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Cerebral venous system and anatomical predisposition to high-altitude headache

Authors

  • Mark H. Wilson BSc, MBBChir, FRCS (SN), FIMC, MRCA, FRGS,

    Corresponding author
    1. Centre for Altitude, Space, and Extreme Environment Medicine, University College London, London
    2. Department of Neurosurgery, National Hospital for Neurology and Neurosurgery, London
    3. London's Air Ambulance, Queen Mary College, London
    4. Caudwell Xtreme Everest Group, London
    5. Birmingham Medical Research Expeditionary Society, Birmingham, United Kingdom
    • The Traumatic Brain Injury Centre, St Mary's Hospital, Imperial College, London
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  • Indran Davagnanam MB, BCh, BAO, BMedSci, FRCR,

    1. Lysholm Department of Neuroradiology, National Hospital for Neurology and Neurosurgery, London
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  • Graeme Holland,

    1. Centre for Altitude, Space, and Extreme Environment Medicine, University College London, London
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  • Raj S. Dattani,

    1. Centre for Altitude, Space, and Extreme Environment Medicine, University College London, London
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  • Alexander Tamm,

    1. Centre for Altitude, Space, and Extreme Environment Medicine, University College London, London
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  • Shashivadan P. Hirani MSc, PhD, CPsychol,

    1. Health Services Research, City University London, London
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  • Nicky Kolfschoten MD,

    1. Centre for Altitude, Space, and Extreme Environment Medicine, University College London, London
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  • Lisa Strycharczuk,

    1. Lysholm Department of Neuroradiology, National Hospital for Neurology and Neurosurgery, London
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  • Cathy Green,

    1. Lysholm Department of Neuroradiology, National Hospital for Neurology and Neurosurgery, London
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  • John S. Thornton PhD,

    1. Lysholm Department of Neuroradiology, National Hospital for Neurology and Neurosurgery, London
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  • Alex Wright MB, FRCP,

    1. Medical School, University of Birmingham, Birmingham
    2. Birmingham Medical Research Expeditionary Society, Birmingham, United Kingdom
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  • Mark Edsell FRCA,

    1. Centre for Altitude, Space, and Extreme Environment Medicine, University College London, London
    2. Birmingham Medical Research Expeditionary Society, Birmingham, United Kingdom
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  • Neil D. Kitchen MD, FRCS (SN),

    1. Department of Neurosurgery, National Hospital for Neurology and Neurosurgery, London
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  • David J. Sharp PhD,

    1. The Traumatic Brain Injury Centre, St Mary's Hospital, Imperial College, London
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  • Timothy E. Ham PhD,

    1. The Traumatic Brain Injury Centre, St Mary's Hospital, Imperial College, London
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  • Andrew Murray DPhil,

    1. Department of Physiology, Development, and Neuroscience, University of Cambridge, Cambridge
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  • Cameron J. Holloway FRACP, D.Phil,

    1. Department of Physiology, University of Oxford, Oxford
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  • Kieran Clarke PhD,

    1. Department of Physiology, University of Oxford, Oxford
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  • Mike P.W. Grocott BSc, MBBS, MD, FRCA, FRCP, FFICM,

    1. Integrative Physiology and Critical Illness Group, Clinical and Experimental Sciences, Faculty of Medicine, University of Southampton, Southampton
    2. Anaesthesia and Critical care Research Unit, University Hospital Southampton NHS Foundation Trust
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  • Hugh Montgomery FRCP, MD, FRGS, FRI, FFICM,

    1. Centre for Altitude, Space, and Extreme Environment Medicine, University College London, London
    2. Caudwell Xtreme Everest Group, London
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    • Montgomery and Imray share senior authorship.

  • Chris Imray PhD, FRCS, FRCP, FRGS,

    1. Centre for Altitude, Space, and Extreme Environment Medicine, University College London, London
    2. Warwick Medical School, UHCW NHS Trust, Coventry, UK
    3. Birmingham Medical Research Expeditionary Society, Birmingham, United Kingdom
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    • Montgomery and Imray share senior authorship.

  • and on behalf of the Birmingham Medical Research Expeditionary Society and Caudwell Xtreme Everest Research Group


  • Members of the Caudwell Xtreme Everest Research Group are listed in the Appendix on page 388.

Address correspondence to Dr Wilson, Imperial College, Imperial College, Department of Neurosurgery, Praed Street, London W1 1NY, United Kingdom. E-mail: mark.wilson@imperial.nhs.uk

Abstract

Objective

As inspired oxygen availability falls with ascent to altitude, some individuals develop high-altitude headache (HAH). We postulated that HAH results when hypoxia-associated increases in cerebral blood flow occur in the context of restricted venous drainage, and is worsened when cerebral compliance is reduced. We explored this hypothesis in 3 studies.

Methods

In high-altitude studies, retinal venous distension (RVD) was ophthalmoscopically assessed in 24 subjects (6 female) and sea-level cranial magnetic resonance imaging was performed in 12 subjects ascending to 5,300m. Correlation of headache burden (summed severity scores [0–4] ≤24 hours from arrival at each altitude) with RVD, and with cerebral/cerebrospinal fluid (CSF)/venous compartment volumes, was sought. In a sea-level hypoxic study, 11 subjects underwent gadolinium-enhanced magnetic resonance venography before and during hypoxic challenge (fraction of inspired oxygen = 0.11, 1 hour).

Results

In the high-altitude studies, headache burden correlated with both RVD (Spearman rho = 0.55, p = 0.005) and with the degree of narrowing of 1 or both transverse venous sinuses (r = −0.56, p = 0.03). It also related inversely to both the lateral + third ventricle summed volumes (Spearman rho = −0.5, p = 0.05) and pericerebellar CSF volume (r = −0.56, p = 0.03). In the hypoxic study, cerebral and retinal vein engorgement were correlated, and rose as the combined conduit score fell (a measure of venous outflow restriction; r = -0.66, p < 0.05 and r = −0.75, p < 0.05, respectively).

Interpretation

Arterial hypoxemia is associated with cerebral and retinal venous distension, whose magnitude correlates with HAH burden. Restriction in cerebral venous outflow is associated with retinal distension and HAH. Limitations in cerebral venous efferent flow may predispose to headache when hypoxia-related increases in cerebral arterial flow occur. ANN NEUROL 2013;73:381–389

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