Venous insufficiency – Chronic Cerebrospinal Venous Insufficiency and neurologic-like problems

Ross Hauser, MD

Chronic cerebrospinal venous insufficiency is in some medical circles considered very controversial. It is a problem of blood outflow from the brain. The controversy stems from the identification of chronic cerebrospinal venous insufficiency as a possible cause of Multiple Sclerosis. This article is not about this controversy. This article is about problems of compression and slow or interrupted drainage or outflow of the blood from the brain via the internal jugular veins that may cause some neurologic-type symptoms.

In this article, we discuss symptoms and conditions of Chronic Cerebrospinal Venous Insufficiency outside of a primary diagnosis of Multiple Sclerosis, Alzheimer’s Disease, and Parkinson’s Disease. At our center we do not treat these diseases, we treat craniocervical instability, upper cervical spine instability, cervical spine instability, or problems related to neck pain and loss of cervical spine curvature that may share common symptoms and characteristics of neurological-like and vascular-like disorders such as those just mentioned.

Blood flow constriction in the upper cervical spine is probable when upper cervical instability is caused by weakened or torn cervical spine ligaments. This occurs because of the unique path the vertebral artery takes to go from the skull to the brain, where it is especially vulnerable to compression and stretch in the posterior neck at the level of the C1 and C2 vertebrae (atlas and axis, respectively). The internal carotid artery is subject to compression and stretch, as it lies just anterior to the transverse processes of the C1, C2, and C3 vertebrae before entering the skull via the carotid canal.

Symptoms and diagnoses such as dizziness, lightheadedness, fainting (drop attacks), imbalance, dysarthria (slurred speech), facial dropping, transient ischemic attacks (weakness or sensory deficits on one side of the body/face that resolve completely within an hour), as well as strokes (weakness or sensory deficits on one side of the body/face that last greater than one hour) imply a loss of circulation to the brain or other vital nervous tissue. (9)

This article is a companion article to my other articles on this website. Please see:

Discussion points of this article:

  • The many names and consequences of Chronic Cerebrospinal Venous Insufficiency.
  • The controversy surrounding chronic cerebrospinal venous insufficiency as a cause of multiple sclerosis.
  • Chronic Cerebrospinal Venous Insufficiency and the many symptoms it may cause
  • Chronic Cerebrospinal Venous Insufficiency and cardiovascular problems
  • A story of a patient who went from being “in great shape” to one that is almost completely disabled following an injury event.
  • Testing for Internal Jugular Vein Stenosis induced by the C1 transverse mass.
  • When a patient’s head was tilted downward, this head position alleviated her symptoms.
  • Jugular venous outflow disturbance.
  • Adult-onset Hydrocephalus.
  • there are many ways that we document the conditions and components of a clogged brain drainage system.

What are we seeing in this image? The many names and consequences of Chronic Cerebrospinal Venous Insufficiency

The caption reads: 70% of the blood in the brain is in the venous system. If venous outflow disturbance exists it can turn the brain into a clogged toilet and potentially cause a cascade of neuro-catastrophic symptoms. The image lists these varying names for Chronic Cerebrospinal Venous Insufficiency.

  • Compression jugular vein stenosis or Internal jugular vein stenosis.
  • Jugular venous flow disturbance
  • jugular venous reflux
  • Venous dyscirculation
  • Venous dysgemia
  • Venous hypertension
  • Venous ischemia
  • Venous obstruction
  • Venous statis
  • Venous vasoconstriction

The controversy surrounding chronic cerebrospinal venous insufficiency as a cause of multiple sclerosis

I will only touch briefly on this topic as the controversy has been well documented and covered by such groups as the National Multiple Sclerosis Society.

In 2010, Italian researcher Paolo Zamboni published a paper in the Journal of neurology, neurosurgery, and psychiatry (1) in which he documented the “extracranial venous outflow routes in clinically defined multiple sclerosis.” What he suggested was that “clinically defined multiple sclerosis is strongly associated with chronic cerebrospinal venous insufficiency, a scenario that has not previously been described, characterized by abnormal venous hemodynamics determined by extracranial multiple venous strictures of unknown origin.” Basically, the suggestion is that chronic cerebrospinal venous insufficiency can cause multiple sclerosis.

