Neck Veins Research Articles

Jugular Vein Insufficiency and Choroidal Neovascularization in Moderate Myopia: A New Unknown Factor of Additional Risk?

To date, choroidal blood flow reduction in highly myopic eyes appears to be related to the development of choroidal neovascularization secondary to local reduction of arterial flow. Instead, no evidence of choroidal neovascularization was found in subjects with low or moderate myopia. The authors' aim has been to encourage new studies regarding the potential role of chronic retinal venous congestion in the pathogenesis of choroidal neovascularization. In December 2011, a 54-year-old woman with moderate bilateral myopia had a sudden block upon swallowing while she was eating. Subsequently (January 2013) metamorphopsia in the left eye revealed macular degeneration with choroidal neovascularization. The related echo-color Doppler study of the neck veins, performed in November 2014, showed an atypical left jugular insufficiency associated with homolateral hypertension of the superior ophthalmic veins. This singular case highlights the necessity to further investigate the potential role of chronic alterations of intra- and extracranial venous drainage in the disruption of choroidal flow in myopic patients.

Pemberton Sign in Diagnosis of Retrosternal Goiter

ABSTRACT The Pemberton maneuver (elevating both arms until they touch the sides of the head for a minute) is a method to increase pressure in the thoracic inlet and further narrow the aperture.1 If congestion, cyanosis of face or distension of neck veins or distress become apparent, it is suggestive of retrosternal goiter. We describe two patients with Pemberton sign. How to cite this article Mishra A, Agarwal A, Singh RK, Tewari S. Pemberton Sign in Diagnosis of Retrosternal Goiter. World J Endoc Surg 2015;7(3):79-80.

Distinctive neck swelling in a patient with a vein of Galen arteriovenous malformation.

A vein of Galen arteriovenous malformation (VGAM) is a rare intracranial shunt lacking a capillary bed and resulting in subsequent aneurysmal enlargement. VGAM has been previously reported to present as cardiovascular abnormalities, including increased right-sided cardiac load and pressure, cardiac dilatation, pulmonary hypertension and retrograde flow into the aortic arch. We report the first case of VGAM presenting as a gross right-sided neck swelling in a 39-week-old immediately at birth. Transthoracic echocardiography detected dilatation of the superior vena cava and innominate vein, increased right ventricular and pulmonary arterial pressure, and retrograde flow into the aortic arch. Follow-up neck ultrasound revealed tortuous carotid artery and bilateral dilatation of neck veins. Transcranial ultrasound revealed abnormally dilated vessels posterior to the third ventricle, confirming VGAM. Our case demonstrates that while the differential diagnoses of neck swelling are extensive, such a presentation upon Doppler and echocardiographic investigation, may be suggestive of extracardiac causes such as VGAM. The management of such a condition remains critical due to risk of hemorrhage and extensive cerebral involvement.

Anomalous External Jugular Vein with variant Omohyoid – anatomico-clinical appraisal

Variability in size, formation, course and termination of superficial system of veins of Head and Neck are common. This is due to the complex development of veins and various stages of evolution and involution of multiple paired embryonic veins. These variations often noticed during routine anatomical dissection, may provide invaluable assistance for the clinicians, surgeons and radiologist. External Jugular Vein is routinely used in the estimation of Central Venous Pressure, IV Catheterization for haemodialysis, parental nutrition in critically ill patients and in trans – jugular procedures. An unusual termination of left External Jugular Vein (EJV) and atypical left Omohyoid muscle was noticed during routine dissection of a 65 year old male cadaver. The left EJV crossed the jugular notch in the midline and drained into the right Subclavian vein. On the same side Omohyoid had a single belly that originated from the medial half of the clavicle and was inserted into the hyoid bone. This unilateral spectrum of anatomic variation makes it a rare special case.

