prevalence of incidental narrowing in upper IJV

A forum to discuss Chronic Cerebrospinal Venous Insufficiency and its relationship to Multiple Sclerosis.

prevalence of incidental narrowing in upper IJV

Postby Cece » Tue Aug 27, 2013 12:05 pm

http://link.springer.com/article/10.100 ... 013-0232-z
Prevalence of Incidental Narrowing of the Superior Segment of the Internal Jugular Vein in Patients Without Multiple Sclerosis

F. E. Diehn MD, K. M. Schwartz MD, C. H. Hunt MD, L. J. Eckel MD, N. G. Campeau MD, R. E. Carter PhD, J. B. Allred, D. F. Kallmes MD

Abstract

Purpose

Internal jugular vein (IJV) narrowing superiorly is likely relatively frequent. IJV narrowing has been proposed as a potential pathophysiologic component for multiple sclerosis (MS). Our purpose was to investigate the prevalence of incidental superior IJV narrowing in patients imaged with neck computed tomography angiography (CTA) for reasons unrelated to IJV pathology or MS.

Methods

We retrospectively identified 164 consecutive adult patients who had undergone neck CTA in which at least one IJV superior segment was opacified (158 right, 155 left IJVs). At the narrowest point of the upper IJV, each IJV was assessed for dominance, graded (shape and narrowing), measured (diameter and area), and located (axially and craniocaudally). Associations were analyzed using Spearman rank correlations (p < 0.05 significant). Medical records were reviewed for MS.

Results

Among 164 patients, at least one IJV was: absent/pinpoint in 15 % (25/164), occluded/nearly occluded in 26 % (43/164). Shape, narrowing, and the three measurements all correlated with each other (all p < 0.01). Lateral location with respect to C1 transverse foramen correlated with subjectively and objectively smaller IJVs (p < 0.01). The most common craniocaudal location was at the C1 transverse process (79 % (125/158) of right and 81 % (126/155) of left IJVs). No patient had a diagnosis of MS.

Conclusions

The appearance of the superior IJV is variable, with an occlusive/near-occlusive appearance present in approximately one-quarter of patients without known MS undergoing CTA. Radiologists should be aware of and cautious to report or ascribe clinical significance to this frequent anatomic variant.

Ok this is a different approach: they looked through CTA scans to identify patients with upper jugular narrowings, then reviewed the medical records for MS. This didn't pan out but perhaps a larger study would find an assocation. It's an interesting approach. If there was a database looking at the jugular in the lower neck area for reasons unrelated to MS, it could be checked to see if there was a higher incidence of MS in patients with jugular valve stenosis.

Anyway the conclusion here was that in about 25% of the CT scans, there was upper jugular narrowing without any MS diagnosis, and that this is an anatomic variant that may be without clinical significance.

I'd have to check but I thought Dr. Sclafani said he saw true upper jugular narrowings in about 5% of patients? So that is less even than what was found in this study.
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Re: prevalence of incidental narrowing in upper IJV

Postby Cece » Tue Aug 27, 2013 12:13 pm

http://pending.jnis.bmj.com/content/ear ... 1.abstract
J NeuroIntervent Surg doi:10.1136/neurintsurg-2013-010691

Long-term patency of venous sinus stents for idiopathic intracranial hypertension

Andrew F Ducruet, R Webster Crowley, Cameron G McDougall, Felipe C Albuquerque

Division of Neurological Surgery, Barrow Neurological Institute, St Joseph's Hospital and Medical Center, Phoenix, Arizona, USA
Published Online First 12 April 2013

Abstract

Background Recent reports suggest that placement of a venous sinus stent improves symptoms in selected patients with idiopathic intracranial hypertension (IIH). We report our evaluation of the long-term patency of venous stents placed for IIH.

