Cranial venous outflow obstruction explained

Cranial venous outflow obstruction
Synonyms:Intracranial venous congestion
Field:Neurology
Diagnosis:Medical imaging

Cranial venous outflow obstruction, also referred to as impaired cranial venous outflow, impaired cerebral venous outflow, cerebral venous impairment is a vascular disorder that involves the impairment of venous drainage from the cerebral veins of the human brain.[1]

The cause of cranial venous outflow obstruction is not fully understood. It is believed to be associated with various factors including anatomical abnormalities, thrombosis, posture, and increased intracranial pressure.[2]

The obstruction can occur in any part of the venous system involved in draining blood from the brain, like vertebral venous system (VVS) or cerebral venous sinus (CVS), but it is most commonly seen in the dural venous sinuses.[3]

Signs and symptoms

Impaired cranial venous outflow can lead to increased venous pressure, decreased cerebrospinal fluid (CSF) absorption, brain cortex hypoperfusion, brain edema, blood–brain barrier (BBB) disruption, inflammatory reactions, hemorrhagic complications, and increased intracranial pressure. Which can result in a variety of neurological symptoms, such as pseudotumor cerebri, chronic fatigue syndrome, different types of headaches, visual disturbances, pulsatile tinnitus and various neurodegenerative diseases.[4] [5] [6] [7] [8]

Pathophysiology

The pathophysiology of cranial venous outflow obstruction involves the disruption of normal venous drainage from the brain. Cerebral veins play a crucial role in draining brain interstitial fluid (ISF), and their significance has been linked in various neurological conditions. It can be caused by extrinsic or intrinsic anomalies.

Extrinsic

Extrinsic anomalies are structural changes near the Internal Jugular Vein (IJV) that can cause venous outflow obstruction. These changes can be due to bone pressure, artery pressure, enlarged lymph nodes, or an enlarged thyroid. These factors can squeeze the vein wall and block the blood flow. This blockage can range from a local narrowing (stenosis) to a complete blockage (occlusion).[9]

Different parts of the IJV can be affected by different factors. The upper part of the IJV is often squeezed by the side parts of the neck bones at the vertebral C1 segment and by the styloid processes. The middle and lower parts of the IJV are more often squeezed by the nearby carotid artery, lymph nodes, and unusual muscles. Among all these factors, bone pressure is the most common, causing about 40% of extrinsic anomalies. A recent study showed that 41.9% of IJV narrowing in a Chinese group was due to external pressure.

Intrinsic

Intrinsic anomalies are changes within the IJV itself. These can include blood clots (thrombi), abnormalities in the vessel wall, and malformed venous valves. IJV thrombosis is rare and has only been mentioned in a few case reports. Defects inside the vein (flaps, webs, septa, membranes, and malformed valves) can hinder normal blood flow from the brain. This can result in changes in blood flow, including backflow (reflux), reduced flow, or no flow entirely. Doppler and intravascular ultrasound are effective tools for seeing malformed valves. There are many types of malformed valves, including fused, elongated, ectopic, accessory leaflet-containing, inverted, and double valves.

Management

Management of cranial venous outflow obstruction involves treating the underlying cause, if identifiable, and managing the symptoms. This can include medication to reduce intracranial pressure, anticoagulation therapy to prevent thrombosis, and in some cases, surgical intervention to restore normal venous drainage.[5] [10]

Epidemiology

The epidemiology of cranial venous outflow obstruction is not well-studied, and the condition is likely underdiagnosed due to the nonspecific nature of its symptoms. However, it is known to affect individuals of all ages, with a higher prevalence in females and individuals with anatomical venous disorders (varicose veins), certain risk factors such as obesity and thrombophilic disorders and sedentary lifestyle.[11] [12]

Types

Styloidogenic jugular venous compression syndrome

Styloidogenic jugular venous compression syndrome (SJVCS) shares symptoms with idiopathic intracranial hypertension (IIH). Patients with SJVCS experience compression of venous outflow on both sides due to bone structures. It occurs due to compression of the internal jugular vein (IJV) between the C1 vertebrae transverse process and the temporal styloid process. Treatments like venous stenting and styloidectomy have shown positive results.[13] [14] [15] [16]

Diagnostics

Diagnostics of this pathology might include advanced MR venography, direct microcatheter venography with manometry, 3D catheter angiographic studies, three-dimensional rotational venography (3D-RV), cone-beam rotational angiography (3D-RA), also CT venography or MRI scans with contrast with would potentially show obstruction.[17]

