Brain Toilet Obstruction (BTO)

Ross Hauser, MD

In this article, I am going to use the analogy of a clogged toilet to describe the problems of a brain, maybe your brain, that is not draining its toxic fluids and replenishing its clean fluids properly. We will discuss the problems these waste products from brain neuron activity may cause and what happens when these fluids back up and cannot be flushed out of the brain. We will also discuss what would happen to your brain cells in this situation of a clogged and backed up brain toilet. What type of symptoms you may develop. What kind of conditions may present themselves. How this would make you feel.

Chronic Cerebrospinal Venous Insufficiency

While most people understand that there are arteries (vertebral and carotid) that supply the brain with blood, oxygen, and nutrients, few are aware that there is an intricate network of lymphatic cells and veins to drain the brain. Obstruction of the venous output of the brain has been coined Chronic Cerebrospinal Venous Insufficiency (CCSVI), which we simply call Brain Toilet Obstruction (BTO). While the condition can be very serious, there are non-invasive ways (e.g., high-resolution ultrasound) to diagnose it.

I discuss this subject at length in my article Venous insufficiency – Chronic Cerebrospinal Venous Insufficiency and neurologic-like problems.

In that article I discuss the this controversial diagnosis as a problem of blood outflow from the brain. In recent research doctors have debated as to whether chronic cerebrospinal venous insufficiency could be a possible cause of Multiple Sclerosis. My article is not about this controversy. My article is about problems of compression and slow or interrupted drainage or outflow of the blood from the brain via the internal jugular veins that may cause some neurologic-type symptoms.

The brain’s interstitial fluid and cerebrospinal fluid.

The caption of this image reads: Diagram demonstrating that relative venous outflow restriction can occur intracranially (with compression / obstruction (with thrombus (a blood clot) or fractures) of isolated or diffuse or many venous structures) and extracranially (from cervical spine, thoracic spine, and abdominal pressures).

In this illustration we show:

• parenchymal swelling (swelling, fluid retention in the brain) compressing venuloes (small veins).
• parenchymal swelling compressing venous sinus (one of the blood flow drains of the brain).

What are these fluids I am talking about? The brain’s interstitial fluid and cerebrospinal fluid are remarkable in their function. However, in many patients we see, there is a dysfunction of this vital interstitial fluid and cerebrospinal fluid in and fluid out process. This can lead to many symptoms and conditions that we will discuss below.

A simple understanding of these fluids

• The brain’s interstitial fluid and cerebrospinal fluid provides cushion, shock-absorbing functions, and nourishing support to the brain’s nerve cells. This support goes far beyond nutrition.
• The interstitial fluid is part of the brain’s interstitial system. The area between the blood vessels (capillaries) and the brain’s neural cells. The brain’s interstitial system accounts for 15% to 20% of total brain volume.
  • What happens in this area? The complex brain interstitial system is the communication and exchange network between the vascular system (blood circulation system) and nerve messaging networks. The nutrients and oxygen the blood brings in is exchanged for waste products in the brain. This vital role helps bring energy (nutrition) to the nerve messaging network while removing waste elements to prevent “clogs.” Disruptions of this function can lead people to have the neurologic-type symptoms we will discuss below.
• The cerebrospinal fluid fills the larger spaces, the ventricles of the brain. Let’s discuss this next.

What is the function of the ventricles of the brain?

What are we seeing in this image?

We see a conventional view of the flow of cerebrospinal fluid. There are four ventricles of the brain. This is what they do.

• The ventricles are filled with cerebrospinal fluid. This fluid protects the Central Nervous System by acting as a shock absorber against impacts.
• Beyond this the ventricles
  • produce cerebrospinal fluid
  • create the flow of the cerebrospinal fluid to collect debris and waste in the brain
  • flushes out the waste-filled cerebrospinal fluid
• We see that the flow of the cerebrospinal fluid starts in the center portion of the brain at the Lateral Ventricle, flows down towards the cerebellum at the base rear of the skull, and then moves in a counter-clockward manner around the brain to the front of the brain and eventually down the front of the brain towards the spinal column.

Symptoms of interstitial fluid and cerebrospinal fluid back up or Brain Toilet Obstruction

Symptoms and conditions of this brain fluid back up is progressive and cumulative in nature.

Suddenly anxious

• An emotionally happy person can start progressing towards being someone who is suddenly anxious about things when they were never anxious before.

Depression develops

• A person can develop depression, lethargy, hopelessness, and emotional numbing. Dissociation can set in. They do not feel like themselves or that belong in their families or relationships. You may say they are disenfranchised from themselves.