Over the years treatments including stenting and balloon angioplasty have been suggested and tried and the results were less than hoped for. In fact, it was almost immediate, in 2010, that researcher Jane Qiu wrote in the prestigious medical journal Lancet (2): “Recent reports of a possible link between venous abnormalities and multiple sclerosis have been associated with high levels of media hype. Many experts caution against the premature promotion of the hypothesis and call for objectivity and skepticism in follow-up studies. Poor judgment in medicine can lead to interventions with fatal consequences. Lives should not be lost before these interventions are halted, but they often are. In August 2009, a patient with Multiple Sclerosis (MS) had two stents inserted into her right jugular vein; she died shortly afterward of a brain hemorrhage while on the anticoagulant warfarin as a result of the procedure. 3 months later, another patient with MS had to have open-heart surgery to remove a jugular-vein stent that had come loose and moved into the right ventricle.”

A 2019 study in the journal Reviews on Recent Clinical Trials (3) examined Chronic Cerebrospinal Venous Insufficiency and its relationship with Multiple Sclerosis and found that this condition could be prevalent in other disorders. Here is what the researchers wrote:

“About 10 years ago, the so-called chronic cerebrospinal venous insufficiency syndrome was discovered. This clinical entity, which is associated with extracranial venous abnormalities that impair venous outflow from the brain, was initially found exclusively in Multiple Sclerosis patients. Currently, we know that such venous lesions can also be revealed in other neurological pathologies, including Alzheimer’s and Parkinson’s diseases. Although the direct causative role of chronic cerebrospinal venous insufficiency in these neurological diseases still remains elusive, in this paper, we suggest that perhaps abnormal venous drainage of the brain affects the functioning of the glymphatic system (the waste clearance system of the central nervous system) which in turn results in the accumulation of pathological proteins in the cerebral tissue (such as β-synuclein, β-amyloid, and α-synuclein) and triggers the venous outflow from the cranial cavity and circulation of the cerebrospinal fluid in the settings of neurodegenerative disease.”

In this paper, there is an identification with the brain being unable to drain wastes and that these accumulated wastes would lead to degenerative disorders. We find here similarities in our cervical spine instability patients. We will discuss this important concept below.

Now in 2021 the understanding that chronic cerebrospinal venous insufficiency can cause Multiple Sclerosis has been disputed, and the use of stents and balloon angioplasty or venoplasty to treat Multiple Sclerosis was not supported in a 2018 paper published in the journal Neurology (4).

Chronic Cerebrospinal Venous Insufficiency and the many symptoms it may cause

The caption of this image reads: Diagram demonstrating that relative venous outflow restriction can occur intracranially (with compression/obstruction (with thrombus (a blood clot) or fractures) of isolated or diffuse or many venous structures) and extracranially (from the cervical spine, thoracic spine, and abdominal pressures).

Chronic Cerebrospinal Venous Insufficiency and neurologic-like problems

In this illustration we show:

  • parenchymal swelling (swelling, fluid retention in the brain) and compressing venules (small veins).
  • parenchymal swelling compressing the venous sinus (one of the blood flow drains of the brain).

Let’s begin this research section with a patient study of 128 people diagnosed with Chronic Cerebrospinal Venous Insufficiency or CCSVI. This is an international study that includes neurologists, brain disorder specialists, neuroscientists, and of course the 128 patients. It was published in the journal Frontiers in Neurology (5) in September 2020.

In this paper the researchers wrote: “The cerebrospinal venous system is a crucial channel for the cerebral venous outflow, which plays an important role in transporting metabolic wastes, collecting cerebral spinal fluid, and regulating intracranial pressure. Intracranial venous outflow insufficiency has attracted much attention in clinical practice due to the typical symptoms. However, as an indispensable part of the cerebral venous system, the disturbance of the extracranial cerebrospinal venous system is far from fully recognized by the non-specific clinical presentations and inadequate awareness. The researchers noted that their previous study “showed that  CCSVI might be relevant to an independent disease entity, with non-focal neurological symptoms such as sleep disturbance, tinnitus, head noise, dizziness, and headache whereas without specific clinical signs and imaging findings in the brain, misdiagnosis or missed diagnosis is common.”

