Persistent Oscillating Vertigo From Extracranial Venous Compression

Persistent oscillating vertigo (POV) can be triggered by motion, when it is called mal de débarquement syndrome (MdDS) but can also occur from nonmotion triggers such as neck injury, inflammation, or homeostatic derangements (nonmotion POV [nmPOV]). The pathology underlying MdDS and nmPOV is unknown but shared symptoms include rocking/bobbing/swaying vertigo, headache, cognitive slowing, and fatigue.

We present a case series of patients with MdDS and nmPOV whose symptoms were relieved after treatment of extracranial venous compression in the neck and thoracic outlet.

POV, regardless of the trigger, was associated with compressions at one or more of the following locations: 1) internal jugular vein (IJV) between the transverse process of the atlas and the styloid process, 2) IJV under the sternocleidomastoid muscle (SCM), and 3) subclavian vein at the thoracic outlet. Compressions were typically bilateral and in tandem. Catheter venography showed dynamic obstruction and shunting of venous blood to the petrosal sinuses around the inner ear and the vertebral veins. Relief of these obstructions with styloidectomy, stenting, neurotoxin to SCM and anterior scalene, SCM partial myotomy, and thoracic outlet decompression significantly relieved POV even with unilateral decompression.

Oscillatory perceptions of POV whether MdDS or nmPOV may be from the detection of low amplitude pulsations induced by venous outflow obstruction in areas of high freedom of motion (occipito-atlanto junction, mid-neck, and thoracic outlet). Impaired venous outflow and raised venous pressure around the inner ear could lead to continuous peripheral stimulation of the vestibular system and downstream central effects.