Cognitive decline

• Someone who is “sharp” will suddenly have brain fog or feel like they are “getting dumber as the day goes on.”

Loss of focus and the ability to work 

• As the progressive and degenerative elements of the brain back up continue, a person can suffer from severe brain fog. They will find it impossible to work and function, normal daily chores, and activities become increasingly difficult to perform.

What are we seeing in this image? The blockage of fluid flow in the brain and its consequence

If you are reading this article or you are looking for information for a loved one on the neurologic-type symptoms that you or they are suffering from, these side-by-side illustrations may help you understand the problem. We are using the imagery of a brain clogged up like a toilet gets clogged up. When the toilet is clogged, if you try to flush the toilet, the fresh fluid from the toilet tank will combine with the toxic water in the bowl to cause an overflow. An overflow in the brain will lead to intracranial pressure.

On the left, we see the damaging effects of the clogged brain. We see obstruction of arteries and veins by the misplaced C1 vertebrae and accompanying cervical spine instability. The obstruction prevents fluids in and fluids out of the brain.  Ultimately there will be an accumulation of cerebrospinal fluid in various parts of the brain including the frontal lobe. This will eventually lead to the destruction of brain neurons and brain tissue. This can be an underlying cause of severe brain fog and mental decline in people with cervical instability. On the right side is a healthy brain with the proper flow of fluids in and out.

Flushing out neuron waste. The brain contains one billion neurons or nerve cells. For these nerve cells to be healthy, fluid has to flow into and out of the brain appropriately.

The brain contains one billion neurons or nerve cells. For these nerve cells to be healthy, fluid has to flow into and out of the brain appropriately. The main fluid in the brain is the cerebrospinal fluid (CSF) that we have been talking about. Not only does it cushion the brain but it is also critical to ensuring the right distribution of substances between the various cells of the body, and it allows the removal of waste products from the brain through the brain’s lymphatic system.

Metabolic waste products from the neurons diffuse rapidly into the CSF (about 150 ml of fluid, 2/3 of a cup) and are removed into the brain’s lymphatic system (“glymphatic system”), and eventually into the veins such as the vertebral and inferior vena cava. Cerebrospinal fluid flow is driven by net blood flow into and out of the brain. If the blood flow in or out is stopped or slowed for any reason, cerebrospinal fluid flow will also be slowed. This slowing can have many detrimental effects as the pressure inside the brain cavity (cranium) increases and the brain’s ability to remove toxic metabolites decreases.

For the brain to have good health, the blood supply and drainage must meet the demand of its metabolic activity. The areas of the brain of extreme importance, those that involve intelligence and problem solving, such as the anterior cingulate cortex and front lobe cortex, have the highest metabolic demands and are very susceptible to injury by a clogged brain toilet. When these vital areas of the brain become injured, the first noticeable symptom will often be brain fatigue or brain fog, and if the brain toilet is not unclogged, will progress to extreme lethargy, emotional numbing, dissociation, severe depression, and hopelessness. Even if the brain toilet obstruction is low-level, if it goes on for too long, it will cause the slow but progressive destruction of brain tissue and brain neurons. As more brain tissue is lost (front lobe atrophy, for example) a person’s mental capacity and emotional well-being continue to decline. We have personally seen many young people in their 20s that would appear to have Alzheimer’s dementia if one were just to do an intelligence or memory test on them. That is how bad it can get. With the resolution of their cervical instability and cervical dysstructure, which caused their clogged brain toilet, their intellect, emotional stability, and mental capacities return.

In this video:

Ross Hauser, MD explains the brain toilet concept and how blocked cerebrospinal fluid (CSF) flow due to cervical instability and dysstructure can create symptoms of brain fog, mental decline, inability to think clearly, or problem solve, and other difficulties with mental processing. 

What are we seeing in this image? Brain neuron cell and tissue death from brain toilet obstruction

In this image, we see a flow chart with a lot of arrows pointing to causes, symptoms, and conditions that someone may suffer from when they have poor brain drainage. As explained, the drastic increase in brain neuron activity combined with drops in brain arterial blood flow and venolymphatic drainage (the system that carries out “sludge” through the lymphatic system) from cervical spine ligament injury causes cervical dysstructure, (breakdown of the cervical spine due to neck instability), ultimately leading to an increase in intracranial pressure and accumulation of toxic metabolites in the cranium. This causes the death of brain neurons and brain tissue.