Assessment of the Effectiveness of Ich Tam Khang as a Supportive Therapy for Chronic Heart Failure

Background: Heart failure is a chronic disease needing lifelong management. Despite the advances that have been made in the treatment of the disease, both the longevity and quality of life for those with chronic heart failure remain impaired. A more effective therapeutic approach with less negative side effects is still needed. In this study, we evaluate Ich Tam Khang (ITK), the poly-ingredient herbal and nutritional preparation with multiple physiological actions, as a supportive therapy for patients with chronic heart failure. Aims of Study: To evaluate the effectiveness and safety of Ich Tam Khang as an adjunctive treatment of chronic heart failure. Methods: A total of 60 patients with chronic congestive heart failure were enrolled in this open label, cross-sectional and prospective study. All patients were treated with a conventional regimen (digoxin, diuretics, angiotensin-converting-enzyme (ACE) inhibitors or angiotensin II receptor blockers (ARBs), beta blockers) for at least 4 weeks before being divided into two equal groups. In the treated patients with ITK, patients received conventional therapy plus 4 tablets ITK per day added in two divided doses. In the control patients, all patients kept the same conventional regimen without ITK. All patients were followed up for 3 months for clinical and para-clinical outcomes. Result: The symptoms of heart failure (dyspnea, palpitation, peripheral edema, neck vein distention, heptojugular reflex) decreased. Heart rate and blood pressure stabilized during treatment in the treated patients with ITK. Additionally, total cholesterol and HDL-cholesterol normalized in the patients treated with ITK. Most of echocardiography parameters in the ITK treated patients were superior to the control patients. ITK is safe and it has no side effects. Conclusion: ITK as a combination of herbal and nutritional preparation is effective in reducing heart failure symptoms, improving patient’s quality of life for the patients with decompensated heart failure and reducing total cholesterol and LDL-C.

Navigating the 7 cs of certified practice.

Navigating the 7 cs of certified practice.

An Unusual Case of an Upper Gastrointestinal Bleed: Pharyngeal Varices

Introduction: Ectopic varices are a rare finding and cause of gastrointestinal bleeding. We report a case of upper gastrointestinal bleeding in a cirrhotic patient due to pharyngeal varices. A 53-yearold man with hepatitis C cirrhosis presented with 6 months of fatigue with episodic hematemesis and melena. He denied use of alcohol, non-steroidal anti-inflammatory drugs, anticoagulants, aspirin or iron supplementation. Physical examination revealed a pale, non-icteric man with spider angiomas and caput madusae. Laboratory findings showed: hemoglobin 6.1 gm/dl, platelets 88,000 U/L, international normalized ratio 1.36, aspartate aminotransferase 51 U/L, alanine aminotransferase 30 U/L, alkaline phosphatase 118 U/L, total bilirubin 1.62 mg/dl. The patient was started on esomeprazole and octreotide drips and was transfused with red blood cells. On esophagogastroduodenoscopy, prior to intubation of the esophagus, the pharynx showed pharyngeal varices with stigmata of recent bleeding. The patient was transferred to a tertiary care center for laryngoscopy and further treatment. Ectopic varices are considered variceal veins other than those found in the esophagus and stomach such as rectal varices. These develop from portosystemic collaterals in portal hypertension that become enlarged. Pharyngeal varices are by definition considered ectopic varices. However, unlike other ectopic varices, pharyngeal varices arise from the lingual venous system and not from the portal venous system. There is no known anastomosis between the two systems; therefore it is unclear if the formation is related to portal hypertension. The fact that these varices have been found in cirrhotic patients suggests a relationship between these two systems, but it is unknown if conventional treatment for esophageal varices including transjugular intrahepatic portosystemic shunt (TIPS) would be an option. Prior cases have reported treating pharyngeal varices with ablation using a continuous carbon dioxide laser or decompressing neck veins with a venous bypass procedure. Ectopic varices are associated with a mortality rate reaching 40%; it is unknown whether pharyngeal varices carry similar risk. Overall, both the prognosis and the optimal management of pharyngeal varices have not been elucidated.

