This Is MS Multiple Sclerosis Knowledge & Support Community

http://radiology.rsna.org/content/188/2/355.short

Compression of the left brachiocephalic vein: cause of high signal intensity of the left sigmoid sinus and internal jugular vein on MR images.

T Tanaka,
K Uemura,
M Takahashi,
S Takehara,
T Fukaya,
T Tokuyama,
A Satoh and
H Ryu

+ Author Affiliations

Department of Neurosurgery, Yaizu Municipal General Hospital, Shizuoka, Japan.

Abstract

To study the asymmetry in signal intensity of the sigmoid sinuses, internal jugular veins (IJVs), or both sets of structures on magnetic resonance (MR) images, the authors reviewed 226 serial sets of routine MR imaging studies. Cerebral digital subtraction angiography was performed in 20 patients with a markedly higher intensity and/or enhancement on the left; 15 of them also underwent venography. With every sequence, the left sigmoid sinus, IJV, or both were higher in signal intensity significantly more often than the right (range, P = .0001 to .0129). Angiography revealed hemostasis in the left IJV in 16 patients that disappeared during full inspiration in 14. In 13, venography revealed that the left brachiocephalic vein was compressed to occlusion between the aortic arch and the sternum during tidal volume ventilation. The occlusion disappeared at full inspiration, when the distance between the aortic arch and the sternum increased. This hemostasis could be the major cause of the frequent increased signal intensity of the left sigmoid sinus and IJV on MR images.

This was an interesting study in which the researchers looked for anomalies in the signal intensity on MR imaging of the sinus or IJV on one side only. They found 20 such patients in 226 serial sets of images. Then they had those patients get DSA done (cerebral digital subtraction angiography, where the arteries are subtracted out and you see only the veins). In sixteen of these patients, angiography revealed stasis in the left IJV. In 2 of those patients, the IJV remained in stasis (when the flow just sits there) but in 14 the stasis disappeared when they breathed fully in. Still with me? And in 13 of these patients, venography revealed a compression of the left brachiocephalic vein! This would be the innominate vein. When the patients breathed fully in, the compression was lifted and that is why the jugular flow resumed, in those patients, upon full inspiration.

Some thoughts: I like this research! The authors followed the path from high intensity one-sidedly seen in the jugulars or sinus, all the way to a compression of the innominate vein that would cause it. This connects an occlusion of the innominate vein with effects on flow in the jugulars and sinus.

Should it be treated? On one hand, if this is physiological and flow gets through every time the patient takes a deep breath, it might be something to leave alone. This was the case for 14 of the patients; in 2 of them, the flow did not get through when the patient took a deep breath, so perhaps only those 2 would warrant treating if symptoms were present.

On the other hand, if even a physiological brachiocephalic compression exists in a CCSVI in MS patient, it might be affecting cerebrospinal blood flow and warrant stenting.

Side note: during my second CCSVI procedure, in July, my left jugular's flow was as described here, in stasis, where the contrast just sat there and went up and down a bit. My left jugular is a scrawny little thing in comparison to my right jugular. But getting that jugular ballooned and the flow restored led to my best reduction in cogfog, and to the numbness that had returned six weeks after my first procedure going away again and, knock on wood, staying away. Other improvements too. From personal experience, I believe stasis even in one jugular is worth treating.

Dr. Sclafani's last case featured an innominate vein stenosis, which he suspected was due to compression by a tortuous innominate artery. Last spring at one of the conferences, there was a Polish doctor who performed a live case CCSVI procedure, which can be watched on youtube, and when jugular flow remained less than optimal after treatment of the valves, he performed a few balloonings of the innominate vein. I was surprised by this because there was nothing in the image to indicate innominate vein stenosis, but the lack of good flow in the jugular after treatment itself was considered a possible sign of obstruction in the innominate. Ballooning the innominate did not improve the jugular flow in that particular patient, but it was interesting to hear the doctor's thought process, and ballooning the innominate being the chosen course of action in such circumstances.

kid , your in a league all your own.


yeah , I'm still with ya'



