Spatial distribution of flow and oxygenation in the cerebral venous drainage system

CO2 cerebrovascular reactivity measured with CBF-MRI in older individuals: Association with cognition, physical function, amyloid, and tau proteins

Vascular pathology is the second leading cause of cognitive impairment and represents a major contributing factor in mixed dementia. However, biomarkers for vascular cognitive impairment and dementia (VCID) are under-developed. Here we aimed to investigate the potential role of CO2 Cerebrovascular Reactivity (CVR) measured with phase-contrast quantitative flow MRI in cognitive impairment and dementia. Forty-five (69 ± 7 years) impaired (37 mild-cognitive-impairment and 8 mild-dementia by syndromic diagnosis) and 22 cognitively-healthy-control (HC) participants were recruited and scanned on a 3 T MRI. Biomarkers of AD pathology were measured in cerebrospinal fluid. We found that CBF-CVR was lower (p = 0.027) in the impaired (mean±SE, 3.70 ± 0.15%/mmHg) relative to HC (4.28 ± 0.21%/mmHg). After adjusting for AD pathological markers (Aβ42/40, total tau, and Aβ42/p-tau181), higher CBF-CVR was associated with better cognitive performance, including Montreal Cognitive Assessment, MoCA (p = 0.001), composite cognitive score (p = 0.047), and language (p = 0.004). Higher CBF-CVR was also associated with better physical function, including gait-speed (p = 0.006) and time for five chair-stands (p = 0.049). CBF-CVR was additionally related to the Clinical-Dementia-Rating, CDR, including global CDR (p = 0.026) and CDR Sum-of-Boxes (p = 0.015). CBF-CVR was inversely associated with hemoglobin A1C level (p = 0.017). In summary, CBF-CVR measured with phase-contrast MRI shows associations with cognitive performance, physical function, and disease-severity, independent of AD pathological markers.

Computed-tomography evaluation of parietal foramen topography in adults: a retrospective analysis

BACKGROUND

The parietal foramen (PF) of the skull is a variable anatomic feature with important implications for venous drainage, infection, and injury. Its topography is clinically relevant for neurosurgeons for intracranial navigation and preoperative planning.

METHODS

PF topography was investigated in a series of 440 head computed-tomography scans of Omani subjects at Sultan Qaboos University Hospital. The mean age of the patients was 52 ± 17 years and there were 160 males and 280 females. The topography features of the PF, including frequency, diameter, patency, and relative position in relation to the superior sagittal sinus (SSS), were recorded. Additionally, sex and laterality differences in PF parameters were analyzed using a Chi-square test.

RESULTS

The overall prevalence of PF was 72.3% (318/440). The bilateral presence of PF was identified in 34% of skulls. Unilateral right-side prevalence was 18.2%, while left prevalence was 13.2% (p = 0.62). The prevalence of unilateral accessory PF on the right side was 1.8%, while it was 1.1% on the left (p = 0.69). PF within the sagittal suture/or intra-sutural PF was observed in 6.8% of skulls, with a frequency of 9.4% in men and 5.4% in women (p = 0.29). The diameter of the PF was 1.45 ± 0.74 mm on the right side, and 1.54 ± 0.99 mm on the left side (p = 0.96). There were 2% of incomplete PF. The PF was located over the SSS in 70.3% on the right side and 53.8% on the left side. No significant differences were observed between the PF topography parameters and sex or laterality.

CONCLUSION

The present study for the first time reports the baseline data of PF topography in a large sample of CT scans in the Arab population. The geography and race influence the PF topography differences. PF may be used as a reliable landmark of SSS. The morphological characteristics and distribution of PF reported in this study have clinical implications for imaging diagnosis, intracranial navigation of vascular disorders, and treatment.

Risk factors for the development of secondary intracranial hypertension in acute cerebral venous thrombosis

PURPOSE

Intracranial hypertension (IH) can complicate cerebral venous thrombosis (CVT), potentially causing permanent visual loss. Current knowledge on risk factors for the development of IH following CVT is scarce. We applied a compound classifier (CSF opening pressure > 25 cmH₂O, papilledema, or optic disc protrusion on MRI) as a surrogate for IH and studied the predictive value of thrombus location, the number of thrombosed segments, and thrombus volume.

