Styloidogenic Jugular Venous Compression Syndrome: Clinical Features and Case Series

The Promise, Mystery, and Perils of Stenting for Symptomatic Internal Jugular Vein Stenosis: A Case Series

BACKGROUND AND OBJECTIVES

Cerebral venous outflow disorders (CVDs) secondary to internal jugular vein (IJV) stenosis are becoming an increasingly recognized cause of significant cognitive and functional impairment in patients. There are little published data on IJV stenting for this condition. This study aims to report on procedural success.

METHODS

A single-center retrospective analysis was performed on patients with CVD that underwent IJV stenting procedures.

RESULTS

From 2019 to 2023, 29 patients with CVD underwent a total of 33 IJV stenting procedures. Most patients (20; 69%) had an underlying connective tissue disorder diagnosis. The mean age of the included patients was 36.3 years (SD 12.4), 24 were female (82.8%), and all were Caucasian except for 2 patients (27; 93.0%). Twenty-eight procedures (85%) involved isolated IJV stenting under conscious sedation, whereas 5 procedures (15%) involved IJV stenting and concomitant transverse sinus stenting under general anesthesia. Thirteen (39%) patients underwent IJV stenting after open IJV decompression and styloidectomy. Three patients had stents placed for stenosis below the C1 tubercle, one of which was for carotid compression. Periprocedural complications occurred in 11 (33%), including intracardiac stent migration in 1 patient, temporary shoulder pain/weakness in 5 (15%), and persistent and severe shoulder pain/weakness in 2 patients (6%). Approximately 75% of patients demonstrated improvement after stenting although only 12 patients (36%) had durable improvement over a mean follow-up of 4.5 months (range 6 weeks-3.5 years).

CONCLUSION

Our experience, along with early published studies, suggests that there is significant promise to IJV revascularization techniques in these patients; however, stenting carries a high complication rate, and symptom recurrence is common. Most neurointerventionalists should not be performing IJV stenting unless they have experience with these patients and understand technical nuances (stent sizing, anatomy, patient selection), which can maximize benefit and minimize risk.

Neurological phenotypes and treatment outcomes in Eagle syndrome: systematic review and meta-analysis

Background

Eagle syndrome is caused by an elongated styloid process affecting carotid arteries and cranial nerves. Pain, dysphagia, tinnitus, paresthesia (classic subtype), and neurovascular events (vascular subtype) may be triggered by head movements or arise spontaneously. However, Eagle syndrome remains underappreciated in the neurological community. We aimed to determine the most common neurological and non-neurological clinical presentations in patients with Eagle syndrome and to assess the clinical outcome post-surgical resection in comparison to non-surgical therapies.

Methodology

We conducted a systematic review of patient-level data on adults with Eagle syndrome, following PRISMA guidelines. We extracted data on demographics, presenting symptoms, neurological deficits, radiological findings, and treatments, including outcomes and complications, from studies in multiple indexing databases published between 2000 and 2023. The study protocol is registered with PROSPERO.

Results

In total, 285 studies met inclusion criteria, including 497 patients with Eagle syndrome (mean age 47.3 years; 49.8% female). Classical Eagle (370 patients, 74.5%) was more frequent than vascular Eagle syndrome (117 patients, 23.5%, p < 0.0001). Six patients (1.2%) presented with both variants and the subvariant for four patients (0.8%) was unknown. There was a male preponderance (70.1% male) in the vascular subtype. A history of tonsillectomy was more frequent in classic (48/153 cases) than in vascular (2/33 cases) Eagle syndrome (Odds Ratio 5.2, 95% CI [1.2-22.4]; p = 0.028). By contrast, cervical movements as trigger factors were more prevalent in vascular (12/33 cases) than in classic (7/153 cases) Eagle syndrome (Odds Ratio 7.95, 95% CI [2.9-21.7]; p = 0.0001). Headache and Horner syndrome were more frequent in vascular Eagle syndrome and dysphagia and neck pain more prominent in classic Eagle syndrome (all p < 0.01). Surgically treated patients achieved overall better outcomes than medically treated ones: Eighty-one (65.9%) of 123 medically treated patients experienced improvement or complete resolution, while the same applied to 313 (97.8%) of 320 surgical patients (Odds Ratio 1.49, 95% CI [1.1-2.0]; p = 0.016).

