Ipsilateral Internal Jugular Vein Research Articles

Comparison of Catheter Malposition Between Left and Right Ultrasound-Guided Infraclavicular Subclavian Venous Catheterizations: A Randomized Controlled Trial.

Catheter malposition after subclavian venous catheterization (SVC) is not uncommon and can lead to serious complications. This study hypothesized that the left access is superior to the right access in terms of catheter malposition after ultrasound-guided infraclavicular SVC due to the asymmetry of the bilateral brachiocephalic veins. Parallel-armed randomized controlled trial. A tertiary referral hospital in Korea. Patients 20-79 years old who were scheduled to undergo SVC under general anesthesia. Patients were randomly assigned to either the left ( n = 224) or right ( n = 225) SVC group. The primary outcome measure was the overall catheter malposition rate. The secondary outcome measures included catheter malposition rates into the ipsilateral internal jugular and contralateral brachiocephalic veins, other catheterization-related complications, and catheterization performance. The catheter malposition rate was lower (10 [4.5%] vs. 31 [13.8%], p = 0.001), especially in the ipsilateral internal jugular vein (9 [4.0%] vs. 24 [10.7%], p = 0.007), in the left SVC group than in the right SVC group. In the left SVC group, catheterization success rates on the first pass (88 [39.3%] vs. 65 [28.9%], p = 0.020) and first-catheterization attempt (198 [88.4%] vs. 181 [80.4%], p = 0.020) were higher whereas times for vein visualization (30 s [18-50] vs. 20 s [13-38], p < 0.001) and total catheterization (134 s [113-182] vs. 132 s [103-170], p = 0.034) were longer. There were no significant differences in other catheterization performance and catheterization-related complications between the two groups. These findings strengthen the rationale for choosing the left access over the right access for ultrasound-guided infraclavicular SVC.

P.083 Use of jugular venous pressure to optimize outcomes of vestibular schwannoma resection: a review of the literature and proof of concept

Background: Surgical resection of vestibular schwannoma (VS) is often curative if gross total resection is achieved, however, it is a delicate procedure with high risk to the facial nerve. With retrosigmoid approach for resection, the head is positioned to maximize lateral head rotation and neck flexion in order to optimize the surgical field. However, this may inadvertently occlude cerebral venous drainage, elevating intracranial pressure (ICP) and increasing intraoperative bleeding. Methods: Here, we review relevant literature regarding the effects of head rotation and neck flexion on internal jugular vein (IJV) occlusion and ICP, and highlight the notion that head rotation and flexion may occlude the ipsilateral IJV, increasing ICP. Subsequently, we propose a novel technique using continuous, real-time monitoring of jugular bulb pressure (JBP) to detect obstructions in jugular venous flow and guide optimal head positioning prior to VS resection. Results: As proof of concept, we present a case in which JBP monitoring was employed to optimize head positioning prior to a VS resection, which shows a significant reduction in JBP compared to traditional positioning. Conclusions: This innovative approach offers promise in enhancing the safety and efficacy of intracranial surgery for VS and potentially other neurosurgical procedures.

Use of jugular venous pressure to optimize outcomes of vestibular schwannoma resection: a review of the literature and proof of concept

Background: Surgical resection of vestibular schwannoma (VS) and other benign posterior fossa tumors is often curative if gross total resection is achieved, however, these lesions pose unique challenges due to their intricate location and proximity to critical structures. Approaches for resection often utilize lateral head rotation and neck flexion in order to optimize the surgical field. However, this may inadvertently occlude cerebral venous drainage, elevating intracranial pressure (ICP) and increasing intraoperative bleeding, potentially increasing the operative risk to patients. Methods: We review relevant literature regarding the effects of head rotation and neck flexion on internal jugular vein (IJV) occlusion and ICP, and highlight the notion that head rotation and flexion may occlude the ipsilateral IJV, increasing ICP. Subsequently, we propose a novel technique using continuous, real-time monitoring of jugular bulb pressure (JBP) to detect obstructions in jugular venous flow and guide optimal head positioning prior to VS resection. Results: As proof of concept, we present a single-patient case in which JBP monitoring was employed to optimize head positioning prior to a VS resection, which shows a significant reduction in JBP compared to traditional positioning. Conclusion: This innovative approach offers promise in enhancing the safety and efficacy of intracranial surgery for VS and other neurosurgical procedures.

