I have looked into the Catheter Angio/Venogram. Nothing new to report except that I see potentially some dynamic involvement of SCM muscle and Internal Carotid Artery (ICA) when you turn your head to the left and to some lesser degree when you flex your head. Really do not know the significance of them since the most of the compression is done by C1 (thank God it is out now). After 3 months or so, you should be able to do another assessment to see if left IJV has opened up fully.
Neck Flexion : Neck flexion images show severe Left (LT) IJV narrowing. You can see the blood is congested around the Jugular Bulb area (Blue Circle) and collateral forming (Blue Arrow). I think it is being squeezed by C1 (Red arrow) and Styloid (Light Green Arrow). I also think Carotid Artery (ICA) is also involved down below as the LT IJV appears to be slightly pushed inward in the area of ICA (Big Yellow Arrow) when you flex your head.
Here is an internet image showing how the 2 IJVs and other veins interconnect so you have an idea when you see the blood following from left side to the right side (Light green arrows) due to compression. Since you are an IT guy, think of full mesh topology as vein interconnect like network.
Head to the left : Turning to the left appears to be second to flexion in severity of left IJV compression. Major collateral veins become prominent (Blue Arrows) and an interesting observation can be seen that the left IJV gets compressed in mid section possibly between Carotid & SCM muscle (Yellow Bars). I speculate that this could be due to the left SCM moving inward as your turn the head left compressing the IJV against the ICA since IJV runs between the ICA & SCM. The first image has pattern of ICA compression of IJV. Also the second image shows the collaterals (connecting veins) going across (Blue arrow) and draining into the right IJV (Light green arrow). This is different when the right IJV is drained into by the right transverse sinus which is coming from the brain. This is potentially caused by left IJV compression getting worse in the left turning position hence draining into right IJV through connecting veins.
Here is an internet image from a study of dynamic SCM compression of left IJV (Source Study: Case Report: Moving target: transient rotational stenosis precipitating jugular bow hunter's syndrome - PMC). I am not saying you have this issue but to illustrate the movement of SCM muscle when you turn your head left can mimic this type of compression. It appears it moves inwardly pushing the left IJV inwardly towards the Carotid Space since IJV runs between the ICA & SCM (Perhaps, forming temporary, dynamic compression from ICA & SCM).
Head in neutral/Straight : In neutral position, C1 (Red arrow) appears to be doing most of the compression and collaterals become prominent (Blue arrows) and can be seen draining since IJV is compressed. I guess you already know this.
Head to the right : Turning to the right appears to be relieving the compression on the left IJV and few to no major collaterals can be seen (blue arrow). This is similar to mine where looking at right appears to be relieving compression and like yours, no collaterals are seen. I speculate that IJV might be moving inwardly away from the nutcracker position of the C1 & Styloid area (Red Arrow).
If you have not seen it, Here is where I talked about my dynamic angiogram with images. Like you, in neutral & left turning exasperates the left-sided IJV compression of C1 and Styloid but right turning relives it.
Today is day 22 post op. I have almost normalized to level where I was before surgery, so no relief from any actual symptoms yet. I have noticed the swelling has slightly gone down in the last few days. So I’m not sure how long most people experienced noticeable swelling, but mine is going to be easily 30+ days.
I have been gone on a family vacation for the past week. I wanted to post some updates and replies while I was away, but just found it too cumbersome on my phone.
I probably pushed myself way too hard the last week, lifting kids and heavy suitcases because I don’t feel any real pain from the surgery. I limited my picking up of heavy objects to the right side and not the side of my surgery. However, I am sure this has prolonged the inflammation around the site of the incision. So don’t go by my example.
Here is a picture of the incision, which is healing up nicely.
Hi @KoolDude, as usual you really went above and beyond when dissecting my venogram. I’m glad that you laid out so many visuals for other potential suffering VES patients to help look at and compare to their own scans.
I looked at this reply a few days ago on my phone, but didn’t fully absorb some of the details.
Comparing the neutral vs the turned to the right head positions are great visualizations of what to look for with collateral vein drainage. It also shows the need for taking the scans in varying head positions. Before my surgery, Dr. Patsalides told me to try turning my head to the right for extended periods of time and this is obviously why.
The other important thing you picked up and that I could never explain was the interference by the SCM muscle and possibly the ICA. I couldn’t figure out why the in the left head position the stenosis appeared much further down, but I think you nailed it.
Yeah, I could not either so it is plausible that it could be SCM muscle moving inwardly (twisting inwardly) as you move your head to the left then it is possible that it is compressing the left IJV against Carotid artery as the compression pattern fits Carotid compression of IJV. Can’t think of any other mechanism. I think, with the right turn, the opposite happens, SCM moves outwardly, away from the IJV.
This is good news. I am betting on that there is still swelling inside and thin walls of IJV are collapsed by them. We shall see. 3 months is the magic number for swelling to abate.
@GCD - your incision really does look good but you’re right, lifting kids & luggage, even w/ the opposite side probably didn’t help resolve your swelling at all. My incision looked similar at 3 weeks post op except due to the way it was sutured, it looked like a caterpillar on my neck. In another couple of weeks it’ll begin to flatten out & become less visible.
As @KoolDude noted, as long as there’s inflammation in your neck, the poor IJV will struggle to stay open. Once that begins settling down, hopefully your blood flow will get stronger & your symptoms will begin to fade.
Today is day 37 since my surgery. I wanted to wait and give everyone following along the CTA imaging I had done last Friday with this update.
I was also worried that the surgery was not having the desired affect on my symptoms. As I showed no improvement for the first month and went backwards in some areas up until a week ago.
