The CCSVI procedure consists of examining and treating the left and right jugular veins as well as the azygos vein. These three veins drain the blood from the brain and the spine. During the CCSVI procedure, Synergy Health Concepts images the jugular veins from the level of the intra-cranial sinus down to the central venous system allows complete evaluation of the venous drainage from the brain. This is important for a number of reasons including documenting the location and degree of blockages or stenosis within the veins.
There are several locations where blockages can be seen within the jugular veins. The most common location is in the valves at the lower portion of the jugular veins (http://www.synergyhealthconcepts.com/wp-content/uploads/2011/03/ccsvi-infographic.jpg). However, there are other areas higher in the jugular veins where stenosis is also seen. In about 10% of patients we find a severe compression of the jugular vein at the level of the skull base. This compression or blockage causes almost complete occlusion of the jugular vein at the craniocervical junction preventing normal blood flow out of the brain. We have seen on MRI/MRV that this compression is caused by the styloid process of the skull and the lateral tubercle of the vertebral body C1. In these patients, during the CCSVI procedure, venogram images demonstrate minimal flow through the internal jugular vein, with the majority of flow through a small network of collateral veins in the upper neck.
Since the majority of patients have blockages at the level of the lower valve in the jugular veins, the CCSVI procedure is focused on opening this area. By tearing this valve, and relieving the blockage at this level, improvement in blood flow through the jugular veins is seen. However, treatment of craniocervical compression of the jugular veins is limited and until now, there has been no treatment available for these patients. Balloon angioplasty in this area is not helpful since the osseous compression causes immediate recoil or re-blockage of the jugular vein. Stents in this area are also not indicated since they would get crushed by the bone and cause worsening of the blood flow.
A recent abstract by Fiorella et al was published in Neurosurgery, Aug 19, 2020 (http://www.ncbi.nlm.nih.gov/pubmed/21866063) which described surgical removal of the styloid process and thus decompression the jugular veins. In their research, two patients had documented increased intracranial venous pressures and evidence of compression of the jugular veins on venogram. Surgical removal of the styloid process resulted in normalization of the intracranial venous pressures, and resolution of the jugular stenosis on followup venogram.
In the 10% of Synergy Health Concepts CCSVI patients seen with severe outflow disease of the jugular veins at the craniocervical junction, this procedure could offer hope. With surgical decompression of the jugular veins, these patients could potentially have some relief of their CCSVI symptoms similar to patients who have disease only within the valves of the lower jugular veins. Until now, there have been no successful treatments for patients with this type of jugular stenosis. Further research will be needed to identify whether CCSVI patients get symptomatic relief after this new procedure.
Todd S. Harris, MD
Synergy Health Concepts
