Superior sagittal sinus thrombosis after internal jugular vein cannulation

Pseudotumor cerebri and lung cancer-associated jugular vein thrombosis: Role of anatomical variations of torcular herophili

A 71-year-old male appeared at the facility complaining of disturbance of consciousness and bilateral papilledema. The laboratory test revealed anemia and coagulation abnormality. A physical examination and magnetic resonance imaging (MRI) of the brain with and without gadolinium showed no abnormalities. A lumbar puncture showed a high pressure, but a normal cerebrospinal fluid (CSF) cell count. Cerebral angiography showed no morphological abnormalities, but it revealed an asymmetric right dominant type of confluence of the sinuses with the partially-communicating left transverse sinus in the late phase. Furthermore, there was a delay in the cerebral circulation time (CCT). Subsequently, venography and ultrasonography revealed right internal jugular vein thrombosis associated with lung cancer. The patient recovered from the disturbance of consciousness immediately after an emergency ventriculoperitoneal shunt and anticoagulation therapy. This case was diagnosed as secondary pseudotumor cerebri (PTC). In order to facilitate the early detection of secondary PTC, it is important to take note of symptoms of intracranial hypertension with no remarkable intracranial lesions and to consider the possibility of PTC, especially in the patients with high risk factors for coagulopathy including lung cancer.

Sigmoid Sinus Thrombosis Associated with Internal Jugular Venous Occlusion: Direct Thrombolytic Treatment

Purpose:

To report our experience with transfemoral direct venous thrombolysis and angioplasty to treat central venous and dural sinus occlusion. The cases presented are rare examples of internal jugular occlusion associated with sigmoid sinus thrombosis.

Methods and Results:

Two middle-aged, symptomatic female patients were diagnosed with sigmoid sinus and internal jugular vein thrombosis. Venography was performed from a contralateral transfemoral approach, followed immediately by urokinase infusion directly to the occlusion using an intermittent “burst-bolus” technique. Successful thrombolysis of the sigmoid sinus and internal jugular vein was documented in both patients. In one case, a venous stenosis was treated with balloon angioplasty. Clinical signs and symptoms resolved in both patients.

Conclusions:

Occluded dural sinuses and central veins can be treated with direct administration of thrombolytic agents. When an underlying stenosis is identified, balloon dilation should be used to reduce the likelihood of recurrence.

Fatal Septic Internal Jugular Vein-Sigmoid Sinus Thrombosis Associated with a Malpositioned Central Venous Catheter

Septic internal jugular vein-sigmoid sinus thrombosis (IJV-SST) associated with a malpositioned central venous catheter is a rare condition. It is potentially life-threatening and necessitates early diagnosis and rapid administration of appropriate medications. Unfortunately, it is difficult to diagnose due to vague clinical presentations. Several studies such as CT, MRI, and cerebral angiography should be performed and carefully examined to help make the diagnosis. We report a case of septic IJV-SST due to a malpositioned central venous catheter.

Superior sagittal sinus thrombosis after radical neck dissection

Dural sinus thrombosis is a rare, potentially fatal complication of a radical neck dissection. The prognosis can vary from complete recovery to rapid death. Magnetic resonance venography provides an effective, noninvasive diagnosis. The goals of therapy are to decrease intracranial pressure and to lyse the thrombus. Systemic anticoagulation and systemic thrombolytics are controversial therapies. The direct intrasinus infusion of thrombolytic agents is under investigation.

Fatal delayed post-operative cerebral venous thrombosis after excision of hypoglossal nerve schwannoma

Lower cranial nerve schwannomas are rare tumours. We present a 35 year old female patient who had a lower cranial nerve schwannoma with both intracranial and extracranial components. The internal jugular vein was injured during the dissection of the extracranial portion of the tumour. Ligation of the internal jugular vein is not associated with significant post-operative complications. Our patient however, developed retrograde cortical venous thrombosis on the 14(th) post-operative day resulting in multiple areas of haemorrhagic venous infarction with raised intracranial pressure. Such a delayed contiguous cortical venous thrombosis has not been reported. We present this report to highlight this event and to outline the probable causes for the same.

Cerebral venous thrombosis in children: a multifactorial origin

BACKGROUND

The present study was performed to assess the association of prothrombotic risk factors and underlying conditions (infections, vascular trauma, immobilization, malignancies, autoimmune diseases, renal diseases, metabolic disorders, obesity, birth asphyxia, cardiac malformations, and use of prothrombotic drugs) with cerebral venous thrombosis (CVT) in children.

