Internal Jugular Vein Thrombosis: A Case Report and Discussion

Stella1, Subadhra Devi. M2, Maha Lakshmi3

1Nursing Supervisor, Kauvery Hospital, Cantonment, Trichy, Tamil Nadu

2Nurse Educator Kauvery Hospital, Cantonment, Trichy, Tamil Nadu

3Nursing Superintendent, Kauvery Hospital, Cantonment, Trichy, Tamil Nadu

Introduction

Internal Jugular Vein (IJV) thrombosis is a rare but potentially serious condition characterized by the formation of a blood clot within the internal jugular vein. Early diagnosis and treatment are crucial. If left untreated it can lead to serious complications including stroke, pulmonary embolism and even death.

Causes and Risk Factors

IJV thrombosis can result from various causes, linked to components of Virchow’s triad:

  • Infections: Most commonly linked to deep neck infection, Lemierre’s syndrome (caused by Fusobacterium necrophorum), and catheter-related bloodstream infections.
  • Trauma and Surgery: Neck trauma, head and neck surgery, or malignancies in the region.
  • Hypercoagulable States: Conditions like cancer, pregnancy, oral contraceptive use, thrombophilia, genetic disorders such as Factor V Leiden mutation or prolonged immobility can predispose individuals to clot formation.
  • Venous Stasis: Prolonged immobility, central venous catheterization, or neck surgery can slow blood flow, increasing the risk of clot formation.
  • Endothelial Injury: Trauma, surgery, or infections like Lemierre’s syndrome, a rare oropharyngeal infection, can damage the vein walls, leading to thrombosis.

Symptoms

Symptoms of IJV thrombosis vary depending on the severity and underlying cause but commonly include:

  • Neck pain and swelling
  • Tenderness along the jugular vein
  • Redness and warmth over the affected area
  • Fever, chills, or signs of systemic infection in cases related to septic thrombophlebitis
  • Difficulty swallowing or breathing in severe cases

Diagnosis

Diagnosing IJV thrombosis requires a combination of clinical assessment and imaging techniques:

  • Ultrasound with Doppler Imaging: The first-line, non-invasive diagnostic tool for detecting thrombus and assessing venous flow.
  • CT or MRI Venography: Provides detailed imaging in complex or unclear cases.
  • Blood Tests: D-dimer levels may be elevated, and inflammatory markers like CRP can indicate infection-associated thrombosis.

Treatment

Treatment of IJV thrombosis depends on the underlying cause and severity:

  • Anticoagulation Therapy: Heparin or low-molecular-weight heparin (LMWH) is commonly used, followed by oral anticoagulants like warfarin or direct oral anticoagulants (DOACs) to prevent clot progression and embolism.
  • Antibiotic Therapy: If infection is present, broad-spectrum antibiotics targeting potential pathogens (e.g., Fusobacterium necrophorum in Lemierre’s syndrome) are crucial.
  • Thrombolytic Therapy: In severe cases, thrombolytics may be used to dissolve the clot.
  • Surgical Intervention: Rarely needed but may be considered in cases of persistent thrombosis, infection, or complications such as abscess formation.

An illustrative clinical presentation

First person account from the patient:

“I’ve been experiencing a severe headache on the right side of my head for a month. Initially I thought it was just stress-related pain, so I didn’t pay much attention to it. During the day, I wouldn’t notice the pain, but at night, it would become unbearable, radiating to my eyes, neck, and face. I couldn’t sleep at night and could only sleep in the morning.

I tried using ointments to alleviate the pain, but they didn’t help. I consulted a Neurosurgeon, who diagnosed it as migraine headaches. However, two days later, the pain intensified, and I developed neck swelling, making it difficult to turn my neck.

I went to the ER, where the doctor advised me to get a scan. The scan revealed a thrombus in my neck, which was confirmed by a Doppler test. The doctor then consulted with a Neurosurgeon to determine whether the thrombus was in my brain or if I had cerebral edema. If it was edema, they planned to drain it.

“I was devastated by the diagnosis and worried about my family. The doctors and my co-workers provided counseling to help me cope. Finally, they started me on anticoagulant medication. After three days of medication, the pain started to subside, and I began to feel better. Now, I’m continuing with my duties, feeling much better.”

H/O

No H/o trauma, no invasive lines. Normal bladder and bowel pattern.

Past history: Post Covid status, recently ruled out SLE

No relevant family history.

On Examination 

Conscious, oriented afebrile.

BP: 120/80mmHg, PR: 92 /min, Spo2: 98 % in room air. CVS: S1 S2(+), RS: NVBS, P/A: Soft.

Neck pain and swelling

Tenderness along the jugular vein

Redness and warmth present.

Investigations

Ultrasound with Carotid and Vertebral Doppler Imaging revealed Acute thrombosis of right mid and distal IJV.MRI Brain,

MRA & MRV imaging revealed hypo plastic left transverse sinus

Echo was normal

Blood investigation for Coagulation studies showed homocysteine (25.9mcmol/l). Anti Cardiolipin Antibody IgM (23.30MPLU) and BETA 2 Glycoprotein IgM (68.42RU/ml) were elevated.

Treatment

Inj. LMWH 60mg BD for 7 days and switched to

Tab. Acitrom 2 mg 6pm daily

Discharge Advice

Advised Thyroid peroxidase (TPO) monitor, Prothrombin time and INR values.

Monitor symptoms of any bleeding, head ache or giddiness.

Prognosis and Prevention

Early detection and appropriate treatment typically result in good outcomes. However, untreated or severe cases can lead to life-threatening complications such as pulmonary embolism.

Preventive measures include prompt treatment of infections, careful management of central venous catheters, and thromboprophylaxis in high-risk patients.

Conclusion

IJV thrombosis is a serious yet manageable condition when diagnosed early. Understanding its risk factors, symptoms, and treatment strategies is crucial in preventing complications and improving patient outcomes. Further research and awareness can aid in early recognition and better management strategies.

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