Rant: JAYARAMAN et al. (2012) Incidence of Extrinsic Compression of the IJV

General Research Papers
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Sometimes, an article just makes you mad… or just sad…

JAYARAMAN, M.V. et al. 2012. Incidence of Extrinsic Compression of the Internal Jugular Vein in Unselected Patients Undergoing CT Angiography. AJNR Am J Neuroradiol 33(7), pp. 1247–1250.

[Incidence of Extrinsic Compression of the Internal Jugular Vein in Unselected Patients Undergoing CT Angiography - PMC]

I’m wondering how many people are not getting treatment for IJV issues because of this paper, which states that IJV compression is asymptomatic and not medically relevant. A paper like this would do much to make IJV compression a controversial diagnosis.

From the final summary of the paper. Here, ‘at this level’ means between the jugular foramen and C3:

These findings suggest that extrinsic compression of the IJV at this level is unlikely to be pathologic in nature.

However, before this conclusion it rightfully noted that

…this is a retrospective series of patients with a neurologic reason for undergoing the CTA, which could be different from a control population of normal subjects.

I’d been wondering this when reading the paper. This means that the CTA scans were only taken from patients that had a reason for having the scan. That means that if compression of IJVs caused concerns about neck issues, this would show up at a higher rate in the scans. Yet, the study goes on to say:

However, given the large number of patients in our study, we feel that the incidence of jugular stenosis is likely representative of a larger cohort of patients.

This is categorically wrong. A higher number of people doesn’t make this a control group (a random group of people without symptoms). The results shown in this paper are also consistent with jugular vein compression CAUSING neurological or neck complaints. The only inferred argument they can make is that there are too many patients with IJV compression, but this argument itself only works with an implicit assumption that IJV compression is not pathological or if symptomatic would be very rare. This is called circular reasoning, and is a logical fallacy.

Now, a careful reading of its methods does state that no tests were ordered specifically for suspected venous problems, but that is also somewhat circular if you’re expecting IJV to not cause any issues. They only looked at CTAs for the neck that didn’t have other imaging done (doing so might have made for a more random selection), and didn’t state how many scans they looked at to select 108 from if that wasn’t the total number of scans.

I’ve seen worse papers. This one at least admits its problem, even if it subsequently brushes it aside as if it didn’t exist. I’d be really interested if those with severe compression could be followed up with. Then, the paper would have merit if it could show their issues were NOT in any way caused by IJV compression or that IJV compression didn’t cause complications. As it is, I worry that so many of these people had their issues dismissed as is common in many of our stories, and that this article has caused much harm in the meantime.

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Thank you very much for the article and your brilliant observations on that. Really appreciate that.

I’m also wondering why they didn’t examine blood flow velocities inside IJV in those patients. It can be done easily and without any harm for the patient by ultrasound. This could then provide further categories for classification. Possibly only patients have problems where the flow velocities are too high…? The classification of the degrees of stenosis also seems to have been chosen rather arbitrarily. The degrees of stenosis could possibly also be determined better on the basis of the flow velocities.
From my point of view, it would also be possible that the body has a certain degree of compensation possibilities, which could be impaired by additional events (e.g. traumata or infections) by affecting either the jugular veins or the collateral vessels.
I also think that the - to put it mildly - controversial studies from Italy in connection with CCVSI and MS have become very well known in the professional world. This is now causing thought blocks in many doctors and preventing further studies with a higher degree of systematicity - like this article too.

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Great points. They didn’t check blood flow velocities because they only studied the images after a year, presumably when all patients had left the hospital, and I suspect were already assuming IJV compression would have no effect so wouldn’t bother checking. If they had checked because they thought it might help the patient, those patients would have been removed from the study anyway. It’s an incredibly flawed paper from an experimental design perspective.

My original misdiagnosis, when things were more mild, was severe migraine aura. One the potential treatments for that was stenting, which completely left the table after that Italian controversy because nobody would touch it afterwards. On the subject of migraine, its possible vascular connection in some cases was already being dismissed out of hand as the pendulum swung to over-compensate for what had earlier been an over-estimation of its importance.

I also found an older article lamenting that vascular issues in the head and neck are a no-man’s land in medicine. Pretty much the only widely accepted issues seem to be stroke and arteriosclerosis. Neurologists see it as in internist’s issue, internists see it as a neurological issue, and nobody seems to want to study or have the time for the complex interplay between blood flow and brain function. Especially since there is a good chance many will ostracize you for even looking.

There is some indication that the pendulum might be swinging back, but these things move slowly. Dementia research (with the failure of tau), recognition of vascular Eagle’s (still a struggle), and even brain fog studies (reduced blood flow when sitting for long periods, etc.) seem to be gaining some small acceptance rather than being dismissed out of hand.

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It seems this paper would be much more accurate, useful and promising if they changed the title and subject to “Incidence of Extrinsic Compression of the Internal Jugular Vein in Unselected Neurologically Symptomatic Patients Undergoing CT Angiography”.

I think it’s quite a systemic issue with various medical articles written “for the sake of grants, titles, promotions and resume lines”. “Researchers” use data about symptomatic patients and then draw conclusions about general population, which includes minority of symptomatic patients and majority of non-symptomatic individuals.

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You all make good points. @Mclean, thank you for posting the link to the paper. I think we’re all learning there’s “good” research & “bad” research that is written up. Being able to discern between the two is what’s most important.

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