An innovative method to prevent guidewire access to the ipsilateral internal jugular vein during pediatric subclavian vein cannulation

ObjectivesCatheter misplacement into the internal jugular vein (IJV) often occurs during pediatric subclavian vein (SCV) catheter placement. The aim of this study was to investigate whether an innovative method of occluding the IJV by applying temporary pressure at the IJV just above the clavicle could help prevent its occurrence. DesignThis is a randomized controlled trial. SettingsThis study was conducted in a single medical center. ParticipantsOne hundred and seventy-eight children undergoing SCV catheterization were recruited. InterventionsChildren were randomly assigned to the traditional group (unassisted placement of the guidewire) and the innovative group (temporary pressure on the IJV just above the clavicle to occlude the IJV during placement of the guidewire). Measurements and Main ResultsThe primary outcome was the incidence of guidewire misplacement into the IJV at the time of first placement. Secondary outcomes included the total number of attempts and the total time of guidewire placement. The incidence of misplacement at the first attempts was reduced from 18.06% in group C to 6.67% in group I (P=0.04). The total number of guidewire entered the IJV in group I was less than in group C [group C vs. group I = 24/96 vs. 7/82, P=0.005]; the total time of guidewire placement was reduced from 35.00s (18.25s, 54.00s) in group C to 26.00s (17.00s, 38.00s) in group I, (P=0.03). ConclusionsTemporary pressure at the IJV just above the clavicle to occlude the IJV during placement of the guidewire helps prevent inadvertent placement of the guidewire into the IJV.

Catheter Misplacement Following Subclavian Vein Catheterization Under Ultrasound Guidance: An Infrequent and Unusual Malposition

The most common malposition seen during subclavian vein cannulation is to the ipsilateral internal jugular vein. We report a case of unusual malposition of a subclavian central venous catheter, where it was found to be forming a “figure of U” in the ipsilateral subclavian vein. Although the catheterization was done under ultrasound guidance, we could not visualize the course of the guidewire due to a poor ultrasound window. This report highlights the fact that although ultrasound can facilitate identification of the vessels and prevent inadvertent arterial puncture, it seldom helps in the positioning of the guidewire tip and prevention of catheter malposition.

Concurrent Cerebral Thrombophlebitis and Nonfunctioning Pituitary Adenoma in a Postpartum Woman: A Rare Coexistence and Diagnostic Challenges

This case report presents a rare occurrence of concurrent cerebral thrombophlebitis and nonfunctioning pituitary adenoma in a postpartum woman. Cerebral thrombophlebitis is a rare condition that can manifest with diverse clinical presentations, posing diagnostic challenges. The patient, a 30-year-old primipara, presented with progressive vision loss, diplopia, and intense frontal headaches shortly after childbirth. Magnetic resonance angiography revealed thrombophlebitis in the right lateral sinus extending into the ipsilateral internal jugular vein, along with a large suprasellar lesion suggestive of a pituitary macroadenoma. Ophthalmological examination revealed papilledema and ptosis. Laboratory analyses ruled out hormonal abnormalities associated with pituitary adenomas. The patient received intravenous methylprednisolone and therapeutic anticoagulation, resulting in neurological and ophthalmological improvements. Subsequently, the patient underwent transsphenoidal resection. This case highlights the diagnostic and management challenges associated with rare postpartum conditions and emphasizes the importance of comprehensive evaluation and multidisciplinary care in such cases.

Abstract Number ‐ 12: First‐In‐Human Endovascular Treatment of Idiopathic Intracranial Hypertension Using a Miniature Biomimetic Transdural Shunt.