In this illustration we see an example progression of cervical spine ligament weakness being caused by the “Facedown Lifestyle.” The continuous looking town at a computer, keyboard, cell phone, tablet, will cause cervical spine instability. While the facedown lifestyle is being used in this example. This type of chronic, prolonged ligament stretching can occur with wear and tear from a physically demanding type of job, a lifetime of activities, or the progression of neck instability caused by injury or whiplash.

Following the flow chart below we see that Facedown lifestyle or progressive neck instability will lead to:

• The stretching of the posterior cervical ligaments that hold the facet joints, the spinous process, of each vertebra to each other which in turn will lead to:
• Instability in the cervical spine and neck pain which will lead to:
• The loss of the natural curvature of the neck or a change of the neck or cervical curve from lordosis (Natural curve) to kyphosis (a hunched neck or hunch back condition that will push the head forward.) This will lead to:
• Obstruction of brain venolymphatic drainage (a clogged being caused by compression of the arteries and veins in the cervical spine).
  • A decrease in blood into the brain and the symptoms and conditions that this may cause.
  • An accumulation of toxic metabolites in the brain. The brain literally floats in neuron waste, or neuron “poop.”
  • The backup causes intracranial pressure or intracranial hypertension. The compression of the brain within the skull, problems of swelling of the optic nerve.

There is a massive price our brains pay for our modern facedown lifestyle, with its constant visual stimulation and multitasking, or switching from one internet visual stimulus to another: the blood supply cannot match the brain neuron metabolic demands, and the brain drainage system is unable to remove all the toxic waste products produced. In other words, the brain’s waste clearance system gets overloaded, much a toilet that is backed up.

At Caring Medical, there are many ways that we document conditions and components of a clogged brain drainage system

• Motion Arterial Obstruction Mapping – by doing B-mode and color duplex high-resolution doppler ultrasound of the head and neck in various positions and motions, brain arterial obstructions can be mapped. The obstructions can be inside the cranial cavity, at the neck, or the craniocervical junction.

• Motional Venous Obstruction Mapping – by doing the same procedure on the venous drainage of the brain, the places of brain venous obstruction can be discovered. Venous obstructions are typically at the craniocervical junctions or in the neck.

• Optic Nerve Measurements – increased intracranial pressure (hypertension) can be seen by swelling of the optic nerves under high-resolution ultrasound. Optic nerve diameters of >5 mm are indicative of an intracranial pressure greater than 20 mmHg.

• Cine phase-contrast MRI – imaging of the brain and brainstem in the supine and upright positions. This can show obstructions of cerebrospinal fluid (CSF) flow, as well as the accumulations of CSF in various parts of the brain and brainstem, compressing these structures and, thus, damaging them.

A swollen optic nerve

In this photograph, an optic nerve measurement is taken via ultrasound.  We are looking for swelling of the optic nerve that may explain vision problems by way of demyelinating optic neuritis (swelling of the nerve sheath and optic nerve) or non-arteritic anterior ischaemic optic neuropathy (loss of blood flow to the optic nerve). Characteristic symptoms of compression or entrapment of the nerves and arteries in the cervical spine.

The bilateral (on both sides of your neck) internal carotid arteries end in the brain to form the middle and anterior cerebral arteries, which supply blood to the most anterior portion of the brain cerebrum (forebrain, anterior three-fifths of the cerebrum), as well as to the thalamus, basal ganglia, and internal capsule.

The posterior part of the brain is supplied by the vertebrobasilar arteries to supply the posterior (back) two-fifths of the cerebrum, most of the cerebellum, and brainstem.

The drainage of the brain through the venous system goes from 614-740 ml/min in the supine position to 280-304 ml/min while upright.(4,5) In the supine position, 75-92% of the venous flow goes through the internal jugular veins but goes down to 25-42% as the venous flow shifts more to the epidural, vertebral, and deep cervical veins while upright.

Headache, primary intracranial hypertension, global amnesia, dementia

Obstruction of venous blood flow from the brain has been implicated as a cause for conditions such as exertional headache, primary intracranial hypertension, global amnesia, dementia, and a host of neurodegenerative conditions.(6,7)

In one study, 133 out of 363 (37%) had greater than 50% narrowing of the cross-sectional area of the internal jugular vein at all levels.(8)

• In 36% of the patients with narrowing, it occurred at the C1 level.
• Almost all of the areas of narrowing greater than 50% occurred above the C4 level (upper cervical).

