Neurosurgical implications of the Jugular Vein Nutcracker

Submitted: 29 September 2023
Accepted: 10 October 2023
Published: 10 October 2023
Abstract Views: 749
PDF: 44
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In the last ten years, a new variant of Eagle Syndrome is emerging and being described: Styloid Jugular Nutcracker (SJN). In SJN, an elongated or vertically directed styloid process causes jugular vein stenosis by compressing the vein against the arch of C1. The clinical consequences appear to be various and misunderstood, ascribable mainly to venous flow impairment and consequent intracranial hypertension. The aim of this paper is to create an overview of Jugular Vein Nutcracker and to focus on its neurosurgical implications. A PRISMA-based literature search was performed to select the most relevant papers on the topic and to realize a mini-review. Future searches in the neurosurgical field should focus on collecting data about further causes of jugular stenosis compression and the association of SJN with cerebrovascular diseases. It would also be interesting to investigate the potential role of primary and secondary prevention, which is unknown so far.

Gisolf J, van Lieshout JJ, van Heusden K, et al. Human cerebral venous outflow pathway depends on posture and central venous pressure. J Physiol. 2004;560:317-27. DOI:

Mohammed NY, Domenico GD, Gambaccini M. Cerebral venous drainage through internal jugular vein. Veins and Lymphatics. 2019;8:8379. DOI:

Mantovani G, Scerrati A, Scerrati A. The Cerebral Venous System: New Pathophysiological Theories and Diseases Related to Veins Occlusion. In: Cerebral Circulation - Updates on Models, Diagnostics and Treatments of Related Diseases. Available from:

De Simone R, Ranieri A, Bonavita V. Starling resistors, autoregulation of cerebral perfusion and the pathogenesis of idiopathic intracranial hypertension. Panminerva Med. 2017;59:76-89. DOI:

Wellcome Collection [Internet].. Studies in intracranial physiology & surgery: the third circulation, the hypophysis, the gliomas / by Harvey Cushing. Available from:

Zamboni P. Chapter 29 - The Contribution of Extra Cranial Venous Drainage to Neuro-Inflammation in Multiple Sclerosis. In: Neuroinflammation (Second Edition). Available from:

Observations on the Structure and Functions of the Nervous System, Illustrated with Tables. Lond Med J. 1783;4:113-35.

De Bonis P, Anile C. Storms, hanged pirates, anemia, exsanguination: the contributions of Monro, Kellie and Abercrombie in understanding intracranial blood circulation. Veins and Lymphatics 2014;3:4682. DOI:

Fusco DJ, Asteraki S, Spetzler RF. Eagle’s syndrome: embryology, anatomy, and clinical management. Acta Neurochir (Wien). 2012;154:1119-26. DOI:

Eagle WW. Elongated styloid process; further observations and a new syndrome. Arch Otolaryngol (1925). 1948;47(5):630-40. DOI:

Zamboni P, Scerrati A, Menegatti E, et al. The eagle jugular syndrome. BMC Neurol. 2019;19:333. DOI:

Mantovani G, Zangrossi P, Flacco ME, et al. Styloid Jugular Nutcracker: The Possible Role of the Styloid Process Spatial Orientation-A Preliminary Morphometric Computed Study. Diagnostics (Basel). 2023;13:298. DOI:

Shayganfar A, Golbidi D, Yahay M, et al. Radiological Evaluation of the Styloid Process Length Using 64-row Multidetector Computed Tomography Scan. Adv Biomed Res. 2018;7:85. DOI:

Cronin CG, Lohan DG, Mhuircheartigh JN, et al. CT evaluation of Chamberlain’s, McGregor’s, and McRae’s skull-base lines. Clin Radiol. 2009;64:64-9. DOI:

Diagnosis and Management of Cerebral Venous Thrombosis | Stroke. Available from:

Rigi M, Almarzouqi SJ, Morgan ML, Lee AG. Papilledema: epidemiology, etiology, and clinical management. Eye Brain. 2015;7:47-57. DOI:

Xiong L, Wang Z. Intracranial hypertension due to bilateral internal jugular venous occlusion in eagle syndrome: a case report. Heliyon. 2023;9. DOI:

Dashti SR, Nakaji P, Hu YC, et al. Styloidogenic jugular venous compression syndrome: diagnosis and treatment: case report. Neurosurgery. 2012;70:E795-799. DOI:

Zhao X, Cavallo C, Hlubek RJ, et al. Styloidogenic Jugular Venous Compression Syndrome: Clinical Features and Case Series. Oper Neurosurg (Hagerstown). 2019;17:554-61. DOI:

Mejia-Vergara AJ, Sultan W, Kostas A, et al. Styloidogenic Jugular Venous Compression Syndrome with Papilloedema: Case Report and Review of the Literature. Neuroophthalmology. 2022;46:54-8. DOI:

Werheim E, Sokol Z, Brown D, Oselkin M. Eagle syndrome causing cerebral sinus hypertension: Case report. Radiol Case Rep. 2023;18:2758-62. DOI:

Zhang FL, Zhou HW, Guo ZN, Yang Y. Eagle Syndrome as a Cause of Cerebral Venous Sinus Thrombosis. Can J Neurol Sci. 2019;46:344-5. DOI:

Scerrati A, De Bonis P, Zamboni P, et al. A New Insight in Nonaneurysmal Subarachnoid Hemorrhage: The Potential Role of the Internal Jugular Veins. J Neurol Surg A Cent Eur Neurosurg. 2022;83:344-50. DOI:

Hardin JS, Ramakrishnaiah RH, Pemberton JD, et al. Idiopathic Intracranial Hypertension Progressing to Venous Sinus Thrombosis, Subarachnoid Hemorrhage, and Stroke. J Neuroophthalmol. 2018;38:60-4. DOI:

Fu FW, Rao J, Zheng YY, et al. Perimesencephalic nonaneurysmal subarachnoid hemorrhage caused by transverse sinus thrombosis: A case report and review of literature. Medicine (Baltimore). 2017;96:e7374. DOI:

De Bonis P, Menegatti E, Cavallo MA, et al. JEDI (jugular entrapment, dilated ventricles, intracranial hypertension) syndrome: a new clinical entity? A case report. Acta Neurochir (Wien). 2019;161:1367-70. DOI:

Nonaka T, Sakata K, Abe T, et al. The eagle jugular syndrome as the cause of delayed intracranial hemorrhage after microvascular decompression for hemifacial spasm: A case report. Surg Neurol Int. 2021;12:584. DOI:

Nastro Siniscalchi E, Raffa G, Germanò A, De Ponte FS. Is Eagle Jugular Syndrome an Underestimated Potentially Life-Threatening Disease? Can J Neurol Sci. 2020;47:581-2. DOI:

Martinelli I. Unusual forms of venous thrombosis and thrombophilia. Pathophysiol Haemost Thromb. 2002;32:343-5. DOI:

Angelini, C., Mantovani, G., Cavallo, M. A., Scerrati, A., & De Bonis, P. (2023). Neurosurgical implications of the Jugular Vein Nutcracker. Veins and Lymphatics, 12(1).


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