Background & Aims
A Rare Presentation of preexisting Internal Jugular Vein Thrombosis and Dural Sinus Thrombosis is reported after Ultrasound Guided peristyloid Glossopharyngeal Nerve Block in a research patient.
Internal jugular vein thrombosis (IJVT) is underdiagnosed and associated with significant morbidity. Clinical presentation is subtle and easy to miss. Symptomatic anterograde and retrograde extension of thrombus has not been reported after neck manipulation & pressure due ultrasound guided procedure. A research subject developed became critically ill due to undiagnosed internal jugular venous occlusion and survived inspite of a huge infarcts in brainstem after ultrasound guided glossopharyngeal nerve block (GPNB).
Methods
A 36 year female with styalgia was planned for ultrasound guided right GPN block. She became critically ill and was put on ventiator in ICU. The procedure was abandoned. deterioration in consciousness.As infarcts were in the area supplied by vertebral artery, CT angiography neck was planned which revealed no thrombus in arterial circulation. But one incidental venogram section revealed a large thrombus in right IJV. Magnetic resonance venogram confirmed this diagnosis with narrowing of right transverse sinus. CT pulmonary angiography revealed hypodense filling defects in posterior segmental branches of pulmonary artery supplying right lower lobe of lung.Treatment was started with antibiotics, aerosolised bronchodilators and storoids. Initial LMWH 60 mg twice daily was replaced with tablet Acitrom 4 mg. Daily therapy was tapered according to INR. Further evaluation revealed raised serum homocysteine levels, D-dimers, and factor V Leiden deficiency
Results
Retrograde as well as anterograde extension of IJV thrombus into dural venous sinus and pulmonary arteries was seen. Deterioration of conscious level in a patient with local signs of neck swelling with jugular vein thrombosis requires investigation into the possibility of dural sinus thrombosis as an extension of the internal jugular venous occlusion. Acute occlusion isusually not well tolerated. Our patient had undiagnosed IJVT and CVT as patient had no symptoms. The tachypnea after block could be explained due to anterograde migration of thrombus dislodged in pulmonary artery due to repeated manipulation of ultrasound transducer and needle. The acute total occlusion of right IJV and transverse sinus led to infarcts in brainstem which could be explained by anatomy of venous drainage of brain. The contributing factors were nasal infection, factor V leiden mutation & hyperhomocystenemia.
Conclusions
A high degree of suspicion IJVT should be kept in mind prior to percutaneous blocks of neck. Genetic mutation is not a routine investigation. Hence, we recommend 2D color Doppler to rule out IJVT prior to percutaneous nerve blocks in neck area. If these investigations raise the doubt, then /CT venogram to rule out IJVT is recommended.
References
1. Serinken M, Karcioglu O, Korkmaz A. Spontaneous Internal jugular vein thrombosis: case report. Kaohsiung J Med Sci 2010; 26: 679-81.
2.G Saposnik, F Barinagarrementeria, RD Brown et al “Diagnosis and management of cerebral venous thrombosis: a statement for healthcare professionals from the American Heart Association/American Stroke Association,” Stroke, 2011; vol. 42, no. 4, pp. 1158–1192.
3.I Martinelli, SM Passamonti, E Rossi, and V. de Stefano, “Cerebral sinus-venous thrombosis,” Internal and Emergency Medicine, 2012;vol. 7, no. 3, pp. S221–S225
4.Özge AltJnta G, Azize Esra Gürsoy, Gözde Baran, Elnur Mehdi, and Talip Asil.
Bilateral Jugular Vein and Sigmoid Sinus Thrombosis Related to an Inherited Coagulopathy: An Unusual Presentation. Case Reports in Vascular Medicine; Hindawi Publishing Corporation; Volume 2014, Article ID 873402, 3 pages https://dx.doi.org/10.1155/2014/873402