METHODS

We prospectively included 26 patients with acute CVT and complete MRI data. IH was defined by CSF opening pressure > 25 cmH₂O, papilledema, or optic disc protrusion on MRI. Using high-resolution contrast-enhanced venography, we determined the thrombus location, number of thrombosed segments, and thrombus volume. We analyzed their association with IH by logistic regression, their predictive power by the area under the receiver operating characteristic curve, and their association with CSF opening pressure by linear regression.

RESULTS

IH occurred in 46% of CVT patients and was associated with higher thrombus volume (AUC 0.759, p = 0.025) and superior sagittal sinus thrombosis both alone (OR 2.086, p = 0.049) and combined with transverse sinus thrombosis (OR 2.014, p = 0.028). Effects in patients presenting CSF opening pressure > 25 cm H₂O and the compound classifier were consistent. Thrombus volume > 4 ml was the single most important predictor of higher CSF opening pressure (ß = 0.566, p = 0.035), increasing IH risk.

CONCLUSION

Larger thrombus volume, dominant transverse sinus occlusion, and extensive superior sagittal combined with transverse sinus thrombosis were associated with IH. Thrombus volumetry might identify patients at risk for IH and direct further clinical evaluation.

Non-contrast assessment of blood-brain barrier permeability to water in mice: An arterial spin labeling study at cerebral veins

Blood-brain barrier (BBB) plays a critical role in protecting the brain from toxins and pathogens. However, in vivo tools to assess BBB permeability are scarce and often require the use of exogenous contrast agents. In this study, we aimed to develop a non-contrast arterial-spin-labeling (ASL) based MRI technique to estimate BBB permeability to water in mice. By determining the relative fraction of labeled water spins that were exchanged into the brain tissue as opposed to those that remained in the cerebral veins, we estimated indices of global BBB permeability to water including water extraction fraction (E) and permeability surface-area product (PS). First, using multiple post-labeling delay ASL experiments, we estimated the bolus arrival time (BAT) of the labeled spins to reach the great vein of Galen (VG) to be 691.2 ± 14.5 ms (N = 5). Next, we investigated the dependence of the VG ASL signal on labeling duration and identified an optimal imaging protocol with a labeling duration of 1200 ms and a PLD of 100 ms. Quantitative E and PS values in wild-type mice were found to be 59.9 ± 3.2% and 260.9 ± 18.9 ml/100 g/min, respectively. In contrast, mice with Huntington's disease (HD) revealed a significantly higher E (69.7 ± 2.4%, P = 0.026) and PS (318.1 ± 17.1 ml/100 g/min, P = 0.040), suggesting BBB breakdown in this mouse model. Reproducibility studies revealed a coefficient-of-variation (CoV) of 4.9 ± 1.7% and 6.1 ± 1.2% for E and PS, respectively. The proposed method may open new avenues for preclinical research on pathophysiological mechanisms of brain diseases and therapeutic trials in animal models.

Anatomy imaging and hemodynamics research on the cerebral vein and venous sinus among individuals without cranial sinus and jugular vein diseases

In recent years, imaging technology has allowed the visualization of intracranial and extracranial vascular systems. However, compared with the cerebral arterial system, the relative lack of image information, individual differences in the anatomy of the cerebral veins and venous sinuses, and several unique structures often cause neurologists and radiologists to miss or over-diagnose. This increases the difficulty of the clinical diagnosis and treatment of cerebral venous system diseases. This review focuses on applying different imaging methods to the normal anatomical morphology of the cerebral venous system and special structural and physiological parameters, such as hemodynamics, in people without cranial sinus and jugular vein diseases and explores its clinical significance. We hope this study will reinforce the importance of studying the cerebral venous system anatomy and imaging data and will help diagnose and treat systemic diseases.

Metabolism of oxygen via T2 and interleaved velocity encoding: A rapid method to quantify whole-brain cerebral metabolic rate of oxygen

PURPOSE

Cerebral metabolic rate of oxygen (CMRO2 ) is an important biomarker of brain function. Key physiological parameters required to quantify CMRO2 include blood flow rate in the feeding arteries and venous oxygen saturation (SvO2 ) in the draining vein. Here, a pulse sequence, metabolism of oxygen via T2 and interleaved velocity encoding (MOTIVE), was developed to measure both parameters simultaneously and enable CMRO2 quantification in a single pass.