In another study looking at cases of moderate ( more than 50%) and severe ( more than 80%) stenosis of the internal jugular vein based on external compression, the most common causes of this were the styloid process or posterior belly of the digastric muscle, often adjacent to the lateral mass of C1.(9) It is clear from the many vascular scans that are done at Caring Medical (motion arterial and venous obstruction mapping), that the key area of compression of the arteries and veins into the neck occurs at or around the C1 vertebrae.

What are we seeing in this image?

Here we see the locational relationship of the internal carotid artery to the upper cervical vertebrae. The internal carotid artery sits just in front of the transverse process of the atlas C1 and axis C2. A shift in cervical spine alignment or hypermobility can cause blood flow to be constricted by atlantoaxial upper cervical instability.

The main danger of brain venous congestion is that it increases intracranial pressure, this pressure is then transmitted to the brain’s arteries, which then increases blood flow to ensure adequate oxygenation of the brain. (10) If the blood vessels cannot respond because of their obstruction in the neck, then of course brain ischemia ensues. The brain’s blood vessels may initially be able to respond via autoregulation (increases in blood vessel diameter in the brain) for a time, but if the cervical/brain venous congestion continues because of cervical dysstructure and cervical instability, the increased intracranial pressure will eventually damage the brain neurons, and ultimately, the brain tissue itself.

While the most common cause of arterial or venous obstruction in patients seen at Caring Medical is narrowing caused by cervical dysstructure or cervical instability, it can also be from autonomic nervous dysfunction. Autonomic nervous dysfunction or dysautonomia can cause detrimental changes in the arterial blood flow to the brain or venous blood flow out.(11,12,13) When the sympathetic nervous system goes unchecked because the parasympathetic vagal system is compromised, arterial and venous blood flow can be slowed and compromised.

What are we seeing in this image?

In this image, the path of the internal jugular vein is shown in relationship to the internal carotid arteries. Again, a shift in upper cervical alignment or instability, can cause blood flow to be constricted or blocked by atlantoaxial upper cervical instability.

Signs and Symptoms of Pending Autonomic Nervous System Collapse

These are the primary, secondary, comorbid, or multimorbidity conditions we see in our patients. Another factor these patients relate to us is that laying flat (supine) is the primary symptom-relieving remedy they employ.

• Exercise intolerance
• Fainting
• Dizziness
• Lightheadedness
• Low blood pressure
• Poor Temperature regulation
• Postural hypotension
• Pupils slow to react to light and are very dilated
• Tachycardia
• Palate higher on one side, Deviated uvula
• Sweating on one body area
• Deviated uvula
• Worsening fatigue

One of the more common symptoms of cervical instability (especially upper cervical instability) is brain fog. This symptom can be described as forgetfulness, cloudy thinking, spaciness, mental fatigue, exhaustion, difficulty processing words read, confusion, detachment, numbness (or numb emotions), and difficulty focusing, thinking, and communicating.(14)

About 90% of people with brain fog state that it impairs schoolwork, work productivity, and social activities.

Some of the patients actually come to Caring Medical with central lines in place because they receive intravenous saline to keep their blood pressures up because of postural orthostatic tachycardia syndrome (POTS) and see improvements in their brain fog with the added salt and water in their systems. While brain fog is worse with standing, it usually never goes away, even with lying down. The most plausible explanation for brain fog, especially in people with symptoms compatible with low vagal tone or dysautonomia, is a clogged-up brain toilet from cervical dysstructure and instability. It is common in our office to see a lifting of the brain fog after cervical stabilization with Prolotherapy and correction of the cervical dysstructure with Prolotherapy, exercises, and cervical curve correction.

Prolotherapy is an injection technique that stimulates the repair of unstable, torn or damaged ligaments. When the cervical ligaments are unstable, they allow for excessive movement of the vertebrae, which can then restrict blood flow to the brain, pinch on nerves (a pinched nerve causing vertigo), and cause other symptoms associated with joint instability, including cervical instability.

The Vagus Nerve

There is a significant connection between the brain’s metabolic waste (neurotoxic) clearance system and the vagus nerve. Because the vagus nerve is a cranial nerve, there is influx (inward) and efflux (outward) CSF flow. The vagus nerve has to get rid of its own toxins. As it turns out in one study, the vagus nerve efflux of CSF was drastically greater than any CSF exchange tested, even that which occurs in the brain! While changes in body position typically change CSF exchange percentages on the order of 50-100% in the brain, the vagus nerves showed a change of 250%, so one of the effects of sleep and the supine position is the clearance of toxins out of the vagus nerves.