Cardiac Tamponade as a Complication of Pseudocyst in Chronic Pancreatitis

Case Report: A 45-year-old male with history of alcoholism and chronic pancreatitis presented to the emergency department with chief complaint of chest pain and shortness of breath. On physical exam, he was in severe distress, with distended neck veins, distant heart sounds, and bilateral crackles on lung exam. He was hemodynamically unstable with a blood pressure of 80/60 mm Hg and pulse of 110. Pulsus paradoxus with drop in systolic blood pressure on inspiration was also observed. A noncontrast chest CT showed massive pericardial effusion. The effusion was drained urgently and a pericardial drain was left in place. Following which, his blood pressure stabilized at 110/70. Pericardial fluid analysis showed WBC of 3750/mm3 with 97% neutrophils, RBC of 59400/mm3, LDH of 1387 u/L, total protein of 4.8 g/dL, glucose 116 mg/dL, amylase 101 u/L, and lipase 196 u/L. The pericardial drain was removed the next day after decreased output. Within hours, he became hypoxic and hypotensive. CT angiogram of the chest showed reaccumulation of fluid in the pericardium along with bilateral pleural effusions. It also revealed a pancreatic pseudocyst that was found to be extending close to the posterior mediastinum and abating the posterior pericardial wall with a fistulous tract from the pseudocyst into the pericardium. He was intubated due to hemodynamic instability and moved to the ICU. He then had a ERCP followed by an EUS-guided cystogastrostomy to drain the pseudocyst. His subsequent post-op course was uneventful. Discussion: Pseudocyst formation is a common complication of both acute and chronic pancreatitis. Approximately, 40% will resolve spontaneously within 6 weeks. Extra-abdominal extension of a pancreatic pseudocyst is uncommon. Mediastinal pseudocysts result from extension of enzyme rich proteolytic fluid through the diaphragm. Most common route is via the aortic or esophageal hiatus. Rarely, it occurs by direct erosion through the diaphragm or via foramen of Morgagni. Even rarer, does a mediastinal pseudocyst penetrate into the pericardial sac. CT scan, ERCP, and magnetic resonance pancreatogram (MRP) are useful for diagnosis. The treatment modalities include (1) medical management, (2) ERCP with endoscopic pancreatic stent placement (endoscopic transpapillary/transmural technique), (3) surgery, and (4) endosonographic drainage. Conclusion: Pancreaticopericardial fistula should be considered in the differential diagnosis of pericardial effusion in a patient with known history of chronic pancreatitis and should be treated promptly.

Lung scintigraphy in the diagnosis of pulmonary embolism: pathophysiological and practical evidence

The protean clinical presentation of pulmonary embolism (PE) is the consequence of a complex series of haemodynamic and respiratory changes caused by the impact of thrombi within the pulmonary vasculature. Haemodynamic changes result from obstruction of the pulmonary arterial bed leading to increased pulmonary vascular resistances and they are manifested clinically as dyspnoea, engorgement of neck veins, and systemic arterial hypotension. Respiratory changes are characterised by lung volume reduction, hypocapnia and hypoxaemia. Reduced lung volume is mainly due to pulmonary consolidation, atelectasis and decreased distension of the thoracic cage due to chest pain. These pathophysiological changes affect both perfusion and ventilation and could explain the low sensitivity of the ventilation/perfusion (V/Q) mismatch scintigraphic approach in diagnosing PE. Acute PE causes redistribution of pulmonary blood flow from non-perfused areas and, to a lesser extent, of ventilation; this is a further factor arguing against the use of V/Q mismatch for the scintigraphic diagnosis of the disease. Hypoxaemia is primarily the consequence of V/Q abnormalities, namely the development of areas with a low V/Q ratio. On a Q scan this can easily be appreciated from hyperperfused lung areas that, by themselves, are a marker for the scintigraphic diagnosis of PE. In conclusion, a Q scan without a V scan, when properly interpreted according to the prospective investigative study of acute pulmonary embolism diagnosis methodology (presence or absence of wedge-shaped perfusion defects) and combined with the formulation of a pre-test clinical probability, can be used in most patients with clinical suspicion of PE, reducing costs and radiation load, increasing the practicality of the examination, and providing diagnostic accuracy comparable to that of CT angiography.

Lemierre's syndrome secondary to community-acquired methicillin-resistant Staphylococcus aureus infection presenting with cardiac tamponade, a rare disease with a life-threatening presentation: a case report.