See also

Notes and References

  1. Wang . Jiaqi . Manaenko . Anatol . Hu . Qin . Zhang . Xiaohua . March 2024 . Cerebral venous impairment and cerebral venous sinus thrombosis . Brain Hemorrhages . 10.1016/j.hest.2024.03.002 . 2589-238X. free .
  2. Gisolf . J . van Lieshout . J J . van Heusden . K . Pott . F . Stok . W J . Karemaker . J M . 2004-10-01 . Human cerebral venous outflow pathway depends on posture and central venous pressure . The Journal of Physiology . 560 . Pt 1 . 317–327 . 10.1113/jphysiol.2004.070409 . 0022-3751 . 1665206 . 15284348.
  3. Strydom . M. A. . Briers . N. . Bosman . M. C. . Steyn . S. . March 2010 . The anatomical basis of venographic filling defects of the transverse sinus . Clinical Anatomy . 23 . 2 . 153–159 . 10.1002/ca.20911 . 1098-2353 . 20014389 . 205535606 . 2263/7415. free .
  4. Owler . B. K. . Parker . G. . Halmagyi . G. M. . Johnston . I. H. . Besser . M. . Pickard . J. D. . Higgins . J. N. . 2005 . Cranial venous outflow obstruction and pseudotumor Cerebri syndrome . Advances and Technical Standards in Neurosurgery . 30 . 107–174 . 10.1007/3-211-27208-9_4 . 978-3-211-21403-9 . 0095-4829 . 16350454.
  5. Rohr . A. . Dörner . L. . Stingele . R. . Buhl . R. . Alfke . K. . Jansen . O. . April 2007 . Reversibility of Venous Sinus Obstruction in Idiopathic Intracranial Hypertension . AJNR: American Journal of Neuroradiology . 28 . 4 . 656–659 . 0195-6108 . 7977370 . 17416816.
  6. Higgins . J. Nicholas P. . Axon . Patrick R. . Lever . Andrew M. L. . 2023-03-30 . Life changing response to successive surgical interventions on cranial venous outflow: A case report on chronic fatigue syndrome . Frontiers in Neurology . 14 . 1127702 . 10.3389/fneur.2023.1127702 . 1664-2295 . 10097901 . 37064208 . free.
  7. Web site: Hauser . Ross . Venous congestion headaches Intracranial hypertension headache . 2024-03-12 . en-US.
  8. Tuță . Sorin . 2022-06-08 . Cerebral Venous Outflow Implications in Idiopathic Intracranial Hypertension—From Physiopathology to Treatment . Life . 12 . 6 . 854 . 10.3390/life12060854 . free . 2075-1729 . 9224858 . 35743885. 2022Life...12..854T .
  9. Bai . Chaobo . Wang . Zhongao . Stone . Christopher . Zhou . Da . Ding . Jiayue . Ding . Yuchuan . Ji . Xunming . Meng . Ran . 2021-02-01 . Pathogenesis and Management in Cerebrovenous Outflow Disorders . Aging and Disease . 12 . 1 . 203–222 . 10.14336/AD.2020.0404 . 2152-5250 . 7801276 . 33532137.
  10. Web site: Venous Drainage of the CNS - Cerebrum - TeachMeAnatomy . 2024-03-12 . teachmeanatomy.info.
  11. Labropoulos . N. . Volteas . N. . Leon . M. . Sowade . O. . Rulo . A. . Giannoukas . A. D. . Nicolaides . A. N. . January 1997 . The role of venous outflow obstruction in patients with chronic venous dysfunction . Archives of Surgery . 132 . 1 . 46–51 . 10.1001/archsurg.1997.01430250048011 . 0004-0010 . 9006552.
  12. Arun . Anirudh . Amans . Matthew R . Higgins . Nicholas . Brinjikji . Waleed . Sattur . Mithun . Satti . Sudhakar R . Nakaji . Peter . Luciano . Mark . Huisman . Thierry AGM . Moghekar . Abhay . Pereira . Vitor M . Meng . Ran . Fargen . Kyle . Hui . Ferdinand K . February 2022 . A proposed framework for cerebral venous congestion . The Neuroradiology Journal . 35 . 1 . 94–111 . 10.1177/19714009211029261 . 1971-4009 . 8826290 . 34224274.
  13. Mooney . James . Lepard . Jacob . Akbari . S. Hassan A. . Johnston . James M. . 2020-12-01 . Styloidogenic jugular venous compression syndrome: a case report and review of the literature . Child's Nervous System . en . 36 . 12 . 3135–3139 . 10.1007/s00381-020-04622-6 . 32346788 . 216560587 . 1433-0350.
  14. Scerrati . Alba . Norri . Nicoló . Mongardi . Lorenzo . Dones . Flavia . Ricciardi . Luca . Trevisi . Gianluca . Menegatti . Erica . Zamboni . Paolo . Cavallo . Michele Alessandro . Bonis . Pasquale De . April 2021 . Styloidogenic-cervical spondylotic internal jugular venous compression, a vascular disease related to several clinical neurological manifestations: diagnosis and treatment—a comprehensive literature review . Annals of Translational Medicine . en . 9 . 8 . 718 . 10.21037/atm-20-7698 . free . 33987416 . 8106058 . 2305-5847.
  15. Zhao . Xiaochun . Cavallo . Claudio . Hlubek . Randall J. . Mooney . Michael A. . Belykh . Evgenii . Gandhi . Sirin . Moreira . Leandro Borba . Lei . Ting . Albuquerque . Felipe C. . Preul . Mark C. . Nakaji . Peter . 2019-12-01 . Styloidogenic Jugular Venous Compression Syndrome: Clinical Features and Case Series . Operative Neurosurgery . 17 . 6 . 554–561 . 10.1093/ons/opz012 . 2332-4260 . 31329946.
  16. Woo . Ho Geol . Ryu . Jiwook . Kim . Eui Jong . Lee . Kyung Mi . August 2022 . Styloidogenic jugular venous compression syndrome as a source of cerebral venous sinus thrombosis . Quantitative Imaging in Medicine and Surgery . en . 12 . 8 . 4316319–4314319 . 10.21037/qims-22-106 . free . 35919052 . 9338375 . 2223-4306.
  17. Anand . Adrish . Crowley . Samantha Claire . Srivatsan . Aditya . Srinivasan . Visish M . Chintalapani . Gouthami . Kan . Peter . Johnson . Jeremiah N . 2022-03-21 . A retrospective anatomical study of the cerebral dural venous sinus outflow pathways utilizing three-dimensional rotational venography . Brain Circulation . 8 . 1 . 38–44 . 10.4103/bc.bc_76_21 . free . 2394-8108 . 8973444 . 35372723.

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