METHODS

The MOTIVE sequence interleaves a phase-contrast module between a nonselective saturation and a background-suppressed T2 -prepared EPI readout (BGS-EPI) to measure T2 of blood water protons and cerebral blood flow in 20 s or less. The MOTIVE and standalone BGS-EPI sequences were compared against TRUST ("T2 relaxation under spin tagging") in the brain in healthy subjects (N = 24). Variants of MOTIVE to enhance resolution or shorten scan time were explored. Intrasession and intersession reproducibility studies were performed.

RESULTS

MOTIVE experiments yielded an average SvO2 of 61 ± 6% in the superior sagittal sinus of the brain and an average cerebral blood flow of 56 ± 10 ml/min/100 g. The bias in SvO2 of MOTIVE and BGS-EPI to TRUST was +2 ± 4% and +1 ± 3%, respectively. The bias in cerebral blood flow of MOTIVE to Cartesian phase-contrast reference was +1 ± 6 ml/min/100 g.

CONCLUSIONS

The MOTIVE sequence is an advance over existing T2 -based oximetric methods. It does not require a control image and simultaneously measures SvO2 and flow velocity. The measurements agree well with TRUST and reference phase-contrast sequences. This noninvasive technique enables CMRO2 quantification in under 20 s and is reproducible for in vivo applications.

A venous mechanism of ventriculomegaly shared between traumatic brain injury and normal ageing

Recently, age-related timing dissociation between the superficial and deep venous systems has been observed; this was particularly pronounced in patients with normal pressure hydrocephalus, suggesting a common mechanism of ventriculomegaly. Establishing the relationship between venous drainage and ventricular enlargement would be clinically relevant and could provide insight into the mechanisms underlying brain ageing. To investigate a possible link between venous drainage and ventriculomegaly in both normal ageing and pathological conditions, we compared 225 healthy subjects (137 males and 88 females) and 71 traumatic brain injury patients of varying ages (53 males and 18 females) using MRI-based volumetry and a novel perfusion-timing analysis. Volumetry, focusing on the CSF space, revealed that the sulcal space and ventricular size presented different lifespan profiles with age; the latter presented a quadratic, rather than linear, pattern of increase. The venous timing shift slightly preceded this change, supporting a role for venous drainage in ventriculomegaly. In traumatic brain injury, a small but significant disease effect, similar to idiopathic normal pressure hydrocephalus, was found in venous timing, but it tended to decrease with age at injury, suggesting an overlapping mechanism with normal ageing. Structural bias due to, or a direct causative role of ventriculomegaly was unlikely to play a dominant role, because of the low correlation between venous timing and ventricular size after adjustment for age in both patients and controls. Since post-traumatic hydrocephalus can be asymptomatic and occasionally overlooked, the observation suggested a link between venous drainage and CSF accumulation. Thus, hydrocephalus, involving venous insufficiency, may be a part of normal ageing, can be detected non-invasively, and is potentially treatable. Further investigation into the clinical application of this new marker of venous function is therefore warranted.

The parietal foramen anatomy: studies using dry skulls, cadaver and in vivo MRI

OBJECTIVE

The aim of this study was to describe the anatomical features encountered in the parietal foramen in a series of 178 human bones and 123 head MRI examinations. A cadaveric specimen was also dissected to demonstrate the trajectory of a superficial scalp vein through the parietal foramen as far as the dura mater. A literature review was performed regarding prevalence of parietal foramen in different populations.

METHODS

Totally, 178 paired adult bones were used to investigate the presence, shape and number of the parietal foramina. In addition, 123 brain MRI examinations were also studied.

RESULTS

The parietal foramina were encountered in 75/89 (84.3%) skulls [32/38 (84.2%) in women vs. 43/51 (84.3%) in men, p > 0.05]. The parietal foramen was present bilaterally in 44.73% of females and 54.9% of males. Regarding unilaterality of the parietal foramen, a right or left laterality was observed in female 21% right versus 18% left; and 16% versus 14% (left) in males (p > 0.05). The accessory parietal foramen was present in the right parietal in 2.6% and in 7.9% on the left side of the females, while 5.9% and 3.9% of the males on the right or left sides, respectively. The parietal foramina located in the proximity of the sagittal suture (male 7.1 ± 2.5 mm vs. female, 7.4 ± 2.7 mm). There was a positive correlation between the right and left parietal foramina regarding the distance from the median line. The distance from a foramen to the contralateral one was 16 ± 4 mm in men and 18 ± 5 mm in women, respectively (p > 0.05).

