Dynamic jugular venography was performed under local anesthesia and sedation, without complications. Venography showed findings consistent with those seen on the CT scan performed prior to the procedure, with a reduction in the caliber of the right internal jugular vein at the level of C1 and a pressure gradient at the borderline of significance (2 mmHg). No significant abnormalities were observed on the left side.
Technique: Supine position, local anesthesia with sedation, puncture of the right basilic vein, and placement of a 5F introducer sheath.
The right internal jugular vein was catheterized above the C1 transverse process. Venography showed a change in caliber compared with the proximal jugular vein. Pressure measurements were then performed, showing a 2 mmHg gradient between the jugular vein distal to the C1 transverse process and the proximal jugular vein.
The left internal jugular vein was catheterized above the C1 transverse process. Venography showed no change in caliber compared with the proximal jugular vein, although its diameter was smaller than that of the contralateral side.
Pressure measurements were then performed, showing a 0–1 mmHg gradient between the jugular vein distal to the C1 transverse process and the proximal jugular vein.
On this forum, we disagree with the statement “styloids are fine” thus cannot be causing symptoms. We have had members who’ve had normal length styloids, but due to their thickness, how curved or angled they’re growing, how pointed, or twisted they are, even their normal length styloids caused nerve irritation, & in some cases, vascular compression at the level of C1. Some time ago, there was a member who had very normal looking styloids - not thick, curved, angled, twisted, or pointed, but hers grew little bony “barbs” on them which caused severe nerve irritation. Another member had what looked like little bony branches growing off a tree trunk. By these examples we know not to judge as person as having ES or not just by styloid length.
I’m pretty sure these doctors have been suggested to you, but here’s the list just incase they haven’t been. All of them do telehealth consults for which they charge a fee, but you could at least get solid medical opinions from one or more of them:
Dr. Aghayev - - https://kamranaghayev.com
Link to set up a consult: Get Expert Neurosurgeon Consultation & Second Opinion Online
I spoke with Kamran, but I’m still not sure whether the problem is more related to an abnormal movement of the cervical spine and C1, with nerve irritation playing a bigger role than the IJV compression.
He told me:
Based on the clinical evaluation and imaging studies, the patient has bilateral internal jugular vein compression at the level of the styloid process and the transverse process of C1, resulting in significant narrowing of both internal jugular veins.
The findings are consistent with bilateral stylo-jugular venous compression syndrome. Due to the anatomical compression and the associated symptoms, surgical treatment is recommended.
The proposed procedure consists of:
Bilateral styloidectomy to remove the elongated styloid process causing venous compression.
Shaving (partial resection) of the C1 transverse process to achieve complete decompression of the internal jugular veins.
The objective of surgery is to restore adequate venous outflow and relieve symptoms related to impaired cerebral venous drainage
Thank you for the reminder, @nemo. I’m sorry I lose track of who’s consulted with whom with so many members on this forum now.
The fact you have bilateral compression but mostly nerve symptoms could, as has been suggested by @Filya, indicate your body is compensating for the lower than normal flow through your jugulars via collateral veins . It would be good for you to get at least one other opinion besides Dr. Kamran’s though you could have another talk with him to discuss that you don’t have vascular symptoms & ask why he thinks that would be. If you do consult w/ another doctor, that is a question that you should ask the second doctor as well.
Description in the report (protocol) Your procedure.
You have had a DSA venography with head turns. (Can you share these snapshots from the disc?)
2)Description -the report partially corresponds to the procedure specified in the articles.
I roughly calculated the pressure difference before (right atrial) and after C1 (torcular pressure) , without compression. And I will say this, that pressure losses (difference ) equal to 2 mmHg or less are very minimal values and very good, i.e. very ideal. In reality, this value is higher (even the calculated value). The calculated value without IJV compression is approximately 2-5 mmHg, and articles indicate 4-6 mmHg. Therefore , 2 mm . The mercury column is a very ideally low pressure loss. Theoretically, the gradient (pressure difference ) is 2 mm. a mercury column is possible, but these are very low pressure losses, ideal. I suspect that they did not take into account all the nuances during the measurements. Do you have developed facial veins, they were measured just after the facial veins and before C1.