Introduction Successful percutaneous transvenous deployment of a miniature valved biomimetic transdural endovascular shunt (CereVasc eShunt, Auburndale, MA, USA) via an inferior petrosal sinus approach was recently described for treatment of post‐subarachnoid hemorrhage communicating hydrocephalus.The endovascular shunt replicates the function of the arachnoid granulation by draining cerebrospinal fluid (CSF) from the cerebello‐pontine angle cistern to the ipsilateral internal jugular vein. Idiopathic intracranial hypertension (IIH), usually resulting from venous transverse sinus stenosis, can be treated with pharmacological inhibition of CSF production, surgical ventriculoperitoneal shunting, or using venous stent angioplasty. In IIH, elevated CSF pressure can act to exacerbate venous sinus stenosis, resulting in worsening CSF reabsorption, thereby perpetuating a vicious cycle. The authors sought to evaluate the role of the minimally invasive eShunt approach in IIH management. Methods A 50‐year‐old male patient with history of dyslipidemia and IIH initially presented 6 years ago with diplopia initially treated with poorly tolerated acetazolamide and periodic lumbar punctures with subsequent symptom improvement. The patient was admitted following rapid evolution of sudden onset horizontal diplopia and headache. Brain magnetic resonance revealed flattening of the posterior sclera, partially empty Sella Turcica, enhancement of the prelaminar optic nerves and enlarged Meckel´s cave. Lumbar puncture was performed with opening pressure of 28 cmH2O. Cerebral angiography with 3D venography confirmed bilateral transverse sinus stenosis, though without a significant pressure gradient. Results The patient declined surgical ventriculoperitoneal shunting and was approved for compassionate use of eShunt by regulatory and bioethics committees.He underwent successful endovascular transdural deployment of the eShunt, which he tolerated well and was discharged at 48 hours post‐procedure with rapid symptomatic headache relief. Upon 30‐day follow‐up repeat brain MRI showed improvement of the prominent subarachnoid space around both optic nerves and sustained improvement of his pre‐procedural headache and diplopia.A repeat lumbar puncture revealed a lowed opening pressure of 20 cmH2O and MRI cisternography confirmed maintained patency of the biomimetic valve with accumulation of Gadolinium‐enhanced CSF drainage through the eShunt into the jugular bulb. Conclusions The current report describes the first‐in‐human use of the eShunt device for treatment of IIH resulting in sustained symptomatic relief along with decrease in CSF pressure and pre‐laminar optic nerve edema. The current results, which require confirmation in a larger cohort with longer follow‐up, are encouraging and suggest a possible role for minimally invasive endovascular transdural eshunt placement in the management of IIH.

Poor Internal Jugular Venous Outflow Is Associated with Poor Cortical Venous Outflow and Outcomes after Successful Endovascular Reperfusion Therapy.

Many patients show poor outcomes following endovascular reperfusion therapy (ERT), and poor cortical venous outflow is a risk factor for these poor outcomes. We investigated the association between the outflow of the internal jugular vein (IJV) and baseline cortical venous outflow and the outcomes after ERT. We retrospectively enrolled 78 patients diagnosed with an acute anterior circulation stroke and successful ERT. Poor IJV outflow on the affected side was defined as stenosis ≥50% or occlusion of ipsilateral IJV, and poor outflow of bilateral IJVs was defined as stenosis ≥50% or occlusion of both IJVs. Poor cortical venous outflow was defined as a cortical vein opacification score (COVES) of 0 on admission. Multivariate analysis showed that poor outflow of IJV on the affected side was an independent predictor for hemorrhagic transformation. The poor outflow of bilateral IJVs was an independent risk factor for poor clinical outcomes. These patients also had numerical trends of a higher incidence of symptomatic intracranial hemorrhage, midline shift >10 mm, and in-hospital mortality; however, statistical significance was not observed. Additionally, poor IJV outflow was an independent determinant of poor cortical venous outflow. For acute large vessel occlusion patients, poor IJV outflow is associated with poor baseline cortical venous outflow and outcomes after successful ERT.

Influence of sigmoid plate and dura mater on vascular wall displacement, vibroacoustic/hydroacoustic sources characteristics, and frequency-loudness assessments of venous pulsatile tinnitus: A coupled-computational fluid dynamics study combining transcanal recording investigation