Methods We retrospectively reviewed our clinical database for 30 patients (mean age 33±10 years) with IIH who underwent placement of 36 venous sinus stents between October 2006 and December 2012. Relevant clinical, demographic and radiographic data were extracted after review of these records. All patients underwent retrograde venography to confirm a >50% stenosis and a trans-stenosis pressure gradient. Follow-up catheter angiography was performed beginning 3 months after the procedure.

Results Follow-up imaging was available for 23 (77%) of the 30 patients (mean 23 months). For seven patients, angiographic follow-up of >2 years (mean 45 months) was available. All stents remained patent with mild (<25%) in-stent stenosis observed in four patients. In five patients, however, we observed a narrowing of the sinus proximal to the stent. Although no patient underwent repeat stent placement for persistent or recurrent symptoms, cerebrospinal fluid diversion was performed in five cases.

Conclusions Venous sinus stent placement has emerged as a promising treatment option for the subgroup of patients with IIH with a pressure gradient across a stenotic venous sinus. We observed long-term patency of all stents placed in this patient population. Further prospective investigation is necessary to improve our understanding of the phenomenon of sinus narrowing upstream of a patent stent and to establish definitively the long-term clinical efficacy of venous sinus stent placement for IIH.

Cheer posted last month about IIH and dural sinus stenosis. The treatment for this can be a venous sinus stent. Here they followed up with patients a few years after stenting to see how the stents held up. Seems like the stents held up pretty good but there were some patients with in-stent narrowing or narrowing just before the stent. In a vein, the narrowing just before a stent is often intimal hyperplasia as a reaction or irritation of the vein wall spurs too much growth of the intima. But dural sinuses don't have intima, I don't think? So why would a sinus stent develop narrowing just upstream of the stent? 'Further prospective investigation is necessary...' Anyway based on this I would feel pretty good about a sinus stent staying patent a few years after being placed.
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Re: prevalence of incidental narrowing in upper IJV

Postby Cece » Tue Aug 27, 2013 12:22 pm

http://onlinelibrary.wiley.com/doi/10.1 ... ated=false
Cerebral venous system and anatomical predisposition to high-altitude headache

Annals of Neurology

Volume 73, Issue 3, pages 381–389, March 2013

Objective

As inspired oxygen availability falls with ascent to altitude, some individuals develop high-altitude headache (HAH). We postulated that HAH results when hypoxia-associated increases in cerebral blood flow occur in the context of restricted venous drainage, and is worsened when cerebral compliance is reduced. We explored this hypothesis in 3 studies.

Methods

In high-altitude studies, retinal venous distension (RVD) was ophthalmoscopically assessed in 24 subjects (6 female) and sea-level cranial magnetic resonance imaging was performed in 12 subjects ascending to 5,300m. Correlation of headache burden (summed severity scores [0–4] ≤24 hours from arrival at each altitude) with RVD, and with cerebral/cerebrospinal fluid (CSF)/venous compartment volumes, was sought. In a sea-level hypoxic study, 11 subjects underwent gadolinium-enhanced magnetic resonance venography before and during hypoxic challenge (fraction of inspired oxygen = 0.11, 1 hour).

Results

In the high-altitude studies, headache burden correlated with both RVD (Spearman rho = 0.55, p = 0.005) and with the degree of narrowing of 1 or both transverse venous sinuses (r = −0.56, p = 0.03). It also related inversely to both the lateral + third ventricle summed volumes (Spearman rho = −0.5, p = 0.05) and pericerebellar CSF volume (r = −0.56, p = 0.03). In the hypoxic study, cerebral and retinal vein engorgement were correlated, and rose as the combined conduit score fell (a measure of venous outflow restriction; r = -0.66, p < 0.05 and r = −0.75, p < 0.05, respectively).

