVENTION:
The neuron max catheter was navigated into the right internal jugular vein.

IVUS:The refinity catheter was navigated into the superior sagittal sinus and pull back was initiated.
Superior Sagittal Sinus: No significant stenosis
Torcula: No significant stenosis
Right transverse sinus: No significant stenosis
Right Sigmoid sinus: No significant stenosis
Right Internal Jugular Vein: Severe stenosis at the level of the C1 transverse process.

Venous Angioplasty:
A viatrac 6 mm x 20 mm balloon was navigated over the wire and postioned across the stenosis in the Right IJV.
It was inflated to a pressure of 10 atm and pulled back gently.
There was a significant deflection of the balloon suggesting hypermobility in the region.
The balloon was then deflated and removed.

The left internal jugular vein was then selected and the neuron max catheter was navigated into it.
A synchro wire was navigated into the IJV but could not go past the occlusion in the left IJV despite multiple attempts including using the microcatheter and different microwires.

IVUS:
The ivus catheter was navigated into the left IJV and pullback was initiated.

Left IJV: No significant stenosis
Left Brachicephalic vein: Moderate stenosis

A decision was made to try and pass the occlusion from a superior approach using the right IJV.

The neuron max catheter was navigated into the right IJV.
A transform 4 mm x 20 mm balloon was navigated over a wire past the torcula into the right sigmoid sinus.

The microwire was then able to cross the left IJV occlusion relatively easily.
The transform catheter was able to after a few attempts, cross the occlusion. The balloon of the transform catheter was inflated and then deflated.
It was then brought proximal to the occlusion and a check injection was performed and it showed no improvement in the occlusion.

3D Dyna CT:
3-D rotational Dyna CT was also performed. All source images from the 3-D rotational acquisition were sent to a dedicated workstation for reconstruction and review that was performed personally by myself.
The dyna ct confirmed that the left IJV occlusion was at the site of the left c1 transverse process against the styloid process.

Follow up Angiogram 1:
The right common carotid artery was selected and injected with cervical and cranial views.
The right common carotid artery appears normal without any areas of irregularity or stenosis.
The right external carotid artery appears normal without any areas of irregularity or stenosis.
The right internal carotid artery appears normal without any areas of irregularity or stenosis.
The right middle cerebral artery appears normal without any areas of irregularity or stenosis.
The right anterior cerebral artery appears normal without any areas of irregularity or stenosis.
There is filling of the posterior circulation via the pcom.
There appears to be some venous congestion.
The right internal jugular vein appears larger with stenosis at the level of the right C1 transverse process.
There is prominence of the right external jugular vein.
The left IJV is not clearly visualized.

Follow up Angiogram 2:
The left common carotid artery was selected and injected with cervical and cranial views.
The left common carotid artery appears normal without any areas of irregularity or stenosis.
The left external carotid artery appears normal without any areas of irregularity or stenosis.
The left internal carotid artery appears normal without any areas of irregularity or stenosis.
The left middle cerebral artery appears normal without any areas of irregularity or stenosis.
The left anterior cerebral artery appears normal without any areas of irregularity or stenosis.
There is filling of the posterior circulation via the PCOM.
There again appears to be some venous congestion.
The right internal jugular vein appears larger with stenosis at the level of the right C1 transverse process.
There is prominence of the right external jugular vein.
The left IJV is occluded at the level of the left C1 transverse process. Venous collaterals are noted in the same area.
There is prominence of the left external jugular vein.

Follow up angiogram 3:
The left vertebral artery was selected and injected with cranial views.
The left vertebral artery appears normal without any areas of irregularity or stenosis.
The basilar artery appears normal without any areas of irregularity or stenosis.
The left PICA appears normal without any areas of irregularity or stenosis.
The right PCA is visualized and appears normal.
There appears to be some venous congestion.

The neuron max and diagnostic catheter were removed.
Conclusion : Hemostasis was obtained using an 5F mynx closure device for the arterial site and manual compression for the venous access site. The patient tolerated the procedure well and there were no complications.
Intraoperative Medications : None
Materials Utilized : Diagnostic Angiography kit
Rest as above
Impression :

  1. Occlusion of the left internal jugular vein with severe stenosis of the right internal jugular vein which is worsened by neck extensison status post venous angioplasty with some improvement in venous congestion but persistent occlusion of the left internal jugular vein between the left styloid process and the left C1 transverse process.
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Thanks for sharing! Unfortunately, I myself don’t have any choice but to assume things because DSA is not an option for this condition where I live. I think your situation actually sounds quite similar to my own - rightward head rotation relieves my symptoms, while neck flexion and leftward rotation provoke them.

Have you posted your imaging of the empty sella and optic nerve issues here before, and were they noted by radiology or self-diagnosed? I would love to compare to my own. What’s your hypothesis of how they developed despite the normal pressures during measurement?

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It is confusing. And you’re right, I will never know what the pressure gradient was like before the surgery. But thats what I was getting at. Thats why I recommend having the test done beforehand.
I just ‘believe’ that it would have also come back normal before the procedure since the compression appears the same before and after on CT.

My symptoms were pretty classic of jugular vein stenosis; and were more than the ones you referenced, so I was pretty confident it was contributing. But that thought is waning now, in a good way I guess. Maybe it did actually help but I can’t really tell.

I also had an eye exam from an ophthalmologist to check for increased pressure in the eyes which also came back normal.

@coldbear Sorry to hear they don’t have the test. Do they not have neurosurgeons where your from because they can do the test. Anyway, I hope your procedure goes well.

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I did share it here though I do have a better MRI imaging which I will share in the future but I need to find it in my numerous imaging I went through.

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I live in Sweden - we have all of the fancy equipment, but do not hire enough staff to use it outside of emergencies and cancer. The average wait here for a styloidectomy is 1-2 years after diagnosis and decision to operate. :roll_eyes:

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lol @coldbear … I thought you guys had better healthcare system than Canada. I am now on a waiting list for Styloidectomy as I was referred to Skull Base Surgeon who seems to be busy with cancer and traumatic cases (20 case are ahead of me…depending how he proceeds I might end up waiting for long time). For me it is either that or out of pocket in the US. I chose the previous for family reasons.

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@elijah I am detail oriented guy so I will need to read your interesting posting multiple times to grasp it. I am glad you are seeing Hackman who is very familiar with vascular ES and much more experienced than the folks here in Canada

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@nolan I absolutely agree with you and blood flow assessment is essential when you have compression but various things affect the accuracy of pressure gradients. For example, they gave me high dose of blood thinner (Warfarin) for the fear of clotting due to the CT Angiogram. Guess what this does. It makes the blood thin (less viscous) and thin blood flow through narrowing much easier than thick blood so pressure is somewhat reduced as the pressure required to push thin blood is less than the pressure required to push thick blood through narrowing. This is just one of many things that affect pressure. Sedation during surgery slows the heartbeat which reduces the overall pressure in the venous system…etc. So take it with a grain of salt.