Investigations of pulsatile tinnitus (PT) caused by sigmoid sinus wall anomalies (SSWAs) using computational fluid dynamics (CFD) have recently increased in prevalence. However, accurate modeling of anatomical structures regarding sigmoid plate dehiscence and acoustic sources of PT remains lacking. This study incorporates coupled CFD techniques, micro-computed tomography, and scanning electron microscope to reveal the vibroacoustic and hydroacoustic sources and displacement characteristics of the transverse-sigmoid sinus system. Furthermore, the in vivo transcanal-recording technique combined with ipsilateral internal jugular vein compression was implemented to cross-reference the captured acoustic profile of PT with the calculated results. In this study, the transient state coupled CFD technique was used to calculate the vibroacoustic and hydroacoustic sources. The dehiscent sigmoid plate and periosteal dura mater were then reconstructed. The displacement characteristics and acoustic results were analyzed. The displacement of the vascular wall underneath the dehiscent area was 9.6 times larger than that of the sigmoid plate and 3,617 times smaller than that of the vascular wall without the overlying osseous structures. The peak amplitude of flow-induced vibroacoustic noise was 119.3dB at 20.2Hz measured at the transverse sinus. Within the observed 20-1,000Hz frequency range, the largest peak amplitude of hydroacoustic noise was 80.0dB at 20.2Hz located at the jugular bulb region. The simulated results conformed with the in vivo acoustic profile which the major frequency of PT falls within 1,000Hz. In conclusion, 1) the sigmoid plate and dura mater greatly impact vascular wall displacement, which should not be overlooked in CFD simulations. 2) By incorporating the transcanal recording technique with IJV compression test, the primary frequency of PT was found fluctuating below 1,000Hz, which matches the frequency component simulated by the current CFD technique; amplitude-wise, however, the peak amplitude of in vivo pulse-synchronous somatosound measures approximately 10dB, which is comparatively lesser than the CFD results and the subjectively perceived loudness of PT. Thus, the transmission pathway, intramastoid acoustic impedance/amplification effect, and the perceptive threshold of PT require further investigations to minimize the incidence of surgical failure.

Subarachnoid hemorrhage due to a craniocervical junction arteriovenous fistula associated with thrombus formation in the internal jugular vein: illustrative case

BACKGROUNDA craniocervical junction arteriovenous fistula (CCJAVF) is a rare vascular malformation, and its etiology remains unclear. Here, to the best of the authors’ knowledge, they present the first case of CCJAVF associated with thrombus formation in the ipsilateral internal jugular vein.OBSERVATIONSAn 80-year-old man presented with a sudden occipital headache. Computed tomography revealed a subarachnoid hemorrhage surrounding the brainstem and upper cervical cord. Digital subtraction angiography showed a CCJAVF fed by the left C2 radiculomeningeal artery with ascending intracranial drainage and epidural plexus. After endovascular treatment, the authors retrospectively found that his ipsilateral internal jugular vein and innominate vein were occluded with a huge thrombus at admission.LESSONSThis case suggested a restricted antegrade venous flow due to thrombus-induced progressive retrograde intracranial drainage causing hemorrhage. Venous hypertension should be considered one of the causes of hemorrhage due to CCJAVF as well as intracranial arteriovenous fistulas.

A new pressure-based device for tip navigation and tip location during central venous catheterization: A prospective clinical study on a cohort of 136 adult patients.

According to current guidelines, tip location of peripherally inserted central catheters (PICCs) should be verified during insertion, preferably using non-invasive methods such as intracavitary ECG (IC-ECG) or echocardiography. An interesting new option is represented by a new pressure-based device, the CatFinder System (CFS), which might be theoretically useful also for tip navigation. We planned a single-center, prospective, non-randomized trial on adult patients requiring PICC insertion, using simultaneously CFS and IC-ECG, with the purpose of verifying the applicability, feasibility, safety, and accuracy of CFS for intra-procedural tip location. Patients with known ECG abnormalities or cardiac diseases of any type were excluded. The ability of CFS to assess wrong directions of the catheter during insertion (tip navigation) was evaluated by comparison with ultrasound scan. Out of 136 enrolled adult patients, CFS was found to be applicable in 131 cases (five cases were excluded because of ECG abnormalities) and feasible in 111 cases (in 20 cases, tip location by CFS could not be carried out because of technical issues). There were no complications directly or indirectly related to the CFS maneuvers. Using IC-ECG as a comparison, 87 tips placed by CFS were within 2 cm from the target, 17 were >2 cm from target. In seven cases, CFS was able to detect a wrong direction (to the ipsilateral internal jugular vein), as confirmed by ultrasound. Applicability of CFS in patients with sinus rhythm was 96.3%, feasibility was 84.7%, and safety was 100%. If compared to IC-ECG, accuracy was 83.6% (accepting an error <2 cm) and 96.1% (for an error <3 cm). Unacceptable tip positions (>3 cm) were 3.8% (the tip was too high inside the SVC). This study confirms a possible future role of CFS for intra-procedural tip location and tip navigation, though its use cannot be currently recommended.

Retroauricular/Transcranial Color-Coded Doppler Ultrasound Approach in Junction With Ipsilateral Neck Compression on Real-Time Hydroacoustic Variation of Venous Pulsatile Tinnitus.