Interpretation

Arterial hypoxemia is associated with cerebral and retinal venous distension, whose magnitude correlates with HAH burden. Restriction in cerebral venous outflow is associated with retinal distension and HAH. Limitations in cerebral venous efferent flow may predispose to headache when hypoxia-related increases in cerebral arterial flow occur. ANN NEUROL 2013;73:381–389

Interesting because they looked at the effect of impaired cerebral venous drainage under additional hypoxic conditions. Interesting because there is such a thing as a 'hypoxic challenge,' which could be used in CCSVI research. Also retinal venous distension could be looked at in CCSVI.
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Re: prevalence of incidental narrowing in upper IJV

Postby Cece » Tue Aug 27, 2013 12:29 pm

http://www.sciencedirect.com/science/ar ... 04449#fig2
This article had an illustration of the neck with J1, J2 & J3 positions marked on the jugular vein. When I forget which is which, I use the mnemonic that jaw has 3 letters in the word and so J3 is by the jaw.
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Re: prevalence of incidental narrowing in upper IJV

Postby Cece » Tue Aug 27, 2013 12:39 pm

http://www.biomedcentral.com/1471-2377/13/9/
Jugular venous reflux and plasma endothelin-1 are associated with cough syncope: a case control pilot study

Chih-Ping Chung12, Chun-Yu Cheng12, Robert Zivadinov3, Wei-Chih Chen45, Wen-Yung Sheng1, Yu-Chin Lee26, Han-Hwa Hu12, Hung-Yi Hsu10119† and Kuang-Yao Yang678*†

Abstract


Background

Jugular venous reflux (JVR) has been reported to cause cough syncope via retrograde-transmitted venous hypertension and consequently decreased cerebral blood flow (CBF). Unmatched frequencies of JVR and cough syncope led us to postulate that there should be additional factors combined with JVR to exaggerate CBF decrement during cough, leading to syncope. The present pilot study tested the hypothesis that JVR, in addition to an increased level of plasma endothelin-1 (ET-1), a potent vasoconstrictor, is involved in the pathophysiology of cough syncope.

Methods

Seventeen patients with cough syncope or pre-syncope (Mean[SD] = 74.63(12.37) years; 15 males) and 51 age/gender-matched controls received color-coded duplex ultrasonography for JVR determination and plasma ET-1 level measurements.

Results

Multivariate logistic analysis showed that the presence of both-side JVR (odds ratio [OR] = 10.77, 95% confident interval [CI] = 2.40-48.35, p = 0.0019) and plasma ET-1 > 3.43 pg/ml (OR = 14.57, 95% CI = 2.95-71.59, p = 0.001) were independently associated with the presence of cough syncope/ pre-syncope respectively. There was less incidence of cough syncope/ pre-syncope in subjects with the absence of both-side JVR and a plasma ET-1 ≦3.43 pg/ml. Presence of both side JVR and plasma ET-1 level of > 3.43 pg/ml, increased risk for cough syncope/pre-syncope (p < 0.001).

Conclusions

JVR and higher plasma levels of ET-1 are associated with cough syncope/ pre-syncope. Although sample size of this study was small, we showed a synergistic effect between JVR and plasma ET-1 levels on the occurrence of cough syncope/pre-syncope. Future studies should confirm our pilot findings.

Cough syncope/pre-syncope are caused by reduced cerebral blood-flow. Here the always brilliant Chung et al found that jugular venous reflux and high plasma ET-1 are associated with cough syncope (fainting). We've talked before about the high levels of ET-1 in MS, and about this article http://www.pnas.org/content/110/14/5654 which is titled, "Cerebral hypoperfusion in multiple sclerosis is reversible and mediated by endothelin-1."
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Re: prevalence of incidental narrowing in upper IJV

Postby 1eye » Tue Aug 27, 2013 1:13 pm

I am quick to hazard: low CBF/high reflux -> lesions -> activation of astrocytes in lesions, -> higher ET-1. ET-1 is higher in pw"MS". Can an ET-1 antagonist help without damage to vital organs? Can activation of these particular astrocytes be suppressed?
"Try - Just A Little Bit Harder" - Janis Joplin
CCSVI procedure Albany Aug 2010
'MS' is over - if you want it
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