BackgroundLemierre's syndrome is a rare condition characterized by thrombophlebitis of internal jugular vein, septicemia and septic metastatic infection of different organs. It is preceded by an oropharyngeal infection by anaerobic organisms. Community-acquired methicillin-resistant Staphylococcus aureus is now emerging as a causative organism in Lemierre's syndrome. Clinical manifestations vary depending on the organ system affected by the infection. Although rare, patients may present with life-threatening conditions such as cardiac tamponade.Case presentationWe report the first case, to our knowledge, of Lemierre's syndrome presenting with cardiac tamponade secondary to community-acquired methicillin-resistant S. aureus in a previously well 45-year-old Sri Lankan lady. Fever, sore throat and left-sided neck pain complicated with facial and left upper limb swelling were followed by severe shortness of breath for 24 h. There was tachycardia with pulsus paradoxus, low blood pressure and soft heart sounds. Pericardial effusion with cardiac tamponade was detected on echocardiogram and methicillin-resistant S. aureus species were isolated in both blood and pericardial fluid cultures. Venous duplex of neck veins and computed tomography scan of the neck showed thrombosis of left-sided internal jugular, external jugular, subclavian and axillary veins. Diagnosis of Lemierre's syndrome was made, and patient had a satisfactory recovery following emergency pericardiocentesis and a prolonged course of antibiotics.ConclusionsAlthough uncommon, Lemierre's syndrome is a life-threatening condition. Patients may present with cardiac tamponade secondary to purulent pericarditis in Lemierre's syndrome, where emergency pericardiocentesis is lifesaving. Community-acquired methicillin-resistant S. aureus is emerging as a causative agent in Lemierre's syndrome, and awareness is required amongst physicians for prompt diagnosis and appropriate empirical treatment to prevent mortality and morbidity associated with the disease.

P04.08: Cariomegaly as a prompt in diagnosing vein of Galen malformation

Vein of Galen malformation is extremely rare congenital arterio-venous malformation. It could present prenatally as cardiomegaly, signs of congestive cardiac failure,hydrops,macrocephaly etc. Routine cranial ultrasound screening planes could potentially miss the finding unless targeted sonogram with color flow map is performed. We present one such case. A 29 year old primigravida was referred to our unit with cardiomegaly of unknown etiology detected at routine anomaly scan at 19 weeks of gestation. There was no significant medical or family history. No history suggestive of parvo virus infection/exposure. Her blood group was A Rh Positive and no history of any abortion/prior blood transfusion. On detailed anomaly screen, there was global cardiomegaly without any structural cardiac abnormalities. Bracheo-cephalic vein was dilated and so are the neck veins. Routine cranial screening planes were normal. With a high suspicion of volume overload probably by A-V malformation, targeted neurosonogram was performed to detect a large venous confluence measuring 4.1 x 3.9 cm. On three-dimensional angio-sonography using 3 D CFM we could demonstrate the presence of large Vein of Galen malformation with multiple feeding vessels with high flow velocity. In view of such findings, poor prognostication was explained to couple. Follow up scan performed a week later and there was increasing cardiomegaly with pericardial effusion. Couple decided to terminate the pregnancy and fetus was expelled 2 days later. Fetopsy confirmed our finding. Finding of a global cardiomegaly should prompt thorough anatomical evaluation. Routine cranial planes would potentially miss Vein of Galen malformation unless suspected. Use of color flow map would help in the diagnosis and 3 D anigosonography could assist in thorough evaluation and prognostication.

Aneurisma da Veia Jugular Externa Trombosado: Causa Rara de Tumefação Cervical

Venous aneurysms are rarely responsible for neck masses, and regarding the neck veins, external jugular vein aneurysms are extremely uncommon, with a few cases reported in the literature. Although most cases are asymptomatic, they may cause pain, be complicated by thrombosis or even rupture. Imaging studies have a role in the diagnosis and surgical planning of this pathology. With emphasis on the imaging techniques, the authors present a case of an external jugular vein aneurysm, initially asymptomatic but thereafter complicated with thrombosis.

Enhanced global mathematical model for studying cerebral venous blood flow

Here we extend the global, closed-loop, mathematical model for the cardiovascular system in Müller and Toro (2014) to account for fundamental mechanisms affecting cerebral venous haemodynamics: the interaction between intracranial pressure and cerebral vasculature and the Starling-resistor like behaviour of intracranial veins. Computational results are compared with flow measurements obtained from Magnetic Resonance Imaging (MRI), showing overall satisfactory agreement. The role played by each model component in shaping cerebral venous flow waveforms is investigated. Our results are discussed in light of current physiological concepts and model-driven considerations, indicating that the Starling-resistor like behaviour of intracranial veins at the point where they join dural sinuses is the leading mechanism. Moreover, we present preliminary results on the impact of neck vein strictures on cerebral venous hemodynamics. These results show that such anomalies cause a pressure increment in intracranial cerebral veins, even if the shielding effect of the Starling-resistor like behaviour of cerebral veins is taken into account.