Conclusions

Eagle syndrome is underdiagnosed with potentially serious neurovascular complications, including ischemic stroke. Surgical treatment achieves better outcomes than conservative management. Although traditionally the domain of otorhinolaryngologist, neurologist should include this syndrome in differential diagnostic considerations because of the varied neurological presentations that are amenable to effective treatment.

Eagle jugular syndrome presenting with intracranial hypertension - Diagnosis and illustration of pathophysiology by multi-modality imaging

Eagle jugular syndrome is an uncommon condition caused by compression of an elongated styloid process onto the internal jugular vein. Its presentation is non-specific but may represent in severe clinical consequences including venous thrombosis and intracranial haemorrhage. Thorough understanding of local anatomy is important in understanding the pathogenesis and establishing the diagnosis. Our case reported here illustrates the use of multimodality imaging, including dynamic Computer tomography manoeuvre, in identifying the site of obstruction and guidance towards successful surgical treatment.

Eagle jugular syndrome accompanied by de novo brainstem cavernous malformation: a case-based systematic review

BACKGROUND

Eagle jugular syndrome (EJS), recently identified as a cause of cerebrovascular disease (CVD) due to venous obstruction by an elongated styloid process (SP), is reported here alongside a case of concurrent de novo cerebral cavernous malformation (CCM). This study aims to explore the potential causal relationship between EJS and de novo CCM through a comprehensive literature review.

METHOD

Systematic literature reviews, spanning from 1995 to 2023, focused on EJS cases with definitive signs and symptoms and de novo CCM cases with detailed clinical characteristics. Data on the pathophysiology and clinical manifestations of EJS, as well as potential risk factors preceding de novo CCM, were collected to assess the relationship between the two conditions.

RESULT

Among 14 patients from 11 articles on EJS, the most common presentation was increased intracranial hypertension (IIH), observed in 10 patients (71.4%), followed by dural sinus thrombosis in four patients (28.6%). In contrast, 30 patients from 28 articles were identified with de novo CCM, involving 37 lesions. In these cases, 13 patients developed CCM subsequent to developmental venous anomalies (43%), seven following dural arteriovenous fistula (dAVF) (23%), and two after sinus thrombosis (6%). In a specific case of de novo brainstem CCM, the development of an enlarged condylar emissary vein, indicative of venous congestion due to IJV compression by the elongated SP, was noted before the emergence of CCM.

CONCLUSION

This study underscores that venous congestion, a primary result of symptomatic EJS, might lead to the development of de novo CCM. Thus, EJS could potentially be an indicator of CCM development. Further epidemiological and pathophysiological investigations focusing on venous circulation are necessary to clarify the causal relationship between EJS and CCM.

Extreme lateral infracondylar approach for internal jugular vein compression syndrome: A case series with preliminary clinical outcomes

BACKGROUND AND OBJECTIVES

Internal jugular vein (IJV) stenosis is associated with several neurological disorders including idiopathic intracranial hypertension (IIH) and pulsatile tinnitus. In cases of extreme bony compression causing stenosis in the infracondylar region, surgical decompression might be necessary. We aim to examine the safety and efficacy of surgical IJV decompression.

METHODS

We retrospectively reviewed patients who received surgical IJV decompression via the extreme lateral infracondylar (ELI) approach between July 2020 and February 2022.

RESULTS

Fourteen patients with IJV stenosis were identified, all with persistent headache and/or tinnitus. Six patients were diagnosed with IIH, three of whom failed previous treatment. Of the eight remaining patients, two failed previous treatment. All underwent surgical IJV decompression via styloidectomy, release of soft tissue, and removal of the C1 transverse process (TP). Follow-up imaging showed significant improvement of IJV stenosis in eleven patients and mild improvement in three. Eight patients had significant improvement in their presenting symptoms, and three had partial improvement. Two patients received IJV stenting after a lack of initial improvement. Two patients experienced cranial nerve paresis, and one developed a superficial wound infection.