Let’s look at the study’s patient group:

  • There were 128 patients, sixty were male, sixty-eight female
  • The average age of these patients was about fifty-five and a half years old.
  • Their symptoms started at about the age of 48
  • The average amount of time from the start of their symptoms until their enrollment in this study was about 36 months. Some as little as five months, one as long as 10 years.

So there you have a profile of the patient. Next, let’s see what they told the doctors of this study bothered them the most by way of symptoms:

  • Sleep disturbance 68.75%
  • Head noise 55.47%
  • Tinnitus 51.56%
  • Dizziness 49.22%
  • Headache 42.19%
  • Hearing disorder 35.16%
  • Visual disorder  32.81%
  • Dry or puffy eyes 32.81%
  • Neck discomfort 32.03%
  • Nausea or vomiting 21.88%
  • Anxiety or depression 17.97%
  • Vertigo 13.28%
  • Subjective memory declined by 8.59%
  • The number of manifestations averages 5 (most between 3–6 symptom complaints)

Chronic Cerebrospinal Venous Insufficiency and cardiovascular problems

A paper with an April 2023 (10) publication date discusses the restoration, rebuilding, and repair of blood vessels that service the heart and other organs, among them the brain in a situation of Cervical spondylotic myelopathy. “Cervical spondylotic myelopathy is the main cause of non-traumatic spinal cord injury, with chronic static and/or dynamic compressive spinal cord injury as the unique pathogenesis (a unique development of disease). In the progression of this cervical spondylotic myelopathy, the microvascular network (the small vessel network that provides blood circulation) is compressed and destroyed, resulting in ischemia (loss of blood flow to organs, such as the heart) and hypoxia (low oxygen levels).”

Let’s stop here for a brief explanation of the symptoms:

  • Chest pain and cervical angina may get more severe with stress or activity.
  • Cardiovascular signs which may mimic heart attack: Left arm pain, numbness, or discomfort. Pain that radiates into the neck and jaw, chest, back, and abdomen causing nausea.
  • Shortness of breath.
  • Fatigue.

Let’s also see how the body reacts to this. Let’s return to the research

“The main pathological changes are inflammation, damage to the blood spinal cord barriers, and cell apoptosis (cell death) at the site of compression. Studies have confirmed that vascular regeneration (new blood vessels) and remodeling (rebuilding existing blood vessels) contribute to neural (nerve) repair by promoting blood flow and the reconstruction of effective circulation to meet the nutrient and oxygen requirements for nerve repair.

Surgical decompression is the most effective clinical treatment for this condition; however, in some patients, residual neurological dysfunction remains after decompression. Facilitating revascularization during compression and after decompression is therefore complementary to surgical treatment.”

In this paper, the doctors looked for the answers to complementary treatment. This is what they found:

“For patients in the early stage of Chronic cerebrospinal venous insufficiency, when nerve compression is not severe, a conservative treatment strategy is usually used, including physical therapy, medication, and epidural steroid injection. For those with moderate to severe clinical symptoms, and those in whom conservative treatment has not succeeded, surgical treatment should be considered. . . .However, since most people with chronic cerebrospinal venous insufficiency present with obvious neurological symptoms, surgical decompression alone cannot completely reverse the pathological changes. It is reported that between 11% and 38% of patients still have some degree of dysfunction after decompression and delayed treatment can lead to worse outcomes or even lifelong disability.”

These are the treatment options currently discussed: “At present, hyperbaric oxygen, neurotrophy (facilitating the normal function of nerves to provide nutrition and healing elements to the nerves, as treatments have limited results) . . . Therefore, early detection of surgical indications and earlier surgical treatment will yield a better prognosis.”

In other words, do not let the problem progress.

Inflammatory markers and cerebral venous sinus stenosis

A June 2022 study in the journal Neurologist (11) looks at the consequences of inflammatory responses in chronic cerebrospinal venous insufficiency. This the researchers say is a poorly understood branch of medicine. Hence, this study aimed to evaluate the peripheral inflammatory biomarkers (simply the amount of inflammation) in patients with intracranial and extracranial Chronic Cerebrospinal Venous Insufficiency pathology. In addition, the researchers evaluated the relationship between inflammatory cytokine (cells that are part of the inflammation process) profile and Chronic Cerebrospinal Venous Insufficiency prognosis.

