Kenneth Liu, MD, a visiting associate professor of clinical neurological surgery at the Keck School of Medicine of USC, discusses venous compression syndromes of the central nervous system. He also highlights the heterogeneity of diseases like idiopathic intracranial hypertension and reviews some of the imaging findings and diagnostic criteria used to determine if patients can be treated with venous stenting.
Hello. My name is Kenneth Flu. I'm an associate professor of neurological surgery at the Keck School of Medicine at the University of Southern California. I specialize in endovascular and open vascular neurosurgery, and today I will be speaking on Intracranial Venus denting Venus. Compression syndromes are caused by a restriction in Venus outflow resulting in upstream congestion and tissue dysfunction. While the true incidence of these entities is unknown, they are becoming increasingly recognized throughout the body. Extra actual examples include May Thorner syndrome or compression of the left iliac vein by the right common iliac artery thoracic outlet syndrome, or compression of the subclavian, vein and Nutcracker syndrome, or compression of the left renal vein. Whether it's a pure esoteric artery. In this presentation, I will be using cases several cases to illustrate various examples of Venus compression syndromes of the central nervous system. It is important to understand that the heterogeneity in clinical presentations can often confound the diagnosed diagnostic process for these patients. The first case is a 30 year old, otherwise healthy woman who presents with severe headaches and double vision. Her past medical history is non contributory on neurological exam, she's noted toe have bilateral abductions, nerve policies, visual field deficits and Pablo Dema. These photographs clearly illustrate the patient's inability to properly abduct her both of her eyes on lateral gays. There's also medial deviation noted on forward gays. Formal visual field testing demonstrates bilateral visual field deficits and fungus. Cop examination demonstrates Florida PayPal oedema with evidence of retinal hemorrhaging. Her intracranial noninvasive imaging was red is normal, with no evidence of mass or hydrocephalus. Given her clinical presentation, our concern was that she harbored elevated intracranial pressures, and an invasive intracranial pressure monitor was placed revealing an opening pressure of 68 millimeters of mercury. With normal being less than 20 this patient represents an extreme case of pseudo tumor Serie Bride, otherwise known as idiopathic intracranial hypertension. Thes patients tend to be young and predominantly female, and there is a strong association with obesity. These patients suffer from by frontal unrelenting pressure headaches typically worse in the mornings and complained of blurry vision. Papadimas often noted on front aske OPIC examination. In patients with elevated intracranial pressure, noninvasive imaging is useful to rule out the presence of a mass lesion or hydrocephalus. This is typically done with CT imaging or M R image ing. Interestingly, in many of these patients, not invasive studies are often interpreted as normal by an experienced physicians. On closer examination, one can notice subtle findings on some of the neuroimaging flattening of the pituitary gland, while a non specific finding could be evidence of increased intracranial pressure. In addition, downward displacement of the cerebellum tonsils can be noticed. A swell. The ventricular system is often smaller than average in volume on actual T to image ing. Thickening and Qingqing of the optic nerve sheets can be noticed, as well as excess fluid signal around the optic nerves. In severe cases, flattening of the globes and elevation of the optic disc can be seen in cases where Venus compression is noted. Non invasive vascular imaging can be used to help with the diagnosis. In this patient's case, an M R venogram demonstrates a focal point of stenosis of the junction of the trans verse and sigmoid Sinus on the left. If left untreated, elevated intracranial pressures can produce neurologic deficits and eventually lead to blindness. As such, treatment is often directed at lowering the intracranial pressures to prevent thes deficits from becoming permanent medical treatment typically involves the weight loss and the use of a Sita's Olumide, a carbonic anhydrous inhibitor, which is thought to slow the rate of CS of production. Surgical therapy is often directed at diverting CSF from the central nervous system with the use of a shunt if additional decompression is needed. Optic nerve sheath administration can be used to help preserve vision in cases such as this one, where vascular Venus compression a suspected the aforementioned therapies Onley service band AIDS and do not address the underlying problem. For this case, Venus outflow reconstruction within a vascular stent placement is the optimal choice. Once based to notice is suspected, this could be confirmed with formal invasive catheter angiography. Catheter angiography is important for two reasons. First, it could be used to rule out rare, life threatening vascular lesions such as brain arteriovenous malformations and dural arteriovenous. Officially, that can produce Venus hypertension. Second, Once these lesions are ruled out, it is important to measure the degree of flow restriction by measuring the physiologic pressures across the stenosis. This is performed by navigating a micro catheter into the Venus anatomy and measuring intravascular pressures, both proximal and distal, to this diagnosis in this patient's case ingredient or pressure difference of 51 millimeters of mercury is noted. This large ingredient is suggestive of severe physiologic flow limitation analogous to the density of vehicles on a freeway before and after a crash. Given the patient's symptoms and vascular snows, is patient elected to proceed with endovascular stent placement, This set of digitally subtracted images demonstrates before and after pictures from her procedure. In addition to restoration of the caliber of the blood vessel, the physiologic grading that was measured prior to stent placement was completely obliterated. This set of AP and lateral extra images demonstrates the placement of the stent in the left transverse Sinus. Because this patient had a pressure monitor insight, you, we were able to monitor her integrated pressures throughout the procedure measurement of her I CPS demonstrated normalization within 60 seconds after stent placement. More importantly, after three month follow up the patient, the patient's visual fields had essentially returned to normal and her Papadimas had resolved. In addition, her extra ocular movements have returned to normal as well. In selected patients. The use of Venus denting to treat intracranial hypertension has been shown to be safe and effective This particular manuscript examines the use of stenting to treat intracranial hypertension and patients with vascular venus compression with a concomitant use of invasive pressure