METHODS AND RESULTS

From 1995 to 2002, 149 pediatric patients aged newborn to <18 years (median 6 years) with CVT were consecutively enrolled. In patients and in 149 age- and gender-matched children with similar underlying clinical conditions but without CVT, the factor V G1691A mutation, the factor II G20210A variant, lipoprotein(a) [Lp(a)], protein C, protein S, antithrombin, and antiphospholipid antibodies, as well as associated clinical conditions, were investigated. Eighty-four (56.4%) of the patients had at least 1 prothrombotic risk factor compared with 31 control children (20.8%; P<0.0001). In addition, 105 (70.5%) of 149 patients with CVT presented with an underlying predisposing condition. On univariate analysis, factor V, protein C, protein S, and elevated Lp(a) were found to be significantly associated with CVT. However, in multivariate analysis, only the combination of a prothrombotic risk factor with an underlying condition (OR 3.9, 95% CI 1.8 to 8.6), increased Lp(a) (OR 4.1, 95% CI 2.0 to 8.7), and protein C deficiency (OR 11.1, 95% CI 1.2 to 104.4) had independent associations with CVT in the children investigated.

CONCLUSIONS

CVT in children is a multifactorial disease that, in the majority of cases, results from a combination of prothrombotic risk factors and/or underlying clinical condition.

Venous pseudo-aneurysm as a late complication of short-term central venous catheterisation

Complications following central venous catheterisation abound in the medical literature. This reflects the under-estimated potential hazards associated with this procedure as well as an increase in the number of such procedures performed in high-risk patients. We report on a case where a venous pseudo-aneurysm developed four months after the removal of a short-term central venous catheter in a moderately high-risk patient.

Extensive experience with dural sinus thrombosis

OBJECTIVE

Dural sinus thrombosis (DST) is an uncommon cause of stroke. The safest and most effective therapy for DST has not been conclusively identified.

METHODS

A retrospective chart review of data for 31 patients who were treated for DST at our institution between 1992 and 2001 was performed. Four treatment strategies were identified, i.e., 1). medical observation only, 2). systemic anticoagulation (AC) therapy with heparin, 3). endovascular chemical thrombolysis with urokinase or tissue plasminogen activator and concurrent systemic AC therapy, and 4). mechanical endovascular clot thrombolysis with concurrent systemic AC therapy. Complications and clinical outcomes were assessed for each group.

RESULTS

Patients treated solely with medical observation fared the worst; four of five patients experienced intracranial hemorrhagic complications, and only two of five exhibited clinical improvement. Patients who received systemic AC therapy experienced no hemorrhagic complications, even when pretreatment hemorrhage was present; 75% (six of eight patients) exhibited improvement with AC therapy alone. Chemical thrombolysis was very effective in restoring sinus patency (90% of patients); however, 30% of patients (3 of 10 patients) experienced hemorrhagic complications. Sixty percent of patients (6 of 10 patients) who underwent chemical thrombolysis exhibited clinical improvement. Patients who underwent mechanical thrombectomies demonstrated a low hemorrhagic complication rate, and most (88%) made good recoveries.

CONCLUSION

Therapy directed at the underlying clot in DST must begin without delay. Our results suggest that supportive medical management of DST, without therapy directed at the clot or clotting process, is not effective. Systemic AC therapy, even in the presence of intracerebral hemorrhage, seems to be safe. Heparin can be safely titrated to yield partial thromboplastin times of 60 to 70 seconds. Chemical clot thrombolysis is efficacious in opening occluded sinuses but may cause intracranial hemorrhage. We currently recommend either systemic AC therapy or systemic AC therapy in conjunction with mechanical clot thrombectomy as a safe effective treatment for DST.

Cerebral infarct following central venous cannulation

Inadvertent carotid artery puncture is a well-known complication of internal jugular vein cannulation. A case of cerebral infarct subsequent to carotid artery puncture during internal jugular vein cannulation is reported.

Traumatic bilateral jugular vein thrombosis: case report and review of the literature

OBJECTIVE AND IMPORTANCE

Thrombosis of the internal jugular vein (IJV) with associated elevated intracranial pressure (ICP) is a rare complication of central venous catheterization but has not been reported as a result of blunt trauma.

CLINICAL PRESENTATION

An 18-year-old male patient was observed to be obtunded after an assault. The initial examination was remarkable for somnolence, bruising of the anterior neck, and diffuse, edematous swelling of the face and scalp. The results of computed tomography of the brain were normal. An angiogram obtained on the 2nd hospital day to rule out carotid injury revealed bilateral IJV thromboses to the cranial base. An ICP monitor was placed with an opening pressure of 33 mm Hg. The central venous pressure was measured to be 9 mm Hg. A catheter was passed through the left IJV thrombus and into the sigmoid sinus, where the pressure was 17 mm Hg.

INTERVENTION

An intravascular stent was deployed in the left IJV. ICP rapidly normalized. A regimen of coumadin was administered to the patient for 6 weeks, at which time the stent remained patent.

CONCLUSION

We conclude that traumatic jugular vein thrombosis can be associated with significant elevation in ICP and that treatment with an endovascular stent can affect the rapid correction of intracranial hypertension in patients who are candidates for anticoagulation.