The study enrolled 248 patients in total, including 102 males and 146 females, with an average age of about 58 years old. Compared with patients with internal jugular vein stenosis, cerebral venous sinus stenosis (CVSS – an obstruction of venous blood outflow) patients were mostly younger and had been suffering from headaches and severe papilledema (swollen optic nerve).

The clinical symptoms and increases in inflammatory marker levels could be distinctly marked in patients with cerebral venous sinus stenosis-related CCSVI than that in internal jugular vein stenosis-related CCSVI, indicating poor prognostic outcomes in these patients. A pro-inflammatory state might be associated with CCSVI pathology. See Ross Hauser, MD Reviews Cervical Spine Instability and Potential Effects on Brain Physiology

A story of a patient who went from being “in great shape” to one that is almost completely disabled following an injury event.

This patient had an unbelievable amount of brain fog, and constant head pressure that won’t go away, there were several times when she almost passed out. In her consultation, I explained to her that for many of the patients that have her kind of symptoms, when they come to the office we diagnose them with chronic cerebrospinal venous insufficiency. This is a compression of the jugular vein. I also explained to her that we assess this problem with testing.

What are we seeing in this image? Testing for Internal Jugular Vein Stenosis induced by the C1 transverse mass

Here we have neuroimaging features of the right Internal Jugular Vein Stenosis induced by the C1 transverse mass. Sagittal or side view (A); Axial view (horizontal plane) and D reconstructive (D) CTV images revealing the right transverse mass of C1 compression on the right Internal Jugular Vein. Magnetic resonance venography (C) reveals the right IJV-J3 segment stenosis accompanied by substantially abnormal collateral veins.

This image comes from a paper published in January 2020 in the journal CNS Neuroscience and Therapeutics (6) In this paper doctors, moreso, neurologists, describe a condition of “cervical spondylotic internal jugular venous compression syndrome.”

This is what they wrote: “Although traditional cervical spondylosis including radiculopathy, myelopathy, axial neck pain and vertebral artery insufficiency has been frequently reported in the literature (medical research), studies focusing on cervical spondylosis‐induced venous outflow disturbance are still lacking. In our clinical practice, we have noticed that a large percentage of Internal Jugular Vein Stenosis patients display osseous (bone) impingement or compression, with the first cervical vertebra (atlas, C1) being the major contributor. As the Internal Jugular Vein passes over the anterior (front) aspect of the transverse process of C1 and once the cervical vertebral structure changes, this Internal Jugular Vein segment is likely to be compressed. Given that, we bring forward a novel concept: “cervical spondylotic internal jugular venous compression syndrome,” to depict the clinical presentations and imaging features in patients with this issue.

Her head was tilted downward, this head position alleviated her symptoms.

I explained to this patient that in a specific position when you lay down and your chin is closer to your chest, that normally patients report that they feel better in this position. The patient replied that “I would lay down and I wouldn’t feel better when my chin is up,  but I have this certain recliner chair and whenever I’m in that I feel so much better. I can watch TV for a long time. But every place else, when I am not in this recliner, I can’t think straight. I almost feel like I don’t exist anymore like there’s somebody else in my body.” This person is a highly intelligent young person. What we found was that in this reclining chair, her head was tilted downward, this head position alleviated her symptoms.

What are we seeing in this image?

Dr. Hauser is pointing to the CT Scan. It is demonstrating that the Internal Jugular Vein is being compressed by the C1 vertebrae. The problem with CT Scans is that the image is taken in a neutral position or static position wherein our office we do motion imagery.

Jugular venous outflow disturbance

I want to remind the reader that much of the research that we examine here and the topic of Chronic Cerebrospinal Venous Insufficiency is controversial. However, doctors, as in the research presented here, are coming to an understanding of how venous outflow can present in patients with neurological-type symptoms.

A 2018 paper published in the journal CNS Neuroscience and Therapeutics (7) offers this explanation:

“Extracranial venous abnormalities, especially jugular venous outflow disturbance, were originally viewed as nonpathological (not a specific disorder) phenomena due to a lack of realization and exploration of their feature and clinical significance.”

