CERVICAL VENOUS REFLUX IN DYNAMIC BRAIN SCINTIGRAPHY

David B. Hayt and LouisA. Perez Misericordia Hospital Medical Center, Bronx, New York

Cervical venous re/lux, shown by dynamic observed activity in the cervical region, only those brain scintigraphy, was investigated through cases in which activity was extremely intense and three avenues of approach: (A) by reviewing well defined were studied further. Two patients with 371 randomly chosen routine dynamic intra cervical venous reflux underwent positive-contrast cerebral blood/low studies to estimate its in superior venacavography. This was done by first per cidence; (B) by correlative positive-contrast forming a left-sided injection into the antecubital superior venacavography in patients with char vein, followed by a second study with bilateral ante acteristic cervical venous reflux; and (c) by cubital vein injections using a deliberately slow performing dynamic brain scintigraphy while (3-sec) hand injection. Renografin-76 (30 cc) was utilizing various positional and physiologic ma introduced into each antecubital vein through a neuvers to attempt to produce cervical venous catheter. Bilateral venous pressures and Decholin reflux in patients who did not exhibit this phe. arm-to-tongue circulation times were also obtained. nomenon on earlier examination. Although any Dynamic scintiphotos were then compared with posi obstruction of the superior vena cava or a prop tive-contrast superior venacavograms. erly timed Valsalva maneuver in selected pa A number of additional patients underwent dy tients can produce the scintigraphic picture of namic brain imaging for a second time (Table 1), cervical venous reflux, in most cases it is a nor using various positional and physiologic maneuvers. mal phenomenon due to incompetent or absent The first study did not exhibit cervical venous reflux: cervical venous valves. 1. Three patients in a left-side-down lateral decubitus position, left arm injected, an terior and posterior dynamic scintiphotos. Unusually high levels of radioactivity in the cervi cal area during the early phase of dynamic enceph aloscintigraphy are sometimes seen in nuclear medi Received March 24, 1975; revision accepted Aug. 6, 1975. For reprints contact: David B. Hayt, Dept. of Radiology, cine laboratories. Speculation that this finding always Misericordia Hospital Medical Center, 600 East 233rd St., indicates a significant pathologic state within the Bronx, N.Y. 10466. neck or in the downstream venous system led to its subsequent investigation. TABLE 1. RESULTSOF POSITIONAL AND MATERIALS AND METHODS PHYSIOLOGIC MANEUVERS

Dynamic brain scintigraphy was performed as fol NumberNumberManeuver lows: A small bolus (average 2.5 cc) of 10—15mCi positiveof cases of o9mTc@pertechnetate was injected into an ante Decubitusprojection,left side down, cubital vein, using Oldendorf's technique (1—3). A left-sided injection 0 3 left-sided injection was used because of the space Sitting up, left-sided injection 0 5 Standing, left-sided injection 0 2 limitations of our camera room. A Searle Radio Supine, head dependent, posterior graphics Pho/Gamma III HP camera recorded the projection, left-sided injection 0 2 images at 2-sec intervals, beginning immediately after Supine, Valsalva maneuver, anterior proiection, left arm injection 2 12 injection, on 35-mm film. Either posterior or anterior Supine, anterior projection,right projections were used, depending on the clinical arm injection 0 6 situation. Although there were varying degrees of

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2. Five patients in sitting position, left arm and 3. Figure 1 shows a striking example of bilateral injected, anterior dynamic scintiphotos. early cervical activity in a dynamic scintigram. Fig 3. Two patients in a standing position, left arm ure 2 is the positive-contrast superior venacavogram, injected, anterior dynamic scintiphotos. showing bilateral ifihing of the posterior cervical 4. Two patients supine, head dependent, left veins, the thyrocervical veins, transverse cervical arm injected, posterior dynamic scintipho veins, suprascapular veins, anterior jugular veins, cx tos. ternal jugular veins, and internal jugular veins (4—6). 5. Twelve patients supine performing a Val Figure 3 shows a clearly patent superior vena cava salva maneuver, prior to and during left arm (bilateral arm injections) . To exclude the possibility injection, anterior scintiphotos. of subclinical cardiac decompensation, the patient 6. Six patients supine, right arm injected, an was carefully examined. Both external jugular veins tenor scintiphotos. ifiled from above. Decholin arm-to-tongue circula tion time on the right was 12 5cc, and on the left, 10 RESULTS sec. Venous pressure on the right was 120 mm. This Of the 37 1 randomly chosen cases, 14 were posi represents normal circulation time and normal ye live for early intense well-defined radioactivity within nous pressure. the neck, an incidence of 3.5% . Of these, ten showed The results of injections made during positional only left-sided cervical activity. Analysis of the cur and physiologic maneuvers are presented in Table 1. rent diagnosis, sex, anatomic position during the These results do not appear to be statistically sig study, and cardiovascular status of the 14 positive nificant,but it is of interest that the only two positive cases showed no common pattern that would aid in instances of cervical venous reflux were produced explaining the phenomenon. The median age was during Valsalva maneuvers. 70 years (excluding a 1-year-old infant). Of the two patients who showed dynamic scinti DISCUSSION graphic cervical venous reflux and who also had The phenomenon of intense cervical radioactivity positive-contrast superior venacavography, both cor in the early phase of dynamic encephaloscintigraphy related well with respect to the presence of reflux represents reflux filling of the cervical venous sys and its laterality. These patients did not have su tern (7). The phenomenon can be assessed in four perior venacaval obstruction. One patient had absent categories : technical, anatomic, physiologic, and valves in the external jugular system; the other had pathologic. valves present, but incompetent to retrograde flow. Technical.The averagesizeof the injectedbolus An example of this latter type is shown in Fig. 1, 2, was 2.5 cc. No bolus exceeded 5 cc in volume. There