Alterations in dural venous sinus hemodynamics have recently been suggested as the major contributing factors in venous pulsatile tinnitus (PT). Nevertheless, little is known about the association between real-time alterations in hemodynamics and the subjective perception of venous PT. This study aimed to investigate the hydroacoustic correlations among diverticular vortices, mainstream sinus flow, and PT using various Doppler ultrasound techniques. Nineteen venous PT patients with protrusive diverticulum were recruited. The mainstream sinus and diverticular hemodynamics before and after ipsilateral internal jugular vein (IJV) compression were investigated using an innovative retroauricular color-coded Doppler (RCCD) method to examine the correlation between the disappearance of PT and hemodynamic alterations. To reveal the hydroacoustic characteristics of disparate segments of venous return, a computational fluid dynamics (CFD) technique combined with the transcranial color-coded Doppler method was performed. When the ipsilateral IJV was compressed, PT disappeared, as the mean velocity of mainstream sinus flow and diverticular vortex decreased by 51.2 and 50.6%, respectively. The vortex inside the diverticulum persisted in 18 of 19 subjects. The CFD simulation showed that the flow amplitude generated inside the transverse–sigmoid sinus was segmental, and the largest flow amplitude difference was 20.5 dB. The difference in flow amplitude between the mainstream sinus flow and the diverticular flow was less than 1 dB. In conclusion, the sensation of PT is closely associated with the flow of kinetic energy rather than the formation of a vortex, whereby the amplitude of PT is correlated to the magnitude of the flow velocity and pressure gradient. Additionally, the range of velocity reduction revealed by the RCCD method may serve as a presurgical individual baseline curative marker that may potentially optimize the surgical outcomes.

Preoperative Significance of Ipsilateral Manual Neck Compression in Patients With Pulsatile Tinnitus Secondary to Sigmoid Sinus Dehiscences and Diverticula.

Venous pulsatile tinnitus (PT) is characterized by an auditory perception of pulse-synchronous sound, suppressed by compression of the ipsilateral internal jugular vein. We sought to determine the preoperative prognostic significance of the effect of ipsilateral neck manual compression on the PT loudness and audiometric changes in patients with sigmoid sinus dehiscences (SS-Deh) and diverticula (SS-Div) by comparing postoperative improvements in ipsilateral low-frequency hearing loss (LFHL) in pure-tone audiogram (PTA) and PT symptoms. Twenty-two subjects with PT originating from SS-Deh/Div were recruited. Air-conduction hearing thresholds were measured using PTA at three time points: twice preoperatively (with neutral neck position and with ipsilateral manual compression of internal jugular vein) and once at 3-months postoperatively with neutral neck position. We defined a positive neck compression effect as a threshold improvement of ≥ 10 dB HL at 250 or 500 Hz after manual neck compression. All but two subjects presented with ipsilateral LFHL in the neutral position. The average hearing threshold in the neutral position markedly improved after manual neck compression, indicating that LFHL originated from the masking effect of venous PT. All subjects had subjective improvements in PT and LFHL after sigmoid sinus surgeries, confirming that LFHL resulted from the masking effect of PT. Additionally, improvement of LFHL after neck compression could be regarded as a positive prognostic indicator after surgery. Collectively, elimination of PT loudness and improvement of LFHL with manual compression over the ipsilateral neck may suggest the venous origin of the PT and predict a favorable outcome following repair of SS-Deh/SS-Div.

Effect of transverse sinus variation on the clinical outcomes of atherosclerotic anterior circulation infarction.

