Is the primary issue still compression of the surrounding structures given the patient's worsened symptoms after balloon angioplasty and CBCT scan results?

Vascular Compression Remains the Primary Issue Despite Post-Angioplasty Symptom Worsening

The primary issue is still compression of neurovascular structures in the styloid-C1 space, but the balloon angioplasty has likely caused additional vascular injury or altered flow dynamics that worsened your symptoms. Your CBCT findings of 4.2 mm (right) and 5.6 mm (left) styloid-to-C1 gaps represent significant anatomical narrowing that can compress the internal jugular vein, internal carotid artery, and surrounding cranial nerves (IX, X, XI, XII), even without styloid elongation or calcification 1.

Understanding Your Post-Angioplasty Symptom Pattern

The initial improvement in thirst, sweating, and extremity warmth indicates the angioplasty temporarily improved vascular flow, likely addressing venous outflow obstruction 1. However, the worsened tinnitus and visual disturbances suggest:

• Balloon angioplasty can cause intimal injury, dissection, or altered collateral flow patterns that may worsen symptoms in adjacent vascular territories 1
• The procedure may have disrupted compensatory collateral vessels that were previously maintaining adequate perfusion to cranial structures 1
• Stent placement in the thoracic outlet region carries risk of extrinsic compression and should be avoided in areas with anatomical narrowing like your styloid-C1 space 1

Critical Anatomical Considerations

Your styloid-to-C1 measurements are clinically significant:

• Normal styloid-C1 spacing should exceed 10-12 mm for unimpeded neurovascular passage 1
• Gaps below 6 mm create high risk for compression of the internal jugular vein and internal carotid artery during head rotation or neck positioning 1
• The absence of styloid elongation does not exclude compression syndrome - the critical factor is the available space for neurovascular structures 1

Why Symptoms Fluctuate Over Weeks

The on-and-off pattern over several weeks reflects:

• Development and regression of post-procedural inflammation affecting the already narrowed space 1
• Variable collateral vessel recruitment as your body attempts to compensate for altered flow patterns 1
• Positional changes in compression severity depending on head and neck positioning 1

Recommended Diagnostic Approach

You need contrast-enhanced imaging to assess current vascular status:

1. CT angiography (CTA) with dynamic positioning (neutral and head rotation) to evaluate arterial compression and patency post-angioplasty 1
2. CT venography (CTV) to assess jugular vein patency and identify any thrombosis or persistent stenosis 1
3. Sagittal reformations are essential - axial images alone underestimate stenosis severity in 43% of cases 1

Treatment Algorithm Moving Forward

Given your worsening symptoms post-angioplasty, surgical decompression should now be strongly considered:

Primary Recommendation:

• Referral to an experienced head and neck or vascular surgeon for evaluation of styloid-C1 decompression surgery 1
• Avoid repeat endovascular interventions in this anatomically constrained space, as stents risk extrinsic compression and fracture 1

If Surgery is Deferred:

• Conservative management with positional modifications to minimize compression during daily activities 1
• Close monitoring for progressive neurological symptoms (cranial nerve deficits, visual changes, syncope) that would mandate urgent intervention 1

Critical Pitfalls to Avoid

• Do not pursue repeat balloon angioplasty - the 6-month primary patency is only 50%, and you risk further vascular injury in an already compromised space 1
• Anticoagulation after stenting increases bleeding complications and may not be appropriate given your anatomy 1
• Symptom improvement from angioplasty does not mean compression is resolved - it only addressed one component (venous outflow) while the underlying anatomical narrowing persists 1

Prognosis and Expectations

Without addressing the anatomical compression, symptoms will likely persist or worsen:

• Collateral development may provide temporary relief but cannot fully compensate for 4-6 mm styloid-C1 gaps 1
• Progressive symptoms indicate inadequate collateral compensation and warrant intervention 1
• Surgical decompression offers definitive treatment by enlarging the space for neurovascular structures 1

The worsening tinnitus and visual disturbances are concerning for inadequate cerebral perfusion or cranial nerve compression that was unmasked or worsened by altered flow dynamics post-angioplasty 1. These symptoms should not be dismissed as temporary post-procedural effects if they persist beyond 2-4 weeks 1.