Sigmoid sinus thrombosis associated with internal jugular venous occlusion: direct thrombolytic treatment

PURPOSE

To report our experience with transfemoral direct venous thrombolysis and angioplasty to treat central venous and dural sinus occlusion. The cases presented are rare examples of internal jugular occlusion associated with sigmoid sinus thrombosis.

METHODS AND RESULTS

Two middle-aged, symptomatic female patients were diagnosed with sigmoid sinus and internal jugular vein thrombosis. Venography was performed from a contralateral transfemoral approach, followed immediately by urokinase infusion directly to the occlusion using an intermittent "burst-bolus" technique. Successful thrombolysis of the sigmoid sinus and internal jugular vein was documented in both patients. In one case, a venous stenosis was treated with balloon angioplasty. Clinical signs and symptoms resolved in both patients.

CONCLUSIONS

Occluded dural sinuses and central veins can be treated with direct administration of thrombolytic agents. When an underlying stenosis is identified, balloon dilation should be used to reduce the likelihood of recurrence.

Use of the internal jugular vein approach in balloon dilatation angioplasty of pulmonary artery stenosis in children

Generally, the approach used for balloon dilatation angioplasty for pulmonary artery stenosis in children is from the femoral vein. However, sometimes an alternative approach must be used because of femoral vein occlusion or some other reason. As reports have been limited about the results achieved using the internal jugular vein approach in pediatric interventional catheterization, we report on the internal jugular vein approach in balloon dilatation angioplasty of the pulmonary artery for pediatric patients and discuss the advantages of this approach. From 1991 through 1993 15 balloon dilatation angioplasties of the pulmonary artery using the internal jugular vein approach were performed in 14 pediatric patients, ranging in age from 4 months to 13 years. Based on this experience, we have evaluated this method from several viewpoints including the technique and possible complications. All procedures were performed without complications in all patients; and by inserting a 7 sheath it was even possible to perform balloon dilatation in a 4-month-old infant. A sheath as large as 9F could be inserted in other patients, and the double balloon method was used in seven patients. The Seldinger method was also available when the balloon catheter was too large to use with a sheath. For pediatric interventional cardiac catheterization, it was found that the internal jugular vein approach is relatively safe and reliable. Furthermore, catheterization of the pulmonary artery was easier with the internal jugular vein approach than with the femoral vein approach.

Risk factors of aseptic intracranial venous occlusive disease

INTRODUCTION

Risk factors for aseptic intracranial venous occlusive disease are varied but only few epidemiologic studies were performed to verify the relative importance of particular factors.

PATIENTS AND METHODS

A 2-year hospital-based prospective study was conducted in two hospitals to identify the clinical characteristics and risk factors of patients with confirmed aseptic intracranial venous occlusive disease.

RESULTS

21 patients were identified, representing 0.9% of the total neurological admissions. Men were more commonly affected than women; 81% of the patients presented in a clinical picture indistinguishable from idiopathic intracranial hypertension. Risk factors included Behçet's disease in 4, the puerperium in 3, thrombophelia in 3, familial Mediterranean fever in 2, malignancies in 1, lupus anticoagulant in 1, and the contraceptive pill in 1.

CONCLUSION

Aseptic intracranial venous occlusive disease proved to be not rare in Arabs. It should be considered seriously in the differential diagnosis of idiopathic intracranial hypertension, particularly in males. Several risk factors were incriminated.

Percutaneous catheterization of the jugular bulb with a Doppler probe: technical note

On-line measurement of jugular venous bulb oxygen saturation may be of clinical value in patients with head injuries. Cannulation of the jugular bulb may be technically difficult in this group of patients. Trendelenberg positioning and head rotation may be associated with increased morbidity or mortality. A technique is described whereby catheterization can be performed with the head of the bed elevated and the neck in a neutral position. A needle with a Doppler probe is used to distinguish between the carotid artery and the internal jugular vein. The needle and the probe are then directed to the audible signal representative of the jugular vein. Once the vein is penetrated, placement of a fiberoptic oxygen saturation catheter is performed in the usual fashion. This technique allows auditory feedback to guide the course of the needle and decreases the morbidity that may be associated with the "blind" technique.

Prolonged barbiturate therapy in a patient with closed head injury and jugular venous thrombosis

The case of a patient who sustained a severe closed head injury complicated by jugular venous thrombosis is presented. Early problems with intracranial pressure were related to bifrontal intracerebral contusions. Jugular vein thrombosis became manifest clinically late in the patient's course and was verified by Doppler ultrasonography. Late problems with intracranial hypertension were presumed to be due to decreased cerebral outflow secondary to the thrombosis. The patient required 4 weeks of a high-dose regimen of pentobarbital to control his intracranial pressure. This is an exceptionally long period of time for a patient to be in barbiturate coma for a closed head injury and still make a satisfactory recovery. The incidence, etiology, prevention, and treatment of upper extremity and jugular venous thrombosis are discussed. The ramifications of jugular venous thrombosis in neurosurgical patients are discussed.