Thrombosis of the internal jugular vein.

Abstract

A 35-year-old woman presented to our Emergency Department with a gradual-onset occipital headache radiating into her neck, and worsening over the prior 6 days. She reported inability to move her neck due to pain and stiffness. She denied trauma, fevers, or other positive findings on review of systems. She further denied any history of prior similar headaches. Past medical history included a history of stage 1 renal cell carcinoma treated with right nephrectomy 5 years prior. She took no medications. Family history was unremarkable. Social history was significant for tobacco use. On physical examination, her blood pressure was 145/88 mmHg, and all other vital signs were within normal limits. The patient did not tolerate any neck motion secondary to pain. There was tenderness over the para-cervical musculature bilaterally, without any bony tenderness. The neurologic examination was normal to include negative Kernig’s and Brudzinski’s signs. Based on this headache presentation with neck involvement in the absence of a history of trauma, osseous injury and intracranial bleeding were both thought to be unlikely. In light of the patient’s new gradual-onset headache with a history of malignancy and tobacco use and now inability to move her neck, our differential diagnosis at this time prioritized vascular thrombosis and neoplasm. Given an absence of trauma or neurologic findings, we reasoned arterial dissection to be less likely. Consequently, to optimize evaluation for neoplasm and venous thrombosis, we ordered computed tomography (CT) of the head and neck with intravenous contrast in the venous instead of arterial phase (Fig. 1). Alternatively, arterial pathology (dissection) would have been better evaluated using arterial phase contrast, if it had been higher on our differential. The CT scan demonstrated an occlusive right internal jugular and dural venous thrombosis. The patient was anticoagulated with unfractionated heparin, and admitted. Serial CT imaging of the head and subsequent MRI of the brain revealed no interval changes of the venous thrombosis. Further work-up for malignancy or hypercoagulability was only notable for a positive Lupus anticoagulant test. She was discharged on rivaroxaban. Her symptoms improved, and she experienced no complications as of 6-month follow-up post-discharge. There is substantial consensus regarding when to obtain emergent non-contrast CT imaging of the head in patients presenting with headache. The most dangerous disease entity of interest in such patients is generally intracranial bleeding, for which head CT scan without contrast has excellent sensitivity [1]. Similarly, there is widespread consensus regarding when to obtain emergent non-contrast cervical spine CT scan in patients presenting after blunt neck trauma. The most common deadly diagnoses in such patients are likely to be osseous spinal injuries, for which CT without contrast again is an optimal diagnostic tool [2]. Conversely, the indications for emergent head and neck imaging with contrast are less well established. This case suggests inability to move the neck as a potential indication The view(s) expressed herein are those of the author(s) and do not reflect the official policy or position of Brooke Army Medical Center, the U.S. Army Medical Department, the U.S. Army Office of the Surgeon General, the Department of the Army and Department of Defense or the U.S. Government.