Interesting article - IJV compression not always pathological / symptomatic. How to determine if it is?

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Found this article:

In the article the author writes:

NOTE that there is almost always some degree of compression there (C1 / styloid area) — and nearly always asymptomatic. Below is a beautiful 3D DSA venous phase of a normal case by Dr. Eytan Raz

And in this very cool 3D clip you can see the compression clearly in an asymptomatic healthy person:

To me it looks like, even though the veins are flat and compressed, they still have quite a bit of volume / mass to them thus allowing blood to flow properly.

So I was wondering how to determine when compression is pathological? One thing is probably what I just mentioned, i.e. looking at the actual circumference / volume / mass rather than the shape. Another thing, growth of collateral veins? Larger collaterals should indicate problems with flow in the IJV’s as far as I know. Other tests that determine blood flow with hard numbers?

Finally, individual variability is something I was thinking about, i.e. you could have 2 people with identically sized IJV’s but one may be symptomatic and other not, because physiology is so variable.

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Very interesting, I didn’t know about this site yet, and it discusses a very interesting and important topic. Thank you for that. This is exactly what, for example, Chris Centeno (CCI specialist) always propagates, that an IJV Stenosis can be asymptomatic and, according to his opinion, is most of the time. Also, this point of view, that a stenosis is always asymptomatic (which isn’t true, of course, is the main struggle I encounter in order to get a CT. One radiologist near me brought up the point that the stenosis is caused by the extremely flat lying position in CTs/MRIs. Probably in many asymptomatic people, the stenosis only occurs when they are lying and not so much in daily positions, and therefore they don’t experience symptoms?

I do think that IJV Stenosis can be asymptomatic in many people, or at least the symptoms are too subtle for them to notice. I believe IJV Stenosis, in general, is a modern time problem as we are more and more looking down, and I suspect posture plays a big role in this type of stenosis.

Also, according to Dr. Heim (probably the Eagle-Expert in Germany), stenosis of the IJV by the transverse process of C1 can be seen very often without symptoms. The symptoms we encounter are probably a combination of bad transverse process position and styloid process position.
Dr. Heim’s Insta post: https://www.instagram.com/p/CihxNLiKBbS

I do think this is probably the main reason we have such a hard time getting properly diagnosed and treated. Compression syndromes, in general, are tricky because everyone’s vascular system is different and compensates differently. I see this disorder as a spectrum that isn’t as static as it seems.

I believe that the growth of collateral veins could be a very good indicator if a stenosis is a cause for concern. Also, an experienced ultrasound practitioner could very much help determine how much flow is in the jugular through velocities at different points (like Dr. Hepworth does). It is also possible to calculate from the velocities the total blood flow per minute through each IJV, which could also be helpful.
The clinical picture (symptoms and so on) does probably hold a lot of value, as many symptoms we experience seem very specific.

Another comment (translated with Google Translate) from Dr. Heim:

“In order to be able to say with certainty whether compressions should always be treated, other tests would have to be carried out. For example, a Doppler sonography. The CT is almost always static and therefore not suitable for precise statements. However, it is always needed for adequate surgical planning. With a little practice, the IJV can be assessed in the native CT. A CT angio is ideal here. Unfortunately, I don’t know anyone in Switzerland/Austria.”

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Thanks for the info. Dr. Heim seems quite knowledgable, is it possible to make an online appointment with him? I’d like to have him review my scans if possible.

Yes I agree it is very complicated when it comes to venous compression / outflow issues. I think one possible reason why compression is asymptomatic in many people is because the collataeral veins grow and can compensate enough. However, maybe in some people they can’t handle the increased blood flow demands and then you get problems. I think you can see some collaterals in the 3D clip I posted too, not 100% sure.

In my case a mystery I never could figure out is why I got very bad suddenly, had symptoms for months and then they almost disappeared for no reason (~ 2014), then in 2017 and 2019 similar things happened, sudden symptoms (esp. high pressure ones indicating hypertension) and then over months they got better (this time they did not disappear though and many stayed until today).

Now that I learned about collateral veins i think I have an explanation. I.e. the IJV’s got compressed / narrowed then I got the symptoms of high pressure, but eventually over many months the collateral veins grew and compensated, but then later on the veins probably got even more compressed and the collaterals could not compensate anymore, hence why many symptoms stayed.