monitoring. The study showed that stents were able to completely normalize the intracranial pressures for every patient in the study, there were no major complications. The scientific literature is also now replete with studies demonstrating and confirming that the complication rate of this Venus stenting procedures are exceedingly low, that the long term Peyton C. Of stents remains very high and that the clinical outcomes are durable. The second cases is 39 year old woman who presents with headaches and a wishing noise in her left ear. The wishing noise, which described his tinnitus, was loud enough and drove her crazy. It made it impossible for her toe, have conversations and use the phone. Her past medical history is otherwise non contributory, not invasive. Image string imaging demonstrates a normal appearing eighth cranial nerve complex on the left side. In the upper right hand corner. Further examination of her memory demonstrates the radiographic stigmata of elevated intracranial pressures. Again, this is demonstrated by a flattened pituitary gland on the saddle emery image on the left, as well as excess CSF signal within the optic nerve sheets on T to imaging. In the lower right, non invasive vascular imaging demonstrates Signal dropout and both of her transfer sciences and cat. This is confirmed with catheter angiography. Her left, a dominant transverse Sinus, is shown toe have a stenosis with a 15 millimeter mercury pressure ingredient. She was offered stenting and elected to proceed this image. This image demonstrates successful stent placement of the love transverse Sinus, and the patient noted that upon awakening from the procedure, her tinnitus had completely disappeared. The next case is a 31 year old obese female who presents with blurred vision, headaches and what she thought was spinal fluid leaking from her nose. She is otherwise healthy, and her past medical history is also non contributory. Neurological examination. She is non vocal. A CT cistern a gram demonstrates active leakage of contrast through the crib. Inform plate into the nasal cavity, likely from elevated intracranial pressures. Her Venus compression is confirmed with a catheter angiogram demonstrating severe stenosis in the right transverse Sinus associated with 11 millimeter pressured radiant after a stent was placed in the right transverse Sinus her pressure, Gradient was eliminated, and she was able to be discharged the following day. She noted that her CSF leak resolved on its own within about a week or two. The next case involves a young 22 year old graduate student who suffered with headaches and was failing her classes in school. She likened her symptoms too early dementia, as it's often seen in older patients. Her past medical history is non contributory, and aside from moderate word finding difficulty in memory problems, her neurologic exam is a non vocal on non invasive vascular imaging. She's noted to have stenosis of the proximal segment of her superior sagittal Sinus, which is a rare air to rare area to develop stenosis. This is confirmed with catheter angiography, where a six millimeter ingredient is detected. She elected to the undergo stent placement. As you can see here, with obliteration of her radiant, it should be noted that the following day, within 24 hours of the procedure, the patient already noted that her brain felt clearer and she's able to fly home the following day 106 month follow up. Her symptoms had completely resolved. Her headaches had disappeared. Her cognitive decline had improved, and she was able to finish her graduate degree without further difficulty. The fifth case involves a 46 year old female high function executive, in addition to complaining of severe headaches, and Estonia was also experiencing symptoms of cognitive decline that were interfering with her work. Given the the dystonia and the and the early signs of early dementia, she was thought toe have a variant of Parkinson's disease. Vascular imaging suggested the presence of cyanosis in the strait Sinus, which is the dural Sinus connecting the vein of Galen to the torque ula of Kharafi Alice. This is confirmed with a catheter angiogram demonstrating a large radiant of 10 millimeters of mercury. Given this finding the patient elected to undergo stent placement a Z, you can see here, interestingly, at six month follow up, her headaches and her cognitive decline had all but disappeared. In addition, her dystonia had disappeared as well. It is hypothesized that snow sis in the deep venous system resulted in mild congestion of for DNC, folic and Mason symbolic structures mimicking a movement disorder. The last case is a 17 year old star soccer athlete. Uh huh, struggled with headaches for most of her life but with within the past one year developed progressive weakness of her arms and her legs. She underwent an extensive image ng work up focused on her spinal cord and her brain and all we're read as a negative. Unfortunately, she was eventually diagnosed with fictitious disorder and referred for psychiatric evaluation. Her mother refused to believe her daughter was pretending and continue to seek medical attention. Non invasive vascular imaging, in this patient's case, demonstrates critically stew noticed right internal jugular vein at the level of the C one vertebra. Her left internal jugular vein is hypoplastic, and thus this critically cyanotic and narrowed right internal jugular vein represented represents the soul venous outflow for her entire brain. Distintos IHS was confirmed with catheter angiography and ingredient of three millimeters of mercury was detected. It's important to note the presence of enlarged venous collaterals surrounding three areas. Stenosis, the patient elected to go stent placement. As you can see here, in addition to restoring the normal caliber of the vein, one can notice the almost instantaneous resolution in the presence and size of the enlarged Venus collaterals. It is hypothesized that because of the critical stenosis parasitism ation of the Perry vertebral venous plexus by the brain caused a mild, congestive vascular apathy of the high cervical cord mimicking a transverse myelitis. After restoration of normal flow, a patient experienced brisk neurological recovery. Within 24 hours, she was walking independently again, and within 48 hours she was running on a treadmill. In conclusion, it is important to note that these patients could be difficult to diagnose. In contrast, strokes from arterial conclusions have consistent work well characterized symptoms defined by the affected vascular territory. Venus compression syndromes, on the other hand, tend to be ill defined entities that can have vague and variable clinical presentations between patients. Without a hike, index of clinical suspicion and appropriate image ing thes patients can be easily misdiagnosed or worse, labeled with a psychiatric diagnosis. Once identified, Venus compression syndrome of the nervous central nervous system could be safely and effectively treated with minimally invasive endovascular stent placement