CONCLUSION

The ELI approach for IJV decompression appears to be safe for patients who are not ideal endovascular candidates due to bony anatomy. Confirming long-term efficacy in relieving debilitating clinical symptoms requires longer follow-up and a larger patient cohort. Carefully selected patients with symptomatic bony IJV compression for whom there are no effective medical or endovascular options may benefit from surgical IJV decompression.

Spinning Through History: Evolution of the Concept of Vestibular Migraine

Vestibular migraine represents a growing public health problem, imposing enormous societal burdens in the form of patient suffering, loss of productivity, and direct healthcare costs. This raises the question of how we developed our ideas about vestibular migraine and how these ideas shape how we treat it. This review walks through the history of how our conceptualization of migraine and vestibular symptoms evolved, starting with clinical observations in ancient times, inclusion under the umbrella of Meniere's disease, and then separation from Meniere's disease with its own identity. Tradition, clinical observations, and diagnostic criteria developed by professional societies have played prominent roles in building our current concept of vestibular migraine. A review of the ideas that have shaped our current conception of vestibular migraine may help us to see which ones have stood the test of time and which ones should continue to evolve. As in other disciplines, we study history in medicine to be inspired, warned, and sometimes, to be freed.

Intracranial hypertension due to bilateral internal jugular venous occlusion in eagle syndrome: a case report

Eagle syndrome is a clinical condition that characterized by myriad of symptoms associated with the compression of neurovascular structures by an elongated styloid process. Herein we describe a rare case of Eagle syndrome who showed bilateral internal jugular venous occlusion duo the compression of the styloid process. A young man presented with headaches for six months. Lumbar puncture showed an opening pressure of 260 mmH₂O and the cerebrospinal fluid analysis was normal. Catheter angiography revealed occlusion of bilateral jugular venous. Computed tomography venography demonstrated compression of bilateral jugular venous by bilateral elongated styloid processes. The patient was diagnosed with Eagle syndrome and suggested to undergo styloidectomy, after which he recovered completely. We emphasize that Eagle syndrome is a rare cause of intracranial hypertension and styloid resection can bring an excellent clinical outcome in patents with intracranial hypertension due to Eagle syndrome.

"Idiopathic" intracranial hypertension: An update from neurointerventional research for clinicians

BACKGROUND

The recognition of venous sinus stenosis as a contributing factor in the majority of patients with idiopathic intracranial hypertension coupled with increasing cerebral venography and venous sinus stenting experience have dramatically improved our understanding of the pathophysiologic mechanisms driving this disease. There is now a dense, growing body of research in the neurointerventional literature detailing anatomical and physiological mechanisms of disease which has not been widely disseminated among clinicians.

METHODS

A literature search was conducted, covering the most recent neurointerventional literature on idiopathic intracranial hypertension, the pathophysiology of idiopathic intracranial hypertension, and management strategies (including venous sinus stenting), and subsequently summarized to provide a comprehensive review of the most recently published studies on idiopathic intracranial hypertension pathophysiology and management.

CONCLUSION

Recent studies in the neurointerventional literature have greatly improved our understanding of the pathophysiologic mechanisms causing idiopathic intracranial hypertension and its associated conditions. The ability to make individualized, patient-specific treatment approaches has been made possible by advances in our understanding of how venous sinus stenosis and cerebral venous hypertension fundamentally contribute to idiopathic intracranial hypertension.

Eagle Syndrome with Internal Carotid Artery Compression Causing Recurred Syncope

We herein report a 54-year-old man with eagle syndrome who presented with repeated episodes of syncope, especially after moving his head to a downward position. Computed tomography with contrast revealed a bilateral elongated styloid process. The left internal carotid artery was obviously compressed by the left elongated styloid processes. A transcranial Doppler examination detected a significantly decreased blood flow velocity in the left middle cerebral artery when the patient slightly lowered his head position. After surgery, the positional cerebral blood flow alteration disappeared. No further similar syncope episodes have been reported to date.