The second is that the left IJV is compressed more strongly and why is the pressure gradient there better (less)? They wrote the threshold value of the anamnal pressure gradient of 2 mmHg, but in the articles they write that the threshold of the pressure gradient is more than 5-8 mmHg (perhaps they did not fully understand these measurements. An increase in pressure by 2-3 mmHg, even from a medical point of view, makes no difference.In general, there are a lot of questions about such measurements and the doctors who made these measurements). What is the pressure measured in the transverse venous sinuses (10-15 mmHg or higher, for example 20-30 mmHg)? In your case, it’s not the pressure gradient that will tell you more, but simply the pressure in the transverse venous sinuses. Share the full report and DSA snapshots.
In fact, you need to take a lot into account when making measurements, but doctors are not engineers and they cannot understand all the subtleties of hydrodynamics. So I don’t think there are doctors who can take all the details into account.
In the sigmoid venous sinus, there are several angles-turns and bends. And in this place there can be no complete absence of pressure losses (zero gradient) or extremely low pressure losses. There will be low losses when there is a bypass bypass nearby, when the pressure is balanced due to another branch. Or the measuring point has a different compression below, and then the pressure also comes into balance at two points. For example, below is the compression like yours, where is the bifurcation on the left. There are a lot of subtleties in hydrodynamics, doctors are not engineers.
In general, such measurements are very difficult. Pressure gradient measurement (pressure difference) . I do not know if two sensors are used to measure pressure at the same time or not (at the same time). Since the pressure in the veins can change rapidly over time (especially by a small amount of 5 mmHg), it also depends on breathing and heartbeat . It is a little easier to measure blood pressure in the transverse venous sinus and compare them with the data from examinations on healthy people. But here, too , you need to take into account your heartbeat and blood pressure , i.e. these are all input data (parameters must be monitored). It’s all very complicated. So such measurements are wrong in conception . Moreover, doctors are technically not very literate, they have other knowledge. In our country, all doctors of ultrasound diagnostics (Doppler scan) made mistakes when measuring blood flow rates in the arteries. They measured the speed of blood flow at corners, turns, and at the point of curvature of the artery vessel, and did not adjust the angle in the program to correctly display the speed value. And they had greatly overestimated blood flow rates, which they mistakenly interpreted as stenosis, i.e. they falsely concluded arterial stenosis when it was not in this place. I pointed out this error to them, and some ultrasound doctors are now correcting the angle in the program.
I repeat once again, in your case, measuring blood pressure, it will be informative to measure blood pressure only in the transverse venous sinus.
Nevertheless, compression of the internal jugular veins cannot be ruled out (but I am not saying that all the symptoms are due to them). Your right IJV is lying down and your head is straight: 70% stenosis, and your left stenosis is more than 90%.Decompression of the IJV may occur when the head is turned.I saw CT scans of a person with a head turn. In the C1 area, there was decompression of the IJV on one side, but not on the other. There was also compression of the IJV between the anterior scalene muscle and the SCM. Dynamic compression. And the pressure will also change. This is a significant compression, and since you do not have developed vertebral veins, this may cause some symptoms. left IJV compression and a bladder, here’s a look at the CT scans.
drive google com/drive/folders/1ISU3GJd9ORMtJvEctKDl_uC2u50q1K4Z?usp=drive_link
pdf drive(dot)google(dot)com/file/d/1lQiy8wMJ7o6Ukv3iSEfrFBWdOkfif750/view?usp=drive_link
Does your throbbing ringing in your right ears get worse when you’re lying down or when you’re standing? Or does it not change?
But I understand that you haven’t had a head-turning DSA arteriography.