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Dr. Heim does indeed offer online appointments and reviews CTs, although I don’t know if he also does them in English, but I think he does: https://www.medizinberatung-heim.de/. I also plan to have an appointment with him once I have my CT.

Collateral veins could indeed be a factor for asymptomatic persons, and that could probably be easily researched in studies. I personally viewed collateral veins more as an indication that there are symptoms and problems because there is/was the need to build them, but it could, of course, also be the other way around (or both could be true on an individual basis). I also think there are bigger-than-normal collateral veins in the 3D clip.

I think, in your case, there are probably many factors that could explain the change in your symptoms. One could be a change of posture, not only in the head and neck area but also in the pelvic area, as they are immensely connected. A change in muscle tone could also contribute to a change (something Kjetil Larsen from MSK Neurology sees as a factor), so it could be you were more tense during bad phases. I can absolutely make a connection between body tension and my symptoms (although I don’t know which way around the problem is). And, of course, compensation through collaterals plays a big role.

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Interesting paper & very interesting thoughts both of you…thanks for that!
My personal opinion is if it’s causing symptoms aligning with intracranial hypertension, then surely it’s pathological? I’ve always thought that mine came on suddenly because of a prolapsed disc shifting structures in the neck, & that could well have been the cause, but you say @borko2100 , maybe the collaterals were coping okay initially, but it all coincided with a time when I started doing alot of cycling, so perhaps the increased exercise & forward head posture put more strain on the system & the collaterals couldn’t cope :woman_shrugging:

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Yes I agree posture is something that is overlooked, if you posture is bad long term this could possibly lead to shifting / change in position of the C1 / C2 and this could lead to compression. I doubt this could be reversed though unfortunately.

When it comes to collaterals indeed they seem to be and indicator that something is off, however I think their presence does not always mean a pathological situation. Their absence however might indicate that that the veins are functioning properly. I need to do more research on this subject.

@Jules I agree with a prolapsed disc shifting things, that’s exactly what might have happened with me (I showed the MRI of my hernia in the other thread).

I think my sudden worsening in 2017 could have been a result of a hernia triggered by intense physical activity I was doing, which then lead to a shift in the C1 process and in result compression of the IJV.

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I do think a compression can, to a certain degree, be reversed by a change in posture and postural training. MSK Neurology (https://mskneurology.com/, which also has great articles) primarily focuses on that. Bryan Johnson, probably the most famous IJV Compression sufferer, apparently reversed his IJV Stenosis with the help of MSK Neurology. He speaks on YouTube about his stenosis and the exercises he does to reverse/maintain good jugular flow. (https://www.youtube.com/watch?v=IaO_kRsMA3I, https://www.youtube.com/watch?v=in9ubCilsT8, https://protocol.bryanjohnson.com/)

To note is that he probably didn’t have such intense symptoms as we do, so it is not certain that we could also benefit as much as he did.

Brian Hutcheson, who is mainly active as a chiropractor in the CCI community, claims the same—to improve jugular flow with postural training and strengthening. And, of course, Chris Centeno, who treats craniocervical instability with stem cell injections, primarily focuses on CCI patients. Accordingly, his approach is to stabilize these structures, which, in his opinion, is the best treatment for this patient group to adress a compression of the IJV.

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Great discussion! There is still so much to learn/understand about vascular compressions of all types. I’m so glad there are doctors who are taking an earnest interest in this problem & seeking to understand it better & discover the best treatments for resolution of symptoms.

This is why we HIGHLY RECOMMEND that our members who get scans looking for vascular compression request a DYNAMIC CT scan i.e. w/ the head in various positions, not static. Compression that doesn’t show up when the head is in a static, neutral position, can be revealed when the head is turned to the left/right, looking up/down or on the diagonals.

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I’ve consulted with a few surgeons who work on VES cases. They all wanted to see the IR angiogram with manometry so they could see the pressure changes across the stenosis. A high pressure gradient demonstrates intracranial venous congestion. The angiogram also gives a great look at the collaterals if there are any. Also, during my consult with Dr. Nakaji they explained that veins are very dynamic, collapsing and expanding due to numerous factors including your hydration level. So seeing a narrowing captured on imaging of a narrowed IJV could represent just a moment in time due to various factors. That’s why they want to see the IR angiogram. And remember, if you are going to have one of those, it has to be done wide awake as there seems to be complete consensus that you can’t get accurate manometry measurements with anesthesia.

