Incidental internal jugular vein thrombosis in a patient with intracranial aneurysm: Implications for the anesthesiologists

Dear Editor,

We report a case of incidental internal jugular vein (IJV) thrombosis in a patient presenting for aneurysm clipping and its implications for anesthesiologist. A 67-year-old female with no known co-morbidity, weighing 55 kg presented with sudden onset throbbing headache and vomiting. Computed tomography (CT) revealed subarachnoid hemorrhage. CT Angiogram showed a right posterior communicating artery aneurysm measuring 8 mm × 9 mm in size. Her coagulation profile was normal and she did not have any known risk factors for deep vein thrombosis (DVT). She was scheduled for a right pterional craniotomy and aneurysm clipping with neck control of right internal carotid artery.

After establishing baseline monitoring, invasive arterial line was secured under local anesthesia. General anesthesia was induced with propofol and fentanyl and endotracheal intubation was facilitated using vecuronium. Anesthesia was maintained with sevoflurane in oxygen and air. Due to surgical requirement, central venous cannulation was planned on the left side (IJV). Ultrasound was used (Site Rite^® Ultrasound System, Bard Limited) to guide cannulation, which revealed a non-compressible hyper echoic lesion partially occluding the lumen of the left IJV [Figure 1a]. Screening of the right IJV revealed a patent lumen [Figure 1b]. Screening of bilateral subclavian vein was difficult. Hence, a peripherally inserted central cannula (PICC) was placed through the right brachial vein. The surgery was uneventful and patient recovered well.

Figure 1.

(a) Ultrasound snapshot image demonstrating thrombus in the left internal jugular vein (IJV)(b) Ultrasound snapshot image showing a patent right IJV. Common Carotid Artery (CCA) is demonstrated adjacent to the IJV

Gbaigudi et al.[1] have shown that among all cases of DVT, IJV thrombosis occurs in 1.5% and can be bilateral in 15% of cases. Female gender, elderly age group and prior central venous catheterization are associated with increased incidence. Spontaneous IJV thrombosis found incidentally can be asymptomatic because of adequate collateral circulation with high venous flow rate.[2] However, it can complicate as septic embolism, pulmonary embolism, elevated intracranial pressure or intracranial venous thrombosis.[3,4] Sub-arachnoid hemorrhage (SAH) induces a prothrombotic state with moderate risk (10-40%) for developing DVT.[5] Presence of reduced intravascular volume can further increase this risk as occurs in SAH. Routine ultrasound screening of IJV before cannulation in this patient group will avoid inadvertent cannulation of thrombosed veins, which can result in dislodgement of thrombus, hemodynamic instability, arrhythmias and pulmonary or systemic embolism. If IJV thrombosis is detected by ultrasound, cannulation of the contralateral IJV also needs to be avoided, as it can result in bilateral IJV thrombosis, compromised venous return from brain, venous infarct, cerebral edema, and raised intracranial pressure. The safe approach would be to cannulate the subclavian vein or a PICC as was carried out in this case.