One of the more interesting facts about how the brain clears its “poop,” or metabolic waste products, is that it does so primarily when we are sleeping on our side or back.(15,16) Cerebrospinal fluid flow is greatest during the night when asleep, so the main effects of sleep are removal of toxic metabolites from the brain, restoration of the brain’s energy supply, and memory consolidation (insight, creativity, and problem-solving). This is why a “cat nap” or natural sleep is so refreshing. One of the effects of insomnia or inadequate restorative sleep is that brain poop accumulates. Most people with cervical instability cannot sleep well because of the pain. By resolving chronic neck pain and headaches, Prolotherapy allows people a more restful sleep, and the side benefit of it just may be a good brain toilet flush.

Summary and contact us. Can we help you? How do I know if I’m a good candidate?

We hope you found this article informative and it helped answer many of the questions you may have surrounding the symptoms and conditions that are challenging you now. Just like you, we want to make sure you are a good fit for our clinic prior to accepting your case. While our mission is to help as many people with chronic pain as we can, sadly, we cannot accept all cases. We have a multi-step process so our team can really get to know you and your case to ensure that it sounds like you are a good fit for the unique testing and treatments that we offer here. Please start by Contacting Us to explain some of the basics about your case and the level of urgency so we know how quickly you are looking to obtain an appointment. We look forward to talking with you and helping you get back to where you want to be!

References

1 Lassen NA. Cerebral blood flow and oxygen consumption in man. Physiol Rev. 1959;39:183-238. [Google Scholar]
2 Prasansuklab A, Tencomnao T. Amyloidosis in Alzheimer’s disease: the toxicity of amyloid beta (Aβ), mechanisms of its accumulation and implications of medicinal plants for therapy. Evidence-Based Complementary and Alternative Medicine. 2013 Oct;2013. [Google Scholar]
3 Zamboni P, Galeotti R. Chronic cerebrospinal venous insufficiency in patients with multiple sclerosis.  J Neurol Neurosurg Psychiatry. 2009;80:392-399. [Google Scholar]
4 Valdueza JM, von Munster T. Postural dependence of the cerebral venous outflow. Lancet. 2000;35-200-201. [Google Scholar]
5 Alperin N, Lee SH. Quantifying the effect of posture on intracranial physiology in humans by MRI flow studies. J of MRI. 2005;22:591-596. [Google Scholar]
6 Nedelmann M, Kaps M. Venous obstruction and jugular valve insufficiency in idiopathic intracranial hypertension. J Neurol. 2009;256:964-969. [Google Scholar]
7 Schreiber SJ, Doepp F. Internal jugular vein valve incompetence and intracranial venous anatomy in transient global amnesia. J Neurol Neurosurg Psychiatry. 2005;’76:509-513. [Google Scholar]
8 Buch K, Groller R. Variability in the cross-=sectional area and narrowing of the internal jugular vein in patients without multiple sclerosis.  AJR. 2016;207;5:1082-1086. [Google Scholar]
9 Jayaraman MV, Boxerman JL. Incidence of extrinsic compression of the internal jugular vein in unselected patients undergoing CT Angiography.  Am J Neuroradiol. 2012;33:1247-1250. [Google Scholar]
10 Frydrychowski AF, Winklewski PJ, Guminski W. Influence of acute jugular vein compression on the cerebral blood flow velocity, pial artery pulsation and width of subarachnoid space in humans. PloS one. 2012 Oct 24;7(10):e48245. [Google Scholar]
11 De Keyser J, Steen C. Hypoperfusion of the cerebral white matter in multiple sclerosis: possible mechanisms and pathophysiological significance. J Cereb Blood Flow Metab. 2008;1645-1651. [Google Scholar]
12 Gisolf J, van Lieshout JJ. Human cerebral venous outflow pathway depends on posture and central venous pressure. J Physiol. 2004;560:317-327. [Google Scholar]
13 Sternberg Z. Chronic cerebrospinal venous insufficiency: is it venoscerleosis? J Endovascular Therapy. 2015.  [Google Scholar]
14 Ross AJ, Medow MS. What is brain fog? An evaluation of the symptom in postural tachycardia syndrome. Clin Auton Res. 2013;223(6):305-311. [Google Scholar]
15 Lee H, Xie L. The effect of body posture on brain Glymphatic transport. J Neurosci. 2015;35(31):11034-11044.  [Google Scholar]
16 Xie L, Kang H. Sleep drives metabolite clearance from the adult brain. Science. 2013;342:373-377.  [Google Scholar]

This article was updated March 5, 2021

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