CONCLUSION

No major differences were encountered between sexes regarding the anatomical features of parietal foramen.

Quantitative Cerebrovascular Reactivity in Normal Aging: Comparison Between Phase-Contrast and Arterial Spin Labeling MRI

Purpose: Cerebrovascular reactivity (CVR) is an index of the dilatory function of cerebral blood vessels and has shown great promise in the diagnosis of risk factors in cerebrovascular disease. Aging is one such risk factor; thus, it is important to characterize age-related differences in CVR. CVR can be measured by BOLD MRI but few studies have measured quantitative cerebral blood flow (CBF)-based CVR in the context of aging. This study aims to determine the age effect on CVR using two quantitative CBF techniques, phase-contrast (PC), and arterial spin labeling (ASL) MRI.

Methods: In 49 participants (32 younger and 17 older), CVR was measured with PC, ASL, and BOLD MRI. These CVR methods were compared across young and older groups to determine their dependence on age. PC and ASL CVR were also studied for inter-correlation and mean differences. Gray and white matter CVR values were also studied.

Results: PC CVR was higher in younger participants than older participants (by 17%, p = 0.046). However, there were no age differences in ASL or BOLD CVR. ASL CVR was significantly correlated with PC CVR (p = 0.042) and BOLD CVR (p = 0.016), but its values were underestimated compared to PC CVR (p = 0.045). ASL CVR map revealed no difference between gray matter and white matter tissue types, whereas gray matter was significantly higher than white matter in the BOLD CVR map.

Conclusion: This study compared two quantitative CVR techniques in the context of brain aging and revealed that PC CVR is a more sensitive method for detection of age differences, despite the absence of spatial information. The ASL method showed a significant correlation with PC and BOLD, but it tends to underestimate CVR due to confounding factors associated with this technique. Importantly, our data suggest that there is not a difference in CBF-based CVR between the gray and white matter, in contrast to previous observation using BOLD MRI.

Baseline cerebral metabolism predicts fatigue and cognition in Multiple Sclerosis patients

BACKGROUND

Cerebral metabolic rate of oxygen (CMRO₂), a measure of global oxygen metabolism, reflects resting cellular activity. The mechanisms underlying fatigue and cognitive dysfunction in multiple sclerosis (MS) remain unknown. If fatigue indeed reflects ongoing autoimmune activity and cortical reorganization, and cognitive decline is the result of gray matter atrophy and white matter degeneration, we postulate that changes in CMRO₂ should reflect disease activity and predict these symptoms.

OBJECTIVE

We sought to utilize T₂-Relaxation-Under-Spin-Tagging (TRUST) and phase-contrast (PC) MRI to measure global CMRO₂ to understand its relationships to white matter microstructure, fatigue and cognitive dysfunction.

METHODS

We measured venous oxygenation (TRUST) and cerebral blood flow (PC-MRI) in superior sagittal sinus to calculate global CMRO₂ and diffusion tensor imaging (DTI) to evaluate white matter microstructure in healthy controls (HC) and MS patients. Participants underwent neuropsychological examinations including Modified Fatigue Impact Scale (MFIS) and Symbol-Digit-Modalities Test (SDMT).

RESULTS

We observed lower CMRO₂ in MS patients compared to HC. After controlling for demographic and disease characteristics (i.e., age, education, disability, lesion volume), CMRO₂ predicted increased fatigue (MFIS) and reduced cognitive performance (SDMT) in MS patients. Finally, MS patients with higher CMRO₂ have reduced FA in normal-appearing white-matter.

CONCLUSION

Altogether, these results suggest that increased CMRO₂ reflects ongoing demyelination and autoimmune activity which plays an important role in both fatigue and cognitive dysfunction.