I also have suspicions about your burning under the collarbones (as I told you earlier TOS), I clearly see that your right IJV in the valve area may be damaged mechanically. Because there’s a valve there that probably won’t close anymore, and you may have retrograde blood flow (reflux). You can easily check this on a Doppler scan. I can’t tell you exactly what kind of symptoms reflux can cause, there are articles on this topic (I don’t remember anymore, but I’m too lazy to look. Moreover, we already know that doctors also make mistakes and may make mistakes in medical articles. ). In addition, a non-working valve will indirectly confirm a significant increase in pulsating ringing (tinnitus) in the prone position (lying position).
as I got used to it Google or Yandex translator. There are so many mistakes in translation, he constantly calls me you, a significant increase- writes a significant decrease, and so on))))))
Yes, with the head turned to the right and to the left. I don’t have the images yet, but I’ll send them as soon as I get them. (What I currently have on the CD is the MRI; I’ll send those images once I download them.)
Maybe they didn’t measure it correctly. The measurements were taken while I was lying down and under light sedation. However, I think the report says that on the left side there was no change in the caliber of the vein (“Venography was performed, and no change in caliber was observed compared with the proximal jugular vein”), yet the CT images appear to show significant compression. Could this be an error?
I don’t have prominent facial veins at rest, but my facial veins become very noticeable and my face turns red when I perform Valsalva maneuvers, although I think that’s probably normal.
Could the gradient be lower on the left because the right side is the main drainage pathway?
Could the gradients have come back low because they measured the right-sided pressures with my head turned to the right and the left-sided pressures with my head turned to the left? Honestly, I don’t remember exactly how it was done because of the sedation.
The full report is the one I sent previously:
“Dynamic jugular venography was performed under local anesthesia and sedation, without complications. Venography showed findings consistent with those seen on the CT scan performed prior to the procedure, with a reduction in the caliber of the right internal jugular vein at the level of C1 and a pressure gradient at the borderline of significance (2 mmHg). No significant abnormalities were observed on the left side.
Technique: Supine position, local anesthesia with sedation, puncture of the right basilic vein, 5F introducer sheath.
The right internal jugular vein was catheterized above the C1 transverse process. Venography showed a change in caliber compared with the proximal jugular vein. Pressure measurements were then performed, showing a 2 mmHg gradient between the jugular vein distal to the C1 transverse process and the proximal jugular vein.
The left internal jugular vein was catheterized above the C1 transverse process. Venography showed no change in caliber compared with the proximal jugular vein, although its diameter was smaller than that of the contralateral side.
Pressure measurements were then performed, showing a 0–1 mmHg gradient between the jugular vein distal to the C1 transverse process and the proximal jugular vein.”
I’ll send the DSA images as soon as I have them.
I don’t think they took all of these factors into account, so I’ll ask the doctor by email. Could you tell me exactly what I should ask her? Thanks in advance.
I agree with you. I don’t think the findings seen on the CT scan are irrelevant. This should be investigated further, along with a possible mechanical cause.
Maybe, as I mentioned in my other comment, they measured the pressures in positions where the vein was actually open. I’ll clarify this with the doctor.
As I mentioned in my other comment, could you please tell me exactly what I should ask her and what information I need to find out?
If you mean hearing my heartbeat in my ear, it has happened on the right side, perhaps with changes in posture or when my pressure increased, but it’s rare. What happens more often is the ringing in my ear (also on the right), which occurs without any apparent trigger, at any time and in any position.
Something else I notice in my right ear is a feeling of fullness or as if it’s blocked. I also have pain behind my right ear that radiates into the right side of my jaw.
Yes, the venography was performed with my head turned both to the right and to the left.
It’s not a burning sensation. It’s more of a feeling of pressure around the collarbone, followed by strong heartbeats. What do you mean by “mechanically damaged”?
Don’t worry, I understand you. After all, that’s the translator available in Russia.
This is what the pain feels like on the right side; the trigger is movement.
The red dot marks the point of origin, which corresponds to the area where the compression is located. The pain mainly radiates toward the area marked in red, and I also feel a sense of fullness or pressure inside my ear, accompanied by pain, similar to the feeling you get when water gets into your ear while swimming.