BackgroundHypoplasia of the transverse sinus (TS) is a common anatomical variation. The aim of this study was to investigate the effects of TS variation (i.e., TS hypoplasia) and no variation (i.e., TS symmetry) and their subgroups on the clinical outcomes of patients with atherosclerotic anterior circulation cerebral infarction (CI).MethodsA total of 75 patients were included in the study and were divided into the no TS variation group and the TS variation group. The TS variation group was further divided into the following subgroups: the TS variation with ipsilateral CI group and the TS variation with contralateral CI group. We retrospectively analyzed the correlations of the endpoint events of patients with large atherosclerotic anterior circulation infarction and TS no variant, and subgroups of TS variants.ResultsWe found that the diameter of the ipsilateral IJV in patients with TS variants were significantly smaller than those without TS variants, which was statistically significant (P<0.05). The differences in primary endpoint events, secondary endpoint events, and responsible vessel stenosis were not statistically significant when comparing the TS variant and no TS variant groups, and the TS variant subgroup (P>0.05). We found statistically significant differences in the National Institute of Health stroke scale (NIHSS) and Modified Rankin Scale (mRS) scores after 90 days of CI between the total anterior circulation infarct (TACI) TS variant group, the ipsilateral CI TS variant group, and the partial anterior circulation infarct (PACI) TS hypoplasia group and the ipsilateral CI TS variant group (P<0.05). There was a statistically significant difference (P<0.05) between the TS variant group with TACI, the TS variant group with ipsilateral CI, and the TS no variant group and the TS variant with contralateral CI group when comparing patients’ mRS scores after 90 days of CI.ConclusionsThe diameter of the internal jugular vein (IJV) ipsilateral to the TS variant was significantly smaller than that of the TS no variant. Patients with TACI in the TS variant group and one of its subgroups (the TS variant with ipsilateral CI group) had more severe clinical symptoms and a worse prognosis than patients in the same group with PACI.

Pulsatile tinnitus secondary to sigmoid sinus diverticulum: A case report

Sigmoid sinus diverticulum (SSD) has been recently recognized as a cause of pulsatile tinnitus (PT). The cause of the SSD and tinnitus caused by a sinus diverticulum is unknown. Numerous cases have reported successful treatment with surgical or radiological intervention. We report the first case of SSD in our region that was treated surgically with a successful outcome. A 40-year-old female presented to the Ear Nose Thorat (ENT) clinic with the chief complaint of right ear ringing for three years. The symptoms were relieved on compression of the ipsilateral internal jugular vein during clinical examination. Computed tomography showed a bony defect and sigmoid sinus diverticulum. Surgical excision was performed under general anaesthesia using the trans-mastoid approach. The diverticulum was identified and obliterated. Temporalis fascia and conchal cartilage were used as grafts. No postoperative complications were noted. A 3-year follow-up showed no signs of recurrence. Tinnitus is a relatively common condition. SSD should be investigated as a probable cause. A successful outcome is governed by the surgeon’s expertise.

Abstract 1122‐000122: The Role of the Venous System in Infarct Burden in Patients with Acute Ischemic Stroke

Introduction : Acute ischemic stroke (AIS) is a leading cause of disability internationally. Most therapies focus on intra‐arterial treatment to improve post‐stroke deficits and neurologic status. However, if a relationship between venous anatomy and post‐stroke deficits or infarct size can be shown, then venous augmentation strategies represent a possibility for future interventions as an adjunct to intra‐arterial treatment. Methods : We retrospectively reviewed all ischemic infarcts at our institution that underwent thrombectomy from January 2018 – October 2020. From these, we selected cases that were demonstrated as M1 occlusions on intra‐procedural angiogram and those who had a CT Head obtained within six hours of the patient’s last known normal (LKN). Patients without a CT Head or CT Angiogram of their head were excluded. Using axial and sagittal reconstructed views of 0.9mm slices, cross‐sectional area measurements were taken of the superior sagittal sinus 1cm above the Torcula, in three locations of the ipsilateral and contralateral transverse sinus, in three locations of the ipsilateral and contralateral sigmoid sinus, and of the ipsilateral and contralateral internal jugular vein (IJV) at the external surface of the skull. For the transverse and sigmoid sinuses, the three measurements were averaged together. These measurements were then compared against patient’s Alberta Stroke Program Early CT Score (ASPECTS). Results : 77 patients were identified in the study period. Average ASPECTS was 8.9, ranging from 5–10. There were three patients included with ASPECTS &lt; 6. Average ipsilateral transverse sinus area was 34.4mm ± 3.34, average ipsilateral sigmoid sinus area was 32.8mm ± 2.74, average ipsilateral IJV area was 46.9 mm ± 5.00. Correlation tests to identify relationships between venous sinus area and ASPECTS was unremarkable (ipsilateral transverse sinus p = 0.574, ipsilateral sigmoid sinus p = 0.548, ipsilateral IJV p = 0.798). When assessed as a ratio of ipsilateral venous sinus area to contralateral sinus area to assess correlation with ASPECTS, results were unremarkable (transverse sinus p = 0.891, sigmoid sinus p = 0.292, IJV p = 0.499). Conclusions : Venous sinus size was not found to be predictive or associated with predominantly favorable ASPECTS for strokes found within six hours. We believe this may be due to our cohort lacking significant numbers of patients with low ASPECTS, yielding a false negative result. We are currently expanding this project to include a comparable number of patients with ASPECTS &lt; 6 to determine the role of venous collateral system in infarct progression.