Cerebral metabolism, oxidation and inflammation in severe passive hyperthermia with and without respiratory alkalosis

KEY POINTS

It was unknown whether respiratory alkalosis impacts the global cerebral metabolic response as well as the cerebral pro-oxidation and inflammatory response in passive hyperthermia. This study demonstrated that the cerebral metabolic rate was increased by ∼20% with passive hyperthermia of up to +2°C oesophageal temperature, and this response was unaffected by respiratory alkalosis. Additionally, the increase in cerebral metabolism did not significantly impact the net cerebral release of oxidative and inflammatory markers. These data indicate that passive heating of up to +2°C core temperature in healthy young men is not enough to confer a major oxidative and inflammatory burden on the brain, but it does markedly increase the cerebral metabolic rate, independently of P aC O 2 .

ABSTRACT

There is limited information concerning the impact of arterial P C O 2 /pH on heat-induced alteration in cerebral metabolism, as well as on the cerebral oxidative/inflammatory burden of hyperthermia. Accordingly, we sought to address two hypotheses: (1) passive hyperthermia will increase the cerebral metabolic rate of oxygen (CMRO₂ ) consistent with a combined influence of Q10 and respiratory alkalosis; and (2) the net cerebral release of pro-oxidative and pro-inflammatory markers will be elevated in hyperthermia, particularly in poikilocapnic hyperthermia. Healthy young men (n = 6) underwent passive heating until an oesophageal temperature of 2°C above resting was reached. At 0.5°C increments in core temperature, CMRO₂ was calculated from the product of cerebral blood flow (ultrasound) and the radial artery-jugular venous oxygen content difference (cannulation). Net cerebral glucose/lactate exchange, and biomarkers of oxidative and inflammatory stress were also measured. At +2.0°C oesophageal temperature, arterial P C O 2 was restored to normothermic values using end-tidal forcing. The primary findings were: (1) while CMRO₂ was increased (P < 0.05) by ∼20% with hyperthermia of +1.5-2.0°C, this was not influenced by respiratory alkalosis, and (2) although biomarkers of pro-oxidation and pro-inflammation were systemically elevated in hyperthermia (P < 0.05), there were no differences in the trans-cerebral exchange kinetics. These novel data indicate that passive heating of up to +2°C core temperature in healthy young men is not enough to confer a major oxidative and inflammatory burden on the brain, despite it markedly increasing CMRO₂ , irrespective of arterial pH.

Characterization of MRI techniques to assess neonatal brain oxygenation and blood flow

There is increasing interest in applying physiological MRI in neonates, based on the premise that physiological parameters may provide an early biomarker of neonatal brain health and injury. Two commonly used techniques are oxygen extraction fraction (OEF) measurement using T₂ -relaxation-under-spin-tagging (TRUST) MRI and cerebral blood flow measurement using phase-contrast (PC) quantitative flow MRI, which collectively provide an assessment of the brain's oxygen consumption. However, prior research has only demonstrated proof of principle of these methods in neonates, without characterization or benchmarking of the techniques. This is because available time is limited in neonatal subjects, especially when scans are performed as add-ons to clinical scans (typically less than 5 min). The work presented aims to examine the TRUST and PC MRI sequences systematically in normal neonates, through research-dedicated scan sessions. A series of characterization and optimization studies were conducted in a total of 26 radiographically normal neonates on 3 T systems. Our results show that TRUST MRI at the superior sagittal sinus (SSS) provides an OEF measurement equivalent to that at the internal jugular vein (r = 0.80, n = 10), yet with shorter scan time. Lower resolution provided better precision in the TRUST measurement (p = 0.001, n = 9). Therefore, the preferred OEF measurement is to apply TRUST MRI at the SSS using a spatial resolution of 2.5 mm. For PC MRI, our results showed that non-gated PC MRI yielded blood flow measurements comparable to those from the more time-consuming gated approach in neonates (r = 0.89, n = 7). It was also found that blood flow could be overestimated by 18% when imaging resolution is larger than 0.3 mm (n = 7). Therefore, non-gated PC MRI with a spatial resolution of 0.3 mm is recommended for neonatal applications. In conclusion, this study verifies consistency of neonatal brain oxygenation and flow measurements across acquisition schemes and points to optimal strategies in parameter selection when using these sequences.

In vivo validation of T2- and susceptibility-based Sv O2 measurements with jugular vein catheterization under hypoxia and hypercapnia

PURPOSE

To investigate the mutual agreement of T2-based and susceptibility-based methods as well as their agreement with jugular catheterization, for quantifying venous oxygen saturation (S_v O₂ ) at a broad range of brain oxygenation levels.