Styloid Jugular Nutcracker: The Possible Role of the Styloid Process Spatial Orientation-A Preliminary Morphometric Computed Study

Styloid Jugular Nutcracker (SJN, also known as Eagle Jugular Syndrome EJS) derives from a jugular stenosis caused by an abnormal styloid process, compressing the vessel in its superior portion (J3) against the C1 anterior arch. It could be considered a venous vascular variant of Eagle Syndrome (ES). Main clinical features of this ES variant are headache, pulsatile tinnitus and dizziness, possibly related to venous hypertension and impaired cerebral parenchyma drainage. In our opinion, conceptually, it is not the absolute length of the styloid bone that defines its abnormality, but its spatial direction. An elongated bone pointing outward far away from the midline could not compress the vein; vice versa, a short styloid process tightly adherent to the cervical spine could be pathological. To prove this hypothesis, we developed a semi-automatic software that processes CT-Angio images, giving quantitative information about distance and direction of the styloid process in three-dimensional space. We compared eight patients with SJN to a sample of healthy subjects homogeneous for sex and age. Our results suggest that SJN patients have a more vertically directed styloid, and this feature is more important than the absolute distance between the two bony structures. More studies are needed to expand our sample, including patients with the classic and carotid variants of Eagle Syndrome.

Poor Internal Jugular Venous Outflow Is Associated with Poor Cortical Venous Outflow and Outcomes after Successful Endovascular Reperfusion Therapy

Many patients show poor outcomes following endovascular reperfusion therapy (ERT), and poor cortical venous outflow is a risk factor for these poor outcomes. We investigated the association between the outflow of the internal jugular vein (IJV) and baseline cortical venous outflow and the outcomes after ERT. We retrospectively enrolled 78 patients diagnosed with an acute anterior circulation stroke and successful ERT. Poor IJV outflow on the affected side was defined as stenosis ≥50% or occlusion of ipsilateral IJV, and poor outflow of bilateral IJVs was defined as stenosis ≥50% or occlusion of both IJVs. Poor cortical venous outflow was defined as a cortical vein opacification score (COVES) of 0 on admission. Multivariate analysis showed that poor outflow of IJV on the affected side was an independent predictor for hemorrhagic transformation. The poor outflow of bilateral IJVs was an independent risk factor for poor clinical outcomes. These patients also had numerical trends of a higher incidence of symptomatic intracranial hemorrhage, midline shift >10 mm, and in-hospital mortality; however, statistical significance was not observed. Additionally, poor IJV outflow was an independent determinant of poor cortical venous outflow. For acute large vessel occlusion patients, poor IJV outflow is associated with poor baseline cortical venous outflow and outcomes after successful ERT.

Vascular compression syndromes: a pictorial review

Vascular compression syndromes include a group of rare vascular changes due to extrinsic compression of veins or arteries by surrounding structures. These pathologies are often underestimated due to their rarity, clinicians’ poor level of knowledge, and the non-specificity of their symptoms. The best known are Eagle syndrome, thoracic outlet syndrome, nutcracker syndrome, May-Thurner syndrome, Dunbar syndrome, and popliteal entrapment syndrome. This work summarizes the main ultrasonographic characteristics, symptoms, and treatments of choice for these syndromes. Knowledge of these conditions’ characteristic signs is essential for the differential diagnosis. Failure to diagnose these rare diseases can expose patients to serious complications and risks to their health.