MrSuccess

Hello Cece,
Thanks for the info and continuing my education.
I would suggest that we slow down on saying what should be treated !!
You and I would agree on the invasive diagnostic tools needed to investigate CCSVI syndrome (catheter venography and intravascular ultrasound). I do not feel there has been sufficent investigations to define which veins must be investigated, let alone which should be treated. My logic tells me that at this stage, pwMS should have as many stenoses investigated and treated as they can afford (hopefully all of them).
I am still hoping for an agreed test which says 'all clear today' for CCSVI syndrome. Maybe the researchers will come up with a cheap answer before too long.
Kind regards,
MarkW

Can you imagine going to the doctor for regular plethysmography tests of your neck, similiar to what can be done for blood pressure? I can see the need for determining what normal looks like in the healthy population; and also what normal looks like as an individual. Then a plethysmography test done right before CCSVI treatment could be compared to one done after treatment could be compared to one done a year later, to see if the effect has been lost. I don't know for sure that plethysmography could be used in this way but! It is hard to know when we are in need of an additional procedure. This is presuming that CCSVI is not a one-and-done treatment but, similiar as is in some other veins and diseases, a treatment that needs repeating at regular intervals, at least in some patients.

I would agree that we cannot yet conclusively say which veins or types of stenoses warrant treating, but I think it is appropriate to raise the question and consider it. What has been fascinating has been the slow realization that there is more to CCSVI than just jugulars and azygous. And there is more to the jugulars than just valve malformations. Jugulars are the most commonly affected, azygous the next most commonly affected, but blockages in the innominate, renal, and iliac vein can impact cerebrospinal drainage as well, especially in conjunction with jugular or azygous stenoses.... so interesting. Dr. Sclafani has talked about not treating physiological stenoses, which disappear when a breath is drawn, and that is what is described in this article, in 14 out of the 16 patients with brachiocephalic stenoses. In my own upper jugulars, I had apparent physiological stenoses. They appeared narrowed but were able to expand when I took a deep breath. Other patients being treated by other doctors might have left with stents in the upper jugular. The best way to prevent in-stent restenosis is to not get a stent.

My conclusion on the article is that only the two patients with brachiocephalic narrowing that caused jugular stasis that was not relieved by changes in breathing are in need of treatment in the brachiocephalic aka innominate vein, and only if they are symptomatic. Otherwise it falls into the physiological stenosis category, and might not be a problem once all other treatable stenoses are treated.

It is interesting too to consider the difference between stasis and reflux.

As for simply getting all stenoses investigated and treated, I fear it is more complex. There is a risk to treatment and to being too aggressive. I know of people who are hesitant to get a stent placed in their sinuses, and of IRs who are hesitant to place one there. I have heard of people diagnosed as having renal vein compressions who have had them ballooned, which is a treatment that will not hold up. I saw an image from Dr. Zamboni of a twisted azygous, both the venogram image and the actual pinned vein removed from the body, and yet I still don't know if that twisted azygous would have warranted treating or not, because we lack an IVUS image and images in different stages of respiration. Some of these are judgement calls on the part of the IR, but it is the patients who live the consequences...and a stent that later occludes is a terrible consequence.

edited: here's another article on innominate vein compression, referring to the compression as physiological because it is relieved when the patient stands but not when supine. Now is that a physiological compression that nevertheless requires treatment? It would prevent the jugular from doing its job when supine.
http://www.jultrasoundmed.org/content/28/2/253.full

Venous pulsations of the left IJV were observed incompletely in the right lateral decubitus position (Figure 3G⇓), and they were completely restored in the sitting position. These findings led to the diagnosis of physiologic left BCV compression.

Anatomically, the left BCV travels anteriorly to the aortic arch at approximately the level of the sternum before draining into the superior vena cava. The left BCV can be easily compressed between the sternum and the aortic arch or its branches, especially in the supine position. Because such conditions are frequently seen in elderly patients, dilatation and tortuosity of the aortic arch caused by arteriosclerosis might be associated with left BCV occlusion or stenosis.