METHODS

S_v O₂ measurements using T2-relaxation-under-spin-tagging (TRUST) and susceptibility-based oximetry (SBO) were performed in 13 healthy subjects under room air, hypoxia, and hypercapnia conditions. Agreement between TRUST and SBO was quantitatively evaluated. In two of the subjects, TRUST and SBO were compared against the clinical gold standard, co-oximeter measurement via internal jugular vein catheterization.

RESULTS

Absolute S_v O₂ measurements using TRUST and SBO were highly correlated across a range of saturations from 45% to 84% (Pearson r = 0.91, P < .0001). S_v O₂ -TRUST was significantly lower than S_v O₂ -SBO under hypoxia and room air conditions, but the two were comparable under hypercapnia. TRUST demonstrated a larger S_v O₂ increase under hypercapnia than SBO and had good agreement with jugular catheterization under hypercapnia but significantly underestimated S_v O₂ under room air and hypoxia. The agreement between S_v O₂ -SBO and the reference did not depend on the physiological state.

CONCLUSION

A systematic bias was observed between T2-based and susceptibility-based methods that depended on the oxygenation state. In vivo validation with jugular catheterization indicated potential underestimation of TRUST under room air and hypoxia conditions. Our findings suggested that caution should be employed in comparison of absolute S_v O₂ measurements using either TRUST or SBO.

Regional Cerebral Perfusion and Cerebrovascular Reactivity in Elderly Controls With Subtle Cognitive Deficits

Background: Recent studies suggested that arterial spin labeling (ASL)-based measures of cerebral blood flow (CBF) as well as cerebral vasoreactivity to CO₂ (CVR CO₂) show significant alterations mainly in posterior neocortical areas both in mild cognitive impairment (MCI) and Alzheimer disease. It remains, however, unknown whether similar changes occur in at risk healthy elders without clinically overt symptoms. This longitudinal study investigated patterns of ASL perfusion and CVR CO₂ as a function of the cognitive trajectories in asymptomatic elderly individuals. Methods: Seventy-nine community-dwelling subjects (mean age: 78.7 years, 34 male) underwent three neuropsychological assessments during a subsequent 3-year period. Individuals were classified as stable-stable (SS), variable (V), or progressive-progressive (PP). Between-group comparisons were conducted for ASL CBF and transit-time delay maps and β-maps of CO₂ response. Spearman's rho maps assessed the correlation between ASL (respectively, CVR CO₂ measures) and Shapes test for working memory, as well as Verbal fluency test for executive functions. Three group-with-continuous-covariate-interaction designs were implemented to investigate group-based differences on the association between neuropsychological scores and ASL or CO₂ measures. Results: Comparison of CBF maps demonstrates significantly lower perfusion in the V-group as to PP-cases predominantly in parietal regions, including the precuneus and, to a lesser degree, in temporal and frontal cortex. A stronger CVR CO₂ response was found in the PP-group in left parietal areas compared to the V-group. V-cases showed a stronger ASL-Shape value relationship than V-group in right temporoparietal junction and superior parietal lobule. CO₂-Shape value correlation was significantly higher in both SS and PP-groups compared to the V-group in right insular and superior perisylvian regions. Conclusion: Our data indicate the presence of decreased ASL and CVR CO₂ values mainly in parietal and fronto-temporal areas in cases with the first signs of cognitive instability (V-group). Importantly, the PP-group, at high risk for MCI transition, displays an increase of both parameters in the same areas. Clinicoradiologic correlations also indicate a clear distinction between the V-group and both PP and SS-cases. These data imply the presence of an inverted U-shape pattern of regional blood flow and CVR in old age that might predict subsequent cognitive fate.

Understanding jugular venous outflow disturbance

Extracranial venous abnormalities, especially jugular venous outflow disturbance, were originally viewed as nonpathological 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 to symptomatic, such as headaches, dizziness, pulsatile tinnitus, visual impairment, sleep disturbance, and neck discomfort or pain. 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 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 the 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 attempt to identify the pathophysiology, diagnostic criteria, and effective approaches to its treatment will provide a profound insight into this issue.