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@‘ .@ FIG. 1. Rapid-sequentialbrain scinti r@ grams in 80-year-old patient. Anterior pro -@- jection. Note persistenceof extremely high concentration of radioactivity in cervical region (lower arrows). Middle cerebral or tery (descending arrow) s best seen at 21 sec. Cervical veins (upper arrows) appear 42SEC 45SEC!, 485EC both early (15 sec)and late (42, 45, and 48 sec)

10 JOURNAL OF NUCLEAR MEDICINE DIAGNOSTICNUCLEARMEDICINE

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FIG. 2. Somepatient, left-sidediniectionvenogramof arm. FIG. 3. Samepatient,bilateralvenogram.Again, injectionis Note filling of external and internal jugular veins, posterior cer deliberately slow (3 sec) to avoid altering normal hemodynamics. vical venous plexus, suprascapular veins, inferior thyroid vein, and Note that superior vena cava is clear. Venous pressure and arm other neck veins, all of which fill with left-sided injection. to-tongue circulationtimes on both sides were normal.

fore, neither rapidity nor volume of injection could ever, since one patient who showed dramatic cervi affect normal venous circulation. The layering phe cal activity was comatose during the injection. nomenon, which occurs when radiographic contrast Pathologic. Superior venacaval obstruction due to material settles into the more dependent posterior tumor has been shown to cause cervical venous re cervical veins, is not present here. flux. Tatsuya Miyame reports one case of superior Anatomic. The intensity and early appearance of venacaval syndrome in which the radionuclide su the cervical activity rule out arterial structures. The perior venacavogram showed reflux filling of the positive-contrast venograms confirm that the struc external jugular vein (12). tures are venous in nature. In addition, one case Although almost all of our cases were in patients did have a thoracic-arch arteriogram which showed of advanced age, these patients were not in con normal arterial vessels. The presence of valveless gestive heart failure at the time of examination. external jugular veins and other valveless cervical Severe cardiac decompensation could probably con veins is not uncommon (8) . Furthermore, the valves tribute to cervical venous reflux, but we have not normally present in the internal jugular vein are been able to document such a case. usually incompetent to retrograde flow (9) . Cervical veins anastomose readily and bilaterally, thus ac CONCLUSIONS counting for the high incidence of bilateral activity. The phenomenon of cervical venous reflux shown Physiologic. Considering that an inadvertent Val by dynamic encephaloscintigraphy can occur in pa salva maneuver by a patient may be a contributing tients with valveless cervical venous systems or cer factor, the effects of deliberate Valsalva were studied. vical venous incompetence. A Valsalva maneuver One child had two dynamic brain scintigrams. The accentuates the phenomenon but is not necessary to first study, performed while the child was mildly produce it. Superior venacaval obstruction can be sedated and quiet, showed a totally normal dynamic a causative factor. Conceivably, congestive heart fail study, whereas the second study, performed while ure could be a contributing factor but was not causa the child was crying, showed dramatic bilateral cer tive in the present series. vical venous reflux. The effects of Valsalva maneu ver are variable (1 0—11 ) . Our findings indicate that REFERENCES it is a significant contributing factor in some cases 1. ROSENThALLL: Detection of altered cerebral arterial cervical venous reflux was produced in two out of blood flow using technetium-99m pertechnetate and the twelve attempts. The Valsalva maneuver accentuates gamma ray scintillation camera. Radiology 88: 713—718, 1967 cervical venous reflux in those patients who have 2. MOODY D, MAnN P, GOODWIN DA : An improved either absent cervical venous valves or borderline method for visualizing carotid blood flow in the neck. competent valves. It is not a necessary factor, how I Nuci Med 12: 520—522,1971

Volume 17, Number 1 11 HAYT AND PEREZ

3. OLDENDORF WH, KimNo M, Smt@uzu S: Evaluation unusual variant in cerebral circulation studies. I Nuci Med of a simple technique for abrupt intravenous injection of 15:363—364,1974 radioisotope. I Nuci Med 6: 205—209,1965 8. BRASHJC: Cunningham's Texibook of Anatomy, 9th 4. SHIMiw-rPM, DOPPMANJK, POWELLD, et al: Dem ed, London, Oxford University Press, 1951, pp 1335—1339 onstration of parathyroid adenomas by retrograde thyroid 9. Goss CM : Anatomy of the Human Body. Philadel venography. Radiology 103 : 63—67,1972 phia, Lea & Febiger, 1956, pp 720—725 10. HAYT DB: Upright inferior venacavography. Radi 5. GRANTJCB: An Atlas of Anatomy, 3rd ed, Baltimore, ology86:865—870,1966 Williams & Wilkins, 1951, pp 463—465,511—512 11. WATSONDD, NELSONJP, GOTrLIEB 5: Rapid bolus 6. THERONJ, DJINDJIAM R: Cervicovertebral phiebog injection of radioisotopes. Radiology 104: 347—352,1973 raphy using catheterization: A preliminary report. Radiology 12. TATSUYAM : Interpretation of ‘@mTcsuperior vena 108:325—331,1973 cavagram and results of studies in 92 patients. Radiology 7. FRIEDMANBH, LOVEGROVEFTA, WAGNERHN : An 108:339—352,1973

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