With this patient, the decision was made not to treat. I would argue that, in a CCSVI patient, this would warrant stenting, despite being physiological and present only when supine.

An image of an innominate vein compression:
http://www.ajronline.org/content/184/5/ ... nsion.html

(Arrows are pointing to the compressed area of the vein)

As these stenoses are not fixed and are caused by extrinsic pressure, balloon expandable stents should be avoided since they can be crushed and can migrate. Self-expanding stents are an option but are probably best avoided in the non-dialysis patient, since metal stents in the subclavian vein have limited patency and these patients are relatively young and healthy.

And another case:
http://www.sciencedirect.com/science/ar ... 8906001357
A stent in an innominate vein fractures, requiring a stent within a stent. Includes an image of the IJV with the flow going straight up, as indicated by the white arrow (first image) and later on an IVUS image of the compressed site of the stent in the innominate vein itself. Restenting was successful, at least at the time of publication.

http://www.jvascsurg.org/article/S0741-5214(00%2902608-2/abstract

Crushed stents in benign left brachiocephalic vein stenoses☆☆☆

Frank Hammer, MD
, Dominique Becker, MD
, Pierre Goffette, MD
, Pierre Mathurin, MD

Received 21 September 1999; accepted 10 January 2000.

Abstract

Two hemodialysis patients presenting with left venous arm congestion due to benign catheter-induced stenosis of the left brachiocephalic vein were treated by angioplasty and stent placement. External compression of the stents was responsible for rapid recurrence of the symptoms. No osseous or vascular malformation could be identified. Mechanical constraints induced by respiratory chest wall motion and aortic arch flow–related pulsation are proposed to explain this observation. This potential hazard should be considered when stent placement into the left brachiocephalic vein is advocated. (J Vasc Surg 2000;32:392-6.)

maybe the left brachiocephalic vein is not a good place for stents...

Cece wrote:Can you imagine going to the doctor for regular plethysmography tests of your neck, similiar to what can be done for blood pressure? I can see the need for determining what normal looks like in the healthy population; and also what normal looks like as an individual. Then a plethysmography test done right before CCSVI treatment could be compared to one done after treatment could be compared to one done a year later, to see if the effect has been lost. I don't know for sure that plethysmography could be used in this way..... .

My vision for checking is that a regular plethysmography test in combination with colour doppler test is used to check that flow is still OK post procedure. I think this would be performed say 3 months and 6 months after the de-stenosis procedure. If flow still OK the next tests after 12 months and then every 12 months if still clear. I see this being performed in the Radiology outpatient clinic as special training is required for the doppler. The tests need to be validated in the research setting maybe using MRV with contrast. Turning research techniques into clinic techniques is very much required by pwMS. I hope a researcher is starting this work as I write.

I wrote about just getting diagnosed and treated. I should have qualified this by saying: get 'gold standard diagnosis' and treat vein values after determining balloon size with IVUS. Cheer called over treatment 'popping valves'. You call this over agressive treatment. My comment to anyone conducting such procedures is remember "do your patient no harm" and to pwMS please avoid such clinics. We seem to agree on this.

it is worth the effort to search out and find medical illustrations of the neck.

what a magnificent structure.

and so we can clearly understand how fragile the neck really and truly is.

The windpipe at the front. The spine at the back. Veins and artery's on the side.

All just beneath the skin ...... and ALL easily subjected to TRAUMA.




MrSuccess

a reference on neck trauma: http://emedicine.medscape.com/article/8 ... view#a0199
A few pages in it lists causes of severe neck trauma: "GSWs" (?) (ok, I bet that's gun shot wounds), stab wounds, motor vehicle crashes, sports-related injuries, "clothesline" injuries," strangulation, blows from fists or feet, and excessive manipulation.
I would avoid all of these, on general principle....

The brachiocephalic vein, however, is in the chest, and a compression is caused by another vessel or structure, not by trauma.

MarkW, we agree on many things. Yes, turning research techniques into clinical techniques is of importance. Combining plethysmography with doppler would be perfect if plethysmography holds the potential I think it does.