I’ve already written all the information to you. The left IJV is more compressed than the right one. That’s why the left IJV is thinner. Your right IJV is the main pathway for venous drainage. They might have made mistakes.
Ask what value was measured for the blood pressure inside the head (in the transverse venous sinuses).And how it changed when the head was turned. The pressure is only in the transverse venous sinuses, not the pressure gradient (the difference in pressure).
DSA arteriography (VA and CCA and source area )with turn of the head (Dynamic test )
3)You can ask them about Doppler scanning of the internal jugular veins to check for the presence or absence of retrograde blood flow (reflux).It’s safe, simple, and inexpensive.
4)Try running lightly for two weeks, two to three times a week. Ask your doctor about blood‑thinning medications( Clopidogrel or heparin) If you feel significant relief, it will indicate a vascular problems.
This is the nerve innervation of Eagle syndrome. The muscle in the neck maybe SCM ,trapzius he controlled accessory nerve,or maybe TOS. Also, ask the doctors about the bubble on the right in the C1 region; it seems more likely that something is obstructing it (possibly the oblique and rectus muscles of the head).
Hi Nemo, You will find this video useful especially between 48:00 minutes and 52:00 minutes. …Doppler flow ultrasound velocities to diagnose internal jugular vein compression, detection of “jetting” at the compression site. …Also how venous pressure gradients under anaesthetic and Xanax (51:15) disappear …cranial venous stenoses that miraculously disappear under anaesthetic and sedation especially in the decubitus position (lying down).
It may also be useful to measure the volume flow rate in the vertebral arteries and the common carotid artery using Doppler (on a direct segment artery and with proper angle correction). It is also necessary to record the spectrum and the diameter of the vessel at the measurement area.
But I don’t know if you’ll find such a good ultrasound diagnostician who measures the volumetric blood flow rate (ml/min) and who also knows how to correctly adjust the angle manually in the program.)))))) Measuring volumetric flow rate in veins is even more complicated( difficult ) and often a utopia.
The jaw pain could well be caused by irritation of the Trigeminal nerve .
Have you had an ECG done to check the hard heart beats you’re getting? It could be Atrial fibrillation or Ventricular ectopic beats, so an idea to get checked out in case. I’ve been having similar recently - there are quite a few things which worsen mine, caffeine being one, but also doing some exercises for my posture & neck, raising my arms above my head in a Y shape & out from the shoulder in a T shape. I don’t know why this causes it, but the feeling of pressure around your collar bone sounds similar to what I’ve noticed…
1.2.3 I will ask about the venous sinus pressures and how the pressure measurements were performed, to see if there may have been any errors or limitations in the test. I will also ask her about TOS and see what she says.
I will also try to get dynamic tests from the neuurosurgeon, such as a dynamic CT scan with head rotation, to investigate possible mechanical causes and irritation of structures with movement.
Antiplatelet medications are safe right? I assume it would be a low dose. Approximately how long would I need to take them to see if there are any changes?
The pain originates in the C1 area (the red dot) and radiates from there, so that would likely be the cause.
The “bubble” in the right IJV above the compression is a dilation of the jugular bulb that goes into the ear because there is no bony plate (jugular plate) separating it from the hypotympanum. I assume this is secondary to the compression. But if it is caused by the compression, and there is blood pooling above the compression, why did the pressure gradient come back negative? Or is the jugular bulb dilation unrelated to the compression?
They wrote the threshold value of the anamnal pressure gradient of 2 mmHg, but in the articles they write that the threshold of the pressure gradient is more than 5-8 mmHg (perhaps they did not fully understand these measurements. An increase in pressure by 2-3 mmHg, even from a medical point of view, makes no difference.In general, there are a lot of questions about such measurements and the doctors who made these measurements). What is the pressure measured in the transverse venous sinuses (10-15 mmHg or higher, for example 20-30 mmHg)? In your case, it’s not the pressure gradient that will tell you more, but simply the pressure in the transverse venous sinuses. Share the full report and DSA snapshots.