Stylo-Jugular Venous Compression Syndrome: Lessons Based on a Case Report

BACKGROUND Eagle syndrome is a vascular compression syndrome that is caused by a very elongated styloid process and/or calcification of the stylohyoid ligament compressing the vascular or nerve structures of the neck, resulting in vascular congestion, thrombosis, or neurological symptoms (eg, dysphagia, neck pain, ear pain). Stylo-jugular venous compression syndrome is a subtype of Eagle syndrome and is caused by compression of the internal jugular vein. Treatment varies according to the symptoms and the severity of the compression, and it can be pharmacological or surgical, with vascular stenting and/or removal of the styloid process. We describe a rare case of left cerebral venous sinus thrombosis and ipsilateral internal jugular vein stenosis sustained by excessive length of the left styloid process. CASE REPORT A 36-year-old woman presented with recurrent episodes of drug-resistant headache and recent memory disturbances. She underwent cerebral and neck multidetector computed tomography-angiography and Doppler ultrasound of the epiaortic vessels that respectively revealed thrombosis of the left cerebral venous sinus and left internal jugular vein stenosis due to a very long styloid process. The patient was treated with anticoagulant drugs and experienced a gradual remission of symptoms. CONCLUSIONS Compression of the jugular vein by the styloid process is a rare entity, and it often goes undiagnosed when it is asymptomatic. Doppler ultrasound is a sensitive method for identifying jugular vein stenosis and can provide an estimated degree of stenosis, which is useful for treatment planning. Doppler ultrasound should be combined with multidetector computed tomography-angiography to rule out compression of other vascular structures and other causes of compression. Failure to treat these patients could have serious health consequences for them.

Interventional and surgical management of internal jugular venous stenosis: a narrative review

BACKGROUND

A small subset of patients with presumed idiopathic intracranial hypertension are found to have isolated internal jugular vein stenosis (IJVS).

OBJECTIVE

To review the current interventions used in patients who present with intracranial hypertension secondary to IJVS.

METHODS

In December 2020, we performed a literature search on Pubmed/Medline and Scopus databases for original articles studying surgical and endovascular interventions used for intracranial hypertension in the setting of internal jugular vein stenosis. No date, patient population, or study type was excluded.

RESULTS

All studies that included at least one case in which a surgical or endovascular intervention was used to treat IJVS were included. Selection criteria for patients varied, most commonly defined by identification of compression of the internal jugular vein. The 17 studies included in this review ranged from case reports to large single-center cohort studies. The most used surgical intervention was styloidectomy. Styloidectomy had an overall better outcome success rate (79%) than angioplasty/stenting (66%). No complications were recorded in any of the surgical cases analyzed. Outcome measures varied, but all studies recorded clinical symptoms of the patients.

CONCLUSION

Few current large cohort studies analyze surgical and endovascular interventions for patients with IJVS. Notably, the most common intervention is styloidectomy, followed by internal jugular vein stenting. By understanding the trends and experience of interventionalists and surgeons, more focused and larger studies can be performed to determine effective strategies with the best clinical outcomes.

A Prolonged Time to Diagnosis Due to Misdiagnoses: A Case Report of an Atypical Presentation of Eagle Syndrome

BACKGROUND Eagle syndrome is an unusual condition in which the styloid process (SP) becomes elongated and causes different clinical symptoms due to pressure on adjacent anatomical structures. The symptoms are non-specific and include severe throat, facial, and ear pain, or headaches. They are usually exacerbated by head rotation, swallowing, yawning, or chewing, but atypical presentations exist. It is a difficult pathology to diagnose and it can take several years before a proper diagnosis is made. CASE REPORT This report describes the case of a dental student presenting with an atypical presentation of Eagle syndrome. His styloid processes were 75 mm long and he was affected with severe pain to his throat, the anterior part of his ears, his submandibular area, and his molar teeth. The pain was exacerbated during maximal mouth opening, yawning, mandibular protrusion, and during downward head tilt, but not during the classically described movements of head rotation, swallowing, yawning, or chewing. Due to the absence of the classic symptoms, even with knowledge of the condition and unusual direct access to several oral and maxillofacial specialists, it took 4 years and multiple misdiagnoses to reach the final diagnosis. Following bilateral styloidectomy, all pain subsided. CONCLUSIONS The clinical presentation of Eagle syndrome varies, and the symptoms are non-specific. This greatly increases the complexity of diagnosing the condition and raises the time to diagnosis and the chances of misdiagnoses. It is, therefore, crucial to recognize the diagnostic tools, applicable imaging, and definitive treatment alternatives to successfully identify and treat patients affected.