The right supraclavicular fossa ultrasound view for correct catheter tip positioning in right subclavian vein catheterisation: a prospective observational study.

Central venous catheter misplacement is common (approximately 7%) after right subclavian vein catheterisation. To avoid it, ultrasound-guided tip navigation may be used during the catheterisation procedure to help direct the guidewire towards the lower superior vena cava. We aimed to determine the number of central venous catheter misplacements when using the right supraclavicular fossa ultrasound view to aid guidewire positioning in right infraclavicular subclavian vein catheterisation. We hypothesised that the incidence of catheter misplacements could be reduced to 1% when using this ultrasound technique. One -hundred and three adult patients were prospectively included. After vein puncture and guidewire insertion, we used the right supraclavicular fossa ultrasound view to confirm correct guidewire J-tip position in the lower superior vena cava and corrected the position of misplaced guidewires using real-time ultrasound guidance. Successful catheterisation of the right subclavian vein was achieved in all patients. The guidewire J-tip was initially misplaced in 15 patients, either in the ipsilateral internal jugular vein (n = 8) or in the left brachiocephalic vein (n = 7). In 12 patients it was possible to adjust the guidewire J-tip to a correct position in the lower superior vena cava. All ultrasound-determined final guidewire J-tip positions were consistent with the central venous catheter tip positions on chest X-ray. Three out of 103 catheters were misplaced, corresponding to an incidence (95%CI) of 2.9 (0.6-8.3) %. Although the hypothesis could not be confirmed, this study demonstrated the usefulness of the right supraclavicular fossa ultrasound view for real-time confirmation and correction of the guidewire position in right infraclavicular subclavian vein catheterisation.

Ipsilateral ultrasound-monitoring technique for reducing malpositions of peripherally inserted central catheters in the intensive care unit.

We performed ultrasonographic examinations of the ipsilateral internal jugular vein after placement of peripherally inserted central catheters (PICCs) and found that more than half of malpositions of PICC went to the head through the ipsilateral internal jugular vein. We aimed to reduce malpositions of PICCs in settings where fluoroscopy is not available. This retrospective study had a case-control, single-center study design. From January to June 2018, PICCs were inserted with the patient's arm abducted without the use of ultrasonography to identify the presence of the PICC in the ipsilateral internal jugular vein (procedure A). From July to December 2018, PICCs were inserted in a similar fashion; however, ultrasonography was employed to detect the catheter tip in the ipsilateral internal jugular vein (procedure B). There were 794 placements of PICCs in 650 patients. Procedures A and B were performed in 418 and 376 patients, respectively. Malpositioning of PICC tips occurred significantly less often in procedure B than in procedure A (2.4% vs. 5.7%, P=0.02). In a setting without fluoroscopy, insertions of PICCs can be performed with the arm abducted at 90°. Ultrasound monitoring for the presence of the catheter in the ipsilateral internal jugular vein can help with correct positioning, thereby reducing the occurrence of catheter tip malpositions.

Follicular Variant of Papillary Carcinoma Thyroid with Massive Angioinvasion of the Internal Jugular Vein: Our Approach

Follicular variant of papillary carcinoma thyroid is an aggressive variant of papillary carcinoma thyroid. It is more commonly associated with extrathyroidal extension and regional lymphadenopathy. It can rarely be associated with microscopic vascular invasion but tumor thrombus into great veins is a rare phenomenon. We present a case of 60-year-old male with follicular variant of papillary carcinoma thyroid with tumor thrombosis in superior thyroid vein and internal jugular vein (IJV). We report a case of a 60-year-old male who presented with a large swelling in the lower part of left side of neck for 4 months. Clinical examination revealed a hard swelling of 12x8 cm in left side of neck. Ultrasonography showed a solitary thyroid mass of the left lobe and a dilated left superior thyroid vein and ipsilateral IJV. Fine-needle aspiration cytology revealed follicular variant of PTC cells. Total thyroidectomy was done. A tumor thrombus was discovered in the superior thyroid vein and left IJV was found to be dilated. The left IJV with superior thyroid vein was ligated and excised. The patient recovered well after the operation with no local or distant metastasis detected. Follicular variant of PTC commonly spreads to the lymph nodes. Vascular spread via direct intravascular extension through superior thyroid vein is extremely rare. On palpation cord like IJV is felt on the involved side. Neck ultrasound play important role in the diagnosis. Aggressive surgical treatment with IJV ligation above and below the tumor thrombus is recommended to minimize the risk of potentially fatal complications of the intraluminal masses. Intravascular tumor extension into IJV of neck in follicular variant of PTC is rare and can be associated with serious consequences. Total thyroidectomy with thrombectomy with ligation of IJV must be done.

