I had my cerebral venography yesterday and followed up with Dr McDougall today.
Basically, the venography did reveal severe stenosis (basically occlusion) in the right jugular vein, but the left was pretty open and draining well.
However, he did not see a major pressure gradient across the right jugular stenosis, so he was uncertain as to the clinical significance of the stenosis. I can’t find the actual numbers, I’ll post them if I can find them.
I did confirm that he actually has not performed any styloidectomy surgeries, but he is absolutely knowledgeable about this evolving area of medicine through his relationship with Dr Hui.
Here’s his notes following today’s appointment:
"Jacob returns with the sister today to discuss the results of his cerebral venogram carried out yesterday. Placed we went over the severe stenosis affecting the right internal jugular vein at the level of the C1 vertebra which appears well compensated in terms of flow across the torcular are to the left transverse sinus in the sense that the venous pressures appear to be within normal limits. Additionally no significant gradients were identified, and no restrictions in flow through the dominant left internal jugular vein were noted with the head turned to the right or the left.
We discussed the evolving understanding of cerebral venous hypertension the potentially confounding possibility of an intermittent CSF leak and my uncertainty as to whether or not the right jugular stenosis is clinically significant given his intracranial cerebral venous pressures which would be considered traditionally to be within the normal range.
He will seek further advice from Dr. Hui and contact us if we can be of further assistance in the future."
I wonder about the effect of the medications they gave me and whether they may have caused erroneously low pressure readings.
But, more importantly, wouldn’t an active nasal or skull base CSF leak cause the pressure gradient readings to be much lower than they otherwise would be without a leak?
If the idea is that pressure gradients indicate that venous outflow obstruction has led to a build up of pressure in the brain (intracranial hypertension) and thus symptoms, then a CSF leak would act as a safety valve lowering the pressure and thus lowering the pressure gradients across the venous stenosis.
So even though the pressure measurements were within “normal” limits, the occluded right jugular vein could still be the underlying cause since the initially high intracranial pressure could have caused the CSF leak.
Therefore, even though Dr McDougall didn’t measure very high pressure gradients across the stenosis, if I were to repair the CSF leak without decompressing the jugular vein, my intracranial pressure would rise and so too would the pressure gradient across the narrowed jugular vein if the cerebral venography were repeated.
Does this make sense?
Has anyone else with both jugular vein compression and an active CSF leak had erroneously low pressure gradient readings on a cerebral venography?
Next steps are to follow up with Dr Hui and maybe go on to get a referral to Dr Hepworth.
I’m also scheduled to get a CT cisternography to hopefully visualize and confirm the CSF leak.
Curious to hear people’s thoughts about these results.