“The etiology and pathogenesis are still unclear, whereas a couple of causal factors have been conjectured. The clinical presentation of this condition is highly variable, ranging from insidious (developing over time) to symptomatic, such as headaches, dizziness, pulsatile tinnitus, visual impairment, sleep disturbance, and neck discomfort or pain.”

The treatment suggested in this research is of a surgical nature.

“Standard diagnostic criteria are not available, and current diagnosis largely depends on a combinatory use of imaging modalities. Although few researches have been conducted to gain an evidence-based therapeutic approach, several recent advances indicate that intravenous angioplasty in combination with stenting implantation may be a safe and efficient way to restore normal blood circulation, alleviate discomfort symptoms, and enhance patients’ quality of life.

In addition, surgical removal of structures that constrain the internal jugular vein may serve as an alternative or adjunctive management when endovascular intervention is not feasible. Notably, discussion on every aspect of this newly recognized disease entity is in the infant stage, and efforts with more rigorous designed, randomized controlled studies in an attempt to identify the pathophysiology, diagnostic criteria, and effective approaches to its treatment will provide a profound insight into this issue.”

Adult-onset Hydrocephalus

In this image, we see a blockage of the cerebrospinal fluid flow from upper cervical instability.

A December 2020 paper in the journal CNS Neuroscience (8) and therapeutics describes idiopathic normal pressure hydrocephalus as the most common type of adult-onset hydrocephalus and that this is a potentially reversible neuropsychiatric entity characterized by dilated ventricles, cognitive deficit, gait apraxia (walking difficulties because of brain injury), and urinary incontinence.

The researchers note: “Despite its relatively typical imaging features and clinical symptoms, the pathogenesis and pathophysiology of idiopathic normal pressure hydrocephalus remain unclear. . . The common consensus is that ventriculomegaly (the ventricles appear larger than normal) resulting from cerebrospinal fluid (CSF) dynamics could initiate a vicious cycle of neurological damage in idiopathic normal pressure hydrocephalus. ”

At Caring Medical, there are many ways that we document conditions and components of a clogged brain drainage system

  • Motion Arterial Obstruction Mapping – by doing B-mode and color duplex high-resolution doppler ultrasound of the head and neck in various positions and motions, brain arterial obstructions can be mapped. The obstructions can be inside the cranial cavity, at the neck, or at the craniocervical junction.
  • Motional Venous Obstruction Mapping – by doing the same procedure on the venous drainage of the brain, the places of brain venous obstruction can be discovered. Venous obstructions are typically at the craniocervical junctions or in the neck.
  • Optic Nerve Measurements – increased intracranial pressure (hypertension) can be seen by swelling of the optic nerves under high-resolution ultrasound. Optic nerve diameters of >5 mm are indicative of an intracranial pressure greater than 20 mmHg.
  • Cine phase-contrast MRI – imaging of the brain and brainstem in the supine and upright positions. This can show obstructions of cerebrospinal fluid (CSF) flow, as well as the accumulation of CSF in various parts of the brain and brainstem, compressing these structures and, thus, damaging them.

Summary and contact us. Can we help you? How do I know if I’m a good candidate?

We hope you found this article informative and that it helped answer many of the questions you may have surrounding Venous insufficiency – Chronic Cerebrospinal Venous Insufficiency and neurologic-like problems. Just like you, we want to make sure you are a good fit for our clinic prior to accepting your case. While our mission is to help as many people with chronic pain as we can, sadly, we cannot accept all cases. We have a multi-step process so our team can really get to know you and your case to ensure that it sounds like you are a good fit for the unique testing and treatments that we offer here.

Please visit the Hauser Neck Center Patient Candidate Form

References

1 Zamboni P, Galeotti R, Menegatti E, Malagoni AM, Tacconi G, Dall’Ara S, Bartolomei I, Salvi F. Chronic cerebrospinal venous insufficiency in patients with multiple sclerosis. Journal of Neurology, Neurosurgery & Psychiatry. 2009 Apr 1;80(4):392-9. [Google Scholar]
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This article was updated September 3, 2021

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