SPONTANEOUS CATHETER MALPOSITIONING: A CASE REPORT

SESSION TITLE: Medical Student/Resident Procedures Posters SESSION TYPE: Med Student/Res Case Rep Postr PRESENTED ON: October 18-21, 2020 INTRODUCTION: Peripherally inserted central catheter (PICC) usage has increased significantly since introduction in the late 1970s. Growing bodies of evidence demonstrate the safety and efficacy of PICCs for treatment regimens up to 6 months in the outpatient setting, but PICCs can have complications. We described a patient with spontaneous repositioning of his PICC line tip with subsequent resolution. CASE PRESENTATION: A 39-year old man with an extensive past medical history presented to a referring hospital for sudden onset, severe abdominal pain, and new associated shortness of breath. On hospital day (HD) 3, a PICC was placed in his right upper extremity with the tip overlying the cavoatrial junction. A CT chest on HD8 demonstrated a change: the tip of the PICC had reversed course and flipped from the SVC into the ipsilateral internal jugular vein. The PICC flushed appropriately and drew briskly. Our medical center’s dedicated peripheral access team power-flushed the catheter a total of three times. The patient reported that he heard the first flush in his right ear, but did not hear the subsequent second nor third flushes. A repeat chest XR demonstrated an interval flip in the direction of the PICC with the tip appropriately at the junction of the right brachiocephalic vein and the superior vena cava. This PICC flipped once more before removal before discharge. DISCUSSION: Although studies have been performed examining rates of inappropriate positioning after initial PICC placement, limited data exist regarding rates of spontaneous malpositioning of PICC tips. Subsequently, no societal guidelines exist for PICC placement monitoring in a patient receiving extended therapy intravenous medication delivery. Our medical center’s policy states that all forms of existing central access in the upper extremity or trunk are verified using chest XR or other imaging upon patient presentation to the emergency department or admission to a hospital before usage. When PICC tips are noted to be inappropriately positioned, there exists data to support both a trial of observation for spontaneous repositioning (especially if the catheter edge is in the ipsilateral internal jugular vein or contralateral subclavian vein) and immediate intervention or manual repositioning. CONCLUSIONS: Given that our patient’s PICC spontaneously repositioned twice during 13 hospital days and the morbidity that inappropriately positioned peripheral catheters can cause, it may be reasonable to obtain a routine chest XR to verify PICC positioning every 1 to 2 weeks for both hospitalized and ambulatory care patients. When PICCs spontaneously malposition, we support decision making on a case-by-case basis, depending on the patient’s acuity, associated symptoms, the ability of the catheter to draw/flush appropriately, availability of other intravenous access, and remaining anticipated required length of central access. Reference #1: King MM, Rasnake MS, Rodriguez RG, Riley NJ, Stamm JA. Peripherally inserted central venous catheter–associated thrombosis: retrospective analysis of clinical risk factors in adult patients. South Med J. 2006;99(10):1073–1077 Reference #2: Chen W, He L, Yue L, Park M, Deng H.: Spontaneous correction of misplaced peripherally inserted central catheters. Int J Cardiovasc Imaging. 2018 Jul;34(7):1005-1008. doi: 10.1007/s10554-018-1321-5. Reference #3: Campagna S, Et Al.: A retrospective study of the safety of over 100,000 peripherally-inserted central catheters days for parenteral supportive treatments. Res Nurs Health. 2019 Jun;42(3):198-204. DISCLOSURES: No relevant relationships by Christian Ghattas, source=Web Response No relevant relationships by Divyesh Mehta, source=Web Response No relevant relationships by Virgil Secasanu, source=Web Response