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@komok that seems fascinating thanks, I might give some of those exercises a shot, worth trying.

@Chrickychricky very interesting. Yea I knew there are some more advanced tests that can be done, I guess this manometry test is what is necessary to confirm pathology for certain.

they explained that veins are very dynamic, collapsing and expanding due to numerous factors including your hydration level. So seeing a narrowing captured on imaging of a narrowed IJV could represent just a moment in time due to various factors.

Yea, I’ve always thought that there is quite a bit of variability to how well those veins can drain the brain. Me, personally I have ups and downs daily and over longer periods as well.

However I am not sure if a narrowing captured on a scan could just disappear due to the veins expanding. Why I think that is because, if the vein is in a collapsed state (due to the dynamics you mentioned), you would expect it to be smaller / narrower along it’s entire length, not in a well defined specific location. In order for the narrowing to disappear then the vein would need to expand in that specific location and that seems quite unlikely. But yea I guess it depends maybe in some cases where the a large section of vein looks narrowed this could be due to those dynamics and not compression / stenosis.

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Does “wide awake” mean it can’t be done with conscious sedation? Meaning you are heavily sedated but still conscious enough to follow instructions like turning your head to the left or right?

When I had my cerebral venography and manometry with Dr McDougall at Swedish in Seattle, I was sedated but conscious. I felt very sedated and for a certain amount of time initially I was completely out of it.

Dr McDougall found severe right jugular vein compression but he judged my pressure measurements to be technically within a normal range.

Dr Hui, based on the results, still recommended surgery given my symptoms.

However, I am wondering whether the conscious sedation I was given made the venous pressure measurement inaccurate? I wonder if the pressures would have been measured higher if I had no sedation at all?

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Did the Dr. explain why the pressure is normal despite there being severe compression? Maybe the other vein could cope well enough or the collaterals?

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From what I understand from Dr. Amans, any sedation could cause you to miss pressure gradients. There seems to be consensus with that in the interventional radiology community. Glad you are still able to move forward!

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Looking at the procedure notes, it looks like I was given Fentanyl and Propofol during the procedure.

I have to assume that the Propofol especially made the pressure gradient readings inaccurate.

Dr McDougall is a very smart guy, but intracranial hypertension and cerebral venous congestion is not really his specialty so maybe he isn’t up on all the effects different sedation can have on venous pressure measurements.

Luckily Dr Hui considered the images enough to recommend proceeding with surgery despite the seemingly “normal” pressure readings.

I’ll see if Dr Hepworth wants me to repeat the procedure without any sedation, but I expect he’ll rely on his patented ultrasound protocol to confirm the diagnosis.

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@Chrickychricky - I recently had an angio/venogram done by a vascular surgeon. I asked about it being done w/o anesthesia, & he said it made no difference in the results. He preferred it w/ anesthesia because it helped his patients be more relaxed which he believes gives more accurate results. He’s done over 1000 of these studies so has a lot of experience. I guess that’s to say different doctors have different opinions, which we all know anyway.

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For sure. I’m just going by what Dr. Amans said and what the consensus was when the issue came up during that venous congestion webinar.

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Myself, and I know of a few others who have had this procedure showing normal pressure gradients and blood flowing. I have huge collaterals. I am proceeding with surgery.

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@Brandy, who did you decide on for surgery?

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Hepworth. I’m hoping it’s the right decision. He wants to address my thyroid and sinuses as well. I have a lot going on. I think he being an engineer (I find that a huge plus), he looks at things differently. I first plan on flying out to Maryland next month to get a proper evaluation from Henderson. Dr. Henderson feels I need a fusion (still debating where ). Dr. Hepworth plans on speaking with Henderson prior to surgery. I want to be SURE I am doing things in the correct order. I also added Dr. Ilene Ruhoy to my team. She wants to do a muscle biopsy. Oy vey!

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Definitely alot going on…let us know how you get on with Dr Henderson too :hugs: