Cerebral Venous Insufficiency: Symptoms, Causes and Treatment Options

Cerebral venous insufficiency is a dangerous increase in intracranial pressure caused by impaired flow, narrowing, or clot formation in the venous system responsible for carrying the brain’s metabolic waste and deoxygenated blood back to the heart. This hemodynamic problem represents a serious clinical condition in which compromised vascular pathways can lead to brain edema, severe headaches, and permanent vision loss. Today, these mechanical problems can be effectively treated using interventional radiology methods without the need for open surgery. Venous stenting and mechanical thrombectomy techniques performed in an angiographic setting reopen blocked drainage pathways, normalize cerebral circulation, and safeguard neurological health.

How Does Cerebral Venous Insufficiency and Brain Circulation Work?

To understand blood circulation in our body, imagining the plumbing system in a home is often the best approach. The pipes that bring clean water to faucets are arteries, while the drain pipes that carry used water away are veins. When it comes to the brain, this “drainage system” has a unique structure. In other parts of the body, such as the legs, veins contain valves that prevent blood from flowing backward due to gravity. However, these valves are absent in the brain’s venous system. This allows blood to flow smoothly from the brain to the heart, but it also makes the system more vulnerable to pressure changes.

The venous structure of the brain is not limited to vessels; there are also large channels called “dural sinuses” located between the layers of the brain’s membranes. These channels collect all the deoxygenated blood from the brain—like small streams merging into a large river—and deliver it to the jugular veins in the neck. Any clot, narrowing, or congenital underdevelopment along this pathway can disrupt the entire system. Just as a blocked drain causes a sink to overflow, the brain becomes subjected to pressure from its own fluid and blood. Our medical approach is to identify where the blockage is and restore flow using highly precise techniques.

What Causes Clotting in the Cerebral Venous System (CVST)?

When people hear the term “blood clot,” stroke is usually the first thing that comes to mind, and this typically involves arteries. However, clots in veins (Cerebral Venous Sinus Thrombosis) function through a different mechanism and usually affect a different patient group. In this condition, the brain’s main drainage channels are blocked by a clot. Blood cannot drain out, accumulates behind the blockage, exerts pressure on vessel walls, and may even leak out, causing brain hemorrhage.

One of the most striking aspects of this disease is that it tends to affect young and middle-aged individuals rather than the elderly, especially women. Hormonal changes or external factors that disrupt the body’s clotting balance play a leading role in its development. A sudden-onset headache that progressively worsens and does not respond to painkillers is often the earliest and most important warning sign.

Risk factors include:

• Pregnancy
• Postpartum period
• Birth control pills
• Hormone therapies
• Genetic clotting disorders
• Severe dehydration
• Ear infections
• Sinus infections
• Head trauma
• Certain types of cancer
• Rheumatologic diseases

Which Methods Are Used in the Treatment of Cerebral Venous Thrombosis?

Once the diagnosis is made, time becomes critical. The brain is a sensitive organ that cannot tolerate prolonged high pressure. In most patients, the first-line treatment is blood-thinning medications. These drugs allow the body time to dissolve the clot naturally and prevent new clot formation. However, in some cases, the clot is so large, dense, and widespread that medications are insufficient. Patients may even deteriorate neurologically despite treatment, lose consciousness, or develop vision loss.

At this stage, interventional radiology comes into play. Minimally invasive methods performed entirely through the vessels are life-saving. By entering through the groin or neck, we reach the blocked vessel deep in the brain using microscopic catheters. Our goal is to mechanically reopen the pathway.

The techniques we use include:

• Mechanical thrombectomy
• Aspiration
• Balloon angioplasty
• Stent retriever
• Chemical thrombolysis

Removing the clot using special vacuum devices (aspiration) is similar to clearing a clogged drain with powerful suction. Sometimes the clot is very adhesive; in such cases, we deploy a temporary stent inside the vessel to capture and remove it. In some cases, we inject highly effective clot-dissolving medications directly into the center of the clot in very low doses. These procedures spare the patient from major brain surgery and the need for opening the skull.

What Are the Symptoms of Idiopathic Intracranial Hypertension (IIH)?

Another important condition under cerebral venous insufficiency is Idiopathic Intracranial Hypertension (IIH), one of the most commonly overlooked conditions in society. Previously referred to as “pseudotumor cerebri,” this condition involves increased intracranial pressure without the presence of a tumor. Patients are typically young women with weight-related issues.

In these patients, the problem is usually not a clot but narrowing in the brain’s main drainage channels (transverse sinuses). These narrowings make it difficult for blood to return to the heart. Just as water rises backward when an obstacle is placed in its path, cerebrospinal fluid and blood accumulate in the brain. This leads to symptoms that can make life unbearable for the patient. Patients often visit multiple doctors, their MRIs appear “normal,” yet their complaints persist.

Common symptoms include:

• Severe headache
• Blurred vision
• Double vision
• Temporary vision loss
• Ringing in the ears
• Whooshing sound
• Hearing the heartbeat in the ear
• Neck pain
• Shoulder pain
• Nausea
• Difficulty concentrating
• Memory problems

How Are Venous Narrowings Detected and Why Is Pressure Measurement Essential?

In a patient suspected of IIH, standard MRI or CT scans provide information about the structure of the vessel. We may identify areas of narrowing. However, imaging alone is not sufficient to determine whether this narrowing is the actual cause of the disease. Some individuals may have congenital vessel narrowings that do not cause any problems. The only way to distinguish a harmless narrowing from one that causes disease is through pressure measurement, known as “Venous Manometry.”

This procedure is performed in an angiography suite. The patient is awake, and we access the vessel through the groin using local anesthesia. With a very thin catheter, we advance to the brain’s main veins. When we reach the narrowed area, we measure the pressure just before and just after the narrowing. If the pressure is very high before the narrowing and suddenly drops after passing it, this indicates the presence of a “pressure gradient.” The existence of this gradient mathematically proves that the narrowing is obstructing blood flow and increasing intracranial pressure. Any intervention without this proof may be incomplete or incorrect. For us, the gold standard is demonstrating the hemodynamic significance of the narrowing.

What Benefits Does Venous Stenting Provide?

Once we prove through pressure measurement that the narrowing is responsible, our treatment strategy becomes venous stenting. This procedure is very similar to stent placement used in coronary arteries, but we use more flexible and specialized stents designed for brain vessels.

The procedure begins with a small entry through the groin. The collapsed stent is delivered to the narrowed area via a delivery system. The stent is deployed exactly at the center of the narrowing. This self-expanding metal mesh pushes the narrowed vessel walls outward and creates a wide tunnel through which blood can flow easily.

As soon as the stent is deployed, the mechanical obstruction is eliminated. Its effect is usually very rapid. In particular, the distressing “whooshing” sound in the ear (pulsatile tinnitus) may disappear while the patient is still on the angiography table. Headaches typically improve within days. Most importantly, the pressure on the optic nerves (papilledema) is relieved. As the swelling in the optic disc subsides, the risk of blindness is eliminated and vision is preserved. This treatment spares patients from repeated lumbar punctures or more invasive surgical risks such as shunt placement in the brain.

Is There a Relationship Between Chronic Cerebrospinal Venous Insufficiency (CCSVI) and MS?

In recent years, a controversial topic frequently encountered online has presented “vein-opening” or “liberation” therapy as a potential solution for patients with Multiple Sclerosis (MS). According to this theory (CCSVI), narrowing in the neck veins leads to iron accumulation in the brain and triggers MS. Therefore, it has been suggested that opening these narrowings with balloons could treat MS.

However, as a physician, it is important to be clear and honest on this matter. Large-scale, well-conducted scientific studies have not definitively confirmed this theory. While some MS patients may have narrowing in their neck veins, there is no strong evidence that treating these narrowings changes the course of MS (such as relapses or walking difficulties).

As interventional radiologists, we are experts in opening vessels and are technically capable of performing this procedure. However, presenting a procedure with uncertain benefit as a “miracle treatment” is not consistent with medical ethics. Therefore, CCSVI treatment is not a standard treatment protocol today. It may only be considered in very specific cases within research protocols and with the opinion of neurology specialists. Patients should be cautious of approaches driven by commercial concerns.

What Preparations Are Required Before an Interventional Procedure?

Whether it is diagnostic angiography or venous stenting for the cerebral venous system, patient safety is the top priority. Before the procedure, we conduct a detailed evaluation. First, we assess kidney function because the “contrast agent” used during the procedure is excreted through the kidneys. The kidneys must be capable of handling this load.

In addition, blood clotting parameters are checked. The blood should be neither too thin nor too thick. If the patient is using blood-thinning medications, we may ask them to stop or adjust these medications before the procedure. Some medications used by diabetic patients (such as those in the Metformin group) may need to be discontinued for a period before and after the procedure.

On the day of the procedure, the patient should arrive at the hospital after fasting for at least 4–6 hours. This ensures safety in case of possible nausea during the procedure. We usually allow patients to take their blood pressure medications with a small amount of water on the morning of the procedure.

Preparation steps include:

• Blood tests
• Kidney function tests
• Coagulation tests
• Medication adjustment
• Fasting period
• IV access
• Hydration
• Consent forms

What Happens During and After the Procedure?

When you are taken into the angiography room, you are greeted by a cool environment filled with technological equipment. After lying on the table, you are covered with sterile drapes. The procedure is usually performed through the groin. Apart from the local anesthesia injection, you do not feel significant pain. Since there are no nerve endings inside the vessels, you do not perceive the movement of catheters or the deployment of the stent as pain.

In IIH stenting procedures, the patient is usually awake because they may need to follow instructions such as holding their breath during pressure measurement. However, for patient comfort, we administer sedative medications intravenously. In this way, the patient remembers the procedure but does not feel fear or anxiety. Thrombectomy procedures, on the other hand, are usually performed under general anesthesia due to their urgency and critical nature.

After the procedure, pressure is applied to the entry site in the groin or it is closed with special closure devices. The patient is then taken to their bed and is usually monitored in the hospital for 24 hours. During this time, blood pressure monitoring, neurological checks, and control of the entry site are performed. For patients who have received a stent, the most critical period is the medication treatment that begins immediately after the procedure.

After discharge, the following should be considered:

• Dual antiplatelet therapy
• High fluid intake
• Avoiding heavy lifting
• Use of stomach-protective medication
• Regular blood pressure monitoring
• Rest

Why Is Medication Use So Important During the Recovery Process?

In patients who undergo venous stenting, the key to success is ensuring that the stent remains open. The body may recognize the metal placed inside the vessel as a “foreign object” and attempt to form a clot on it. To prevent this, we apply a strong blood-thinning protocol called “dual antiplatelet therapy” after the procedure. Medications containing Aspirin and Clopidogrel are usually used together.

Regular use of these medications is vital. Missing even a single dose may lead to clot formation inside the stent. We generally recommend dual therapy for 3 to 6 months, followed by lifelong single therapy (such as Aspirin alone). Since these medications may irritate the stomach, they should be supported with stomach-protective drugs. Patients are also advised to avoid sports that may cause trauma or activities that carry a risk of bleeding during the first months after the procedure.

What Are the Risks of Cerebral Venous Interventions?

As with any medical intervention, procedures involving brain vessels carry certain risks. However, with advancements in technology and increased experience, these risks have been minimized. Patients should still be informed transparently. The most common situation is bruising or small blood collections (hematoma) at the groin entry site, which usually resolve on their own.

Less common but important risks include injury or tearing of the vessel wall during the procedure. Since venous vessel walls are very thin, this risk always exists, but the materials we use are so soft and flexible that the likelihood is low. After stenting, rare cases of stent displacement or stent thrombosis may occur. Additionally, temporary severe headaches due to sudden pressure changes after the procedure may be experienced. All these risks are relatively low compared to the risks of untreated disease (such as blindness or stroke).

Risk categories include:

• Access site bleeding
• Infection
• Allergic reaction
• Vessel injury
• Stent thrombosis
• Temporary headache
• Stent migration
• Kidney failure

Why Should Interventional Radiology Be Preferred?

In the management of cerebral venous diseases, interventional radiology offers the most effective and patient-friendly solutions of modern medicine. The ability to solve problems in the deepest parts of the brain through a tiny needle entry—without the need for open surgery and without leaving surgical scars—is a major advantage. Thanks to these methods, hospital stay is shortened, the recovery process is accelerated, and patients can return to their normal lives in a very short time.

Conditions that were once considered untreatable or required very risky surgeries have now become routine procedures in angiography units. Especially in cases of unexplained headaches, vision loss, and tinnitus, detailed examination of the venous system can be a turning point in restoring the patient’s quality of life. With the right diagnosis, the right technique, and an experienced team, it is possible to protect and improve brain health.

Prof. Dr. Özgür KILIÇKESMEZ

Prof. Dr. Özgür Kılıçkesmez is one of Türkiye’s leading interventional radiology and neuroradiology specialists, focusing on minimally invasive endovascular treatments. His primary areas of expertise include aneurysm and stroke treatments, embolization procedures, non-surgical treatments of thyroid and parathyroid diseases, interventional oncology, and peripheral vascular interventions. He currently serves as the Head of the Interventional Radiology and Neuroradiology Department at Istanbul Memorial Göztepe Hospital.
Graduating from Istanbul University Cerrahpaşa Faculty of Medicine in 1997, Prof. Dr. Kılıçkesmez received advanced training in interventional radiology and oncology as a Clinical Fellow at London Guy’s & St Thomas’ and King’s College Hospital between 2012 and 2013. He earned the title of Professor in 2020 and, in the same year, became the Founding Interventional Radiologist at SBÜ Çam and Sakura City Hospital. He also holds the EBIR (European Board of Interventional Radiology) certification.
Prof. Dr. Kılıçkesmez has 94 international and 40 national publications and over 2500 citations. He serves as a reviewer for prestigious journals such as the American Journal of Roentgenology (AJR) and Diagnostic & Interventional Radiology. With his clinical and academic expertise, he is a nationally and internationally recognized authority in stroke treatment, brain aneurysm, embolization, tumor ablation, and minimally invasive treatments of thyroid/parathyroid diseases.