However prior to my scan last week I started to notice that I have had consistently more energy in the mornings. I can’t notice a big difference day to day, but if I compare where I was week to week I am noticing little changes. Mainly with energy increasing and the visual ghosting dissipating. I want to wait until the 3 month mark to really comment on how I feel on all the symptoms I listed before surgery.
I have also noticed a fair amount of dizziness due to the swelling being an issue. I had minor dizziness before the surgery. If I chew too much, talk for extended periods or get bumped near my surgical site then the dizziness ramps up for a few days. I think the fluid is putting pressure on my left ear.
I still have a fair amount of inflammation all around the surgical incision. It is very slowly going down. At this rate, I’m probably looking at least at 3 months before it totally subsides.
I did a comparison of 3 different scans so you can get an idea of a before and after shots of how the surgery went for me.
Also here are 2 videos of my CTA showing how much of the styloid and transverse process of C1 was removed. You can see that the left IJV is totally free to expand into that area now. Also you can see that the IJV retained some of its compressed shape at the level of C1, hopefully over time it will open more. I will be asking Dr. Lo if he thinks balloon expansion could help with this process.
CBCT prior to surgery (Teal skeleton) overlayed on to top of my CTA. The CBCT was taken sitting up and the CTA was taken while lying down, so my posture is slightly different. I lined everything up at C1 since that was the area of focus. https://vimeo.com/838783843?share=copy
Thank you so much for sharing the detailed views of your scans, @GCD !
I’m really happy that you can see such a significant difference in the before and after images. It appears that the styloid has been resected all the way to the skull base, and the C1 has been resected close to the transverse foramen of the C1, would you agree? It looks like there’s ample space for the IJV to expand into.
This looks to be a very promising result so far? Especially with the IJV cross sectional area increasing by 50%. Here’s hoping it continues to increase even more in the coming months!
It’s great to hear that your symptoms have been improving as well.
Let’s keep our fingers crossed that things continue to improve for you!
@GCD - The images & videos are impressive in the changes they show pre & post op! As far as recovery goes, I really feel you’ve “hit the nail on the head”. Inflammation in the surgical area is still putting pressure on nerves & the IJV as it tries to expand. Giving your symptoms & energy level another couple of months of recovery before doing a hard evaluation is a good idea. I totally felt like I’d had the stuffing knocked out of me for 2 months after my first surgery. Being an active person, lacking energy was really frustrating, but as you’ve noted, it came back gradually, then one day, I felt like my old self. It was so great! It did take getting my second styloid removed to really get me back on my feet closer to 100%, but at least I was on my way.
@GCD this is good news. Your IJV appears to be expanding and it is good indication that whatever stenosis left over will resolve in due time. Also good to hear that you are noticing subtle improvements. I think age is a factor in recovery as well. The younger you are the more likely your IJVs will respond to surgery (less fibrosis). Overall good comparison on pre vs post operation.
@Isaiah_40_31 The inflamation is no joke. It doesn’t hurt, but I can feel the pressure in the general area of the surgery site. I can only imagine what is happening to my nerves, ear and IJV.
@Jules Thanks for the link to thread posted by @patientD I’ll have to watch those videos over the weekend. I did see there was a device that would help, but I’m still too worried to apply any pressure to that area.
@KoolDude I think there is a fair amount of fibrosis. It’s hard to see in the videos, but I did isolate the IJV and where C1 was impinging the vein you can still see indentations.
@GCD Good CTV. I had quick look but find a few things of questionable significance. You right Hyoid bone appears to be abutting your right ICA. I also found that your Hyoid bone is titled to the right. I guess this is only a problem if you get provocative right neck movement which could trigger a compression. You need to be aware in case you have not noticed it in the CTV.
Secondly, I found your left Brachiocephalic Vein (BV) narrowed and compressed between the AORTA and Sternum just before it joins the Vena Cava. Since your left IJV is the dominant one, it connect to BV so I guess it is something to keep in mind since it could b significant if it causes issues down the road. Also, BV are subject to dynamic compression. Sometimes shrugging or lifting arms can make the compression worse or better as I have seen in other cases like that. So it might not be an issue now but something to be aware of. I will explain this in another thread since I might also have dynamic BV compression which I came to know in my last Jan 2023 CTV.
Here are Axial slices showing right Hyoid bone (Cyan arrow) abutting right ICA (Red arrow). Not sure the significance of this.
Question, when Dr P did the angio/venogram, did they measure the pressure gradient in the BV? if so, it would be interesting to see if it is high or normal. If not, may be you can talk to Dr P about this and see what he says though I know an intervention on BV is very risky (due to the proximity of big arteries and veins) and is hardly done. There is also limited (this is even rarer than Eagle Syndrome) so do not expect to get a lot of literature on it or answers from vascular doctors as they rarely encounter it.
I would focus on healing now and see what resolves. Chances are, this is not a problem now. I did not mean to worry you here but I had to point it out since I saw it on the CTV.
Very fun to see the C-1 vertebra in various positions in the video. The before & after images side by side are quite remarkably different. It’s sure easy to see how close the remaining styloid is to C-1 on the right! Really interesting to see how much of the TP of C-1 was removed, too. Hopefully once @GCD 's swelling abates, he’ll begin to have more significant symptoms recovery.
@KoolDude, well I spent most of the day examining this scan now thanks to your thorough analysis.
I totally missed this somehow. I went back to look at my old CT and it was slightly tilted to the right, but not even close to this. It makes sense that the styloid ligament that held it on that side was cut, so it would sag down. I just never thought it would look like that. I will have to discuss with Dr. Costantino, but I assume its to be expected to some degree. Has anyone else seen a single sided styloidectomy that shared their CT post op?
I noticed this too when looking at the CT with the radiologist right after the scan was taken. He was trying to name the anatomy, but it confused him when everything got smashed together. I’m glad you pointed it and will be eager to learn more from your posts and findings on this shared issue.