Occult intracranial hypertension as a sequela of biomechanical internal jugular vein stenosis: A case report

A 27-year-old woman presented with dominant symptoms including chronic migraine, dizziness and nausea with suspected intracranial hypertension (ICH). The patient also had a purpuric (cyanotic) facial discoloration, suggestive of compromised cerebral perfusion. However, her lumbar puncture opening pressure (LPOP) was borderline high, with 20 cm H2O. There was no evidence of partially empty sella turcica nor obliteration of the cerebral cisterns upon MRI. She was initially diagnosed with chronic migraines by her neurologist. However, closer inspection revealed posterior scleral flattening, flattened pons, and most importantly stenosis of the internal jugular veins (IJV) between the C1 transverse processes and styloid processes, due to anterior subluxation of the atlanto-occipital facets. Doppler waveforms of the internal carotid arteries were abnormal and suggestive of ICH, with a significantly delayed systolic upstroke but with normal speeds. Manual compression of the IJVs reproduced her symptoms within 7 sec. Occult biomechanical ICH may have severe and long-lasting consequences for the patient and thus its detection, and distinguishing from the "common migraine" is necessary, so that the patient may receive proper treatment.