Styloidogenic-cervical spondylotic internal jugular venous compression, a vascular disease related to several clinical neurological manifestations: diagnosis and treatment-a comprehensive literature review

Internal jugular vein (IJV) stenosis is associated with several central nervous system disorders such as Ménière or Alzheimer’s disease. The extrinsic compression between the styloid process and the C1 transverse process, is an emerging biomarker related to several clinical manifestations. However, nowadays a limited number of cases are reported, and few information are available about treatment, outcome and complications. Our aim is to collect and identify clinical-radiological characteristics, diagnosis and treatment of the styloidogenic internal jugular venous compression. We performed a comprehensive literature review. Studies reporting patients suffering from extracranial jugular stenosis were searched. For every patient we collected: demography, clinical and radiological characteristics and outcome, type of treatment, complications. Thirteen articles reporting 149 patients were included. Clinical presentation was non-specific. Most frequent symptoms were headache (46.3%), tinnitus (43.6%), insomnia (39.6%). The stenosis was monolateral in 51 patients (45.9%) and bilateral in 60 (54.1%). Anticoagulants were the most common prescribed drug (57.4%). Endovascular treatment was performed in 50 patients (33.6%), surgery in 55 (36.9%), combined in 28 (18.8%). Improvement of general conditions was reported in 58/80 patients (72.5%). Complications were reported in 23% of cases. Jugular stenosis is a complex and often underestimated disease. Conservative medical treatment usually fails while surgical, endovascular or a combined treatment improves general conditions in more than 70% of patients.

Styloidogenic jugular venous compression syndrome: a case report and review of the literature

BACKGROUND

Styloidogenic jugular venous compression syndrome (SJVCS) has been shown to present with a similar symptomatology to idiopathic intracranial hypertension (IIH) and is caused by compression of the internal jugular vein (IJV) between the lateral tubercle of C1 and the styloid process. Treatments including venous stenting and styloidectomy have been reported with good outcomes; however, treatment of a pediatric patient with SJVCS with styloidectomy has not previously been reported in the literature.

CASE REPORT

A 12-year-old male presented with refractory positional headaches, nausea, and vomiting, and after, workup including lumbar puncture (LP) and intracranial pressure (ICP) monitoring was found to have intracranial hypertension associated with contralateral neck turning. Computed tomography venogram (CTV) revealed severe bilateral compression of the IJV's between the styloid processes and C1 tubercle. The patient was successfully treated with unilateral right-sided styloidectomy with symptomatic relief.

CONCLUSIONS

This is the first reported pediatric case of SJVCS treated successfully with styloidectomy to our knowledge and adds to the limited literature that styloidectomy is a durable treatment option for SJVCS.

Dynamic Internal Jugular Vein Compression by Hypertrophic Hyoid Bone: Management and Outcomes

Extracranial osseous compression of the internal jugular vein (IJV) is exceedingly rare. The clinical manifestations of IJV obstruction are very heterogeneous and subtle, and arriving at a diagnosis can be challenging. We describe a case of dynamic IJV compression in a 40-year-old male with progressive, positional, ill-defined right periorbital and neck pain associated with photosensitivity. Imaging showed a hypertrophic right hyoid bone; computed tomography venogram (CTV) with challenging maneuvers demonstrated dynamic compression of the ipsilateral IJV by a hypertrophied hyoid bone and thyroid cartilage. The patient underwent decompression of the right jugular vein which resulted in the resolution of his symptoms. The clinical manifestations of extracranial IJV impingement are variable and diagnostically challenging. Disturbances in extracranial IJV outflow is a diagnosis of exclusion and could be responsible for atypical facial pain in a select group of patients. This entity should be considered in the differential of atypical facial, especially when symptoms tend to be positional.

Styloidogenic compression of the internal jugular vein, a new venous entrapment syndrome?

Internal jugular vein (IJV) thrombosis is mainly related to central venous catheter, malignancy, and ovarian hyperstimulation syndrome. We report a case of IJV thrombosis possibly related to IJV compression between the styloid process and the first cervical vertebra (C1) transverse process. To support this hypothesis, we perform radiological assessment of the IJV and examine its relationship with the styloid process and C1 transverse process in 34 controls. Our results showed a strong correlation between IJV diameter and styloid process-C1 transverse process distance. Compared to control subjects, our patient had a short styloid process-C1 transverse process distance, which suggests its involvement in IJV thrombosis.