Electrocardiogram in a 28-Year-Old Woman with Dyspnea on Exertion

A28-year-old HIV-infected woman with dyspnea on exertion for 6 months had no history of acute rheumatic fever or opportunistic infections and no family history of heart disease. Her CD4 count 3 months earlier was 473/μL, and she was adherent with her antiretroviral therapy. On physical examination her neck veins were normal, as were her carotid pulses. The chest was clear to auscultation. A 1+/4+ left parasternal (right ventricular) lift was felt, and the left ventricular impulse was normal. The first heart sound was loud and split. The second heart sound was loud and palpable in the second left intercostal space. Heard at the cardiac apex were a soft pansystolic murmur of mitral regurgitation and an early low-medium pitched third heart sound immediately followed by a typical diastolic murmur of mitral stenosis. An electrocardiogram was normal except for signs of left atrial enlargement: a negative terminal portion of the P wave in lead V1 ≥ 0.1 mV in amplitude and ≥ 0.04 seconds in duration (2); P waves in leads II, III, aVF, V3, and V4 ≥ 0.12 seconds in duration (3); and bifid with >0.04 seconds between the 2 peaks (4) in leads III and V3 (Figure). Figure. Electrocardiogram in a 28-year-old woman with exertional dyspnea for 6 months. See text for explication. An echocardiogram explained how a patient with a third heart sound could have a typical murmur of mitral stenosis by demonstrating a large left atrial myxoma that fell into the mitral orifice early in each diastole causing a “tumor plop” followed by a mitral stenosis murmur because the orifice of the valve was almost completely occluded. The mean diastolic pressure gradient across the mitral valve was 18 mm Hg as measured by echo-Doppler. Because the hemodynamics of left atrial myxoma and mitral stenosis are so similar, it is not surprising that both the physical exam and the electrocardiogram would be similar in the two conditions, with P waves suggesting left atrial enlargement being early electrocardiographic findings in both. The patient underwent uneventful operative removal of a 5 × 4 × 8.5 cm left atrial myxoma.

Play of Chance Versus Concerns Regarding Dipeptidyl Peptidase-4 Inhibitors: Heart Failure and Diabetes.

The delicate balance of disease management versus off-target effects of treatment continues to be a vital concern to both patients and physicians. This article offers a brief overview of heart failure in diabetes and comments on the recent outcome trials of dipeptidyl peptidase-4 (DPP-4) inhibitors, with a closer look at a few pathobiological concerns. The importance of safe antidiabetic treatments becomes apparent when one considers the increasing obesity and diabetes pandemics. Approximately 150,000 patients with moderate-high cardiovascular (CV) risk factor profiles are currently enrolled in trials of antidiabetic agents. Establishing the CV safety of newer antidiabetic agents, especially with respect to heart failure, remains crucial. Heart failure syndrome is a symptom complex composed of worsening shortness of breath, orthopnea, paroxysmal nocturnal dyspnea, fatigue, and the well-known manifestation of ankle edema. The syndrome is characterized by physical findings of fluid retention (dependent edema), a third heart sound, rales sounds, and distension of the neck veins. In addition, heart failure is associated with chronic inflammation and a prothrombotic state. Endothelial dysfunction and proteomic and neurohormonal activation occur many months before development of the syndrome complex.1,2 Newer areas of basic science research have identified potential prognostic indicators in chronic heart failure (miR126 and miR508-5p) that might be used as novel markers leading to earlier diagnosis and treatment of heart failure.3,4 Heart failure has several etiologies ranging from mechanical and electrical dysfunction to structural and valvular abnormities. Moreover, the consequences of heart failure are multi-systemic and adversely affect the liver, kidneys, bone marrow, and muscle. Recent data from the Olmstead County population study5 showed that patients with diabetes had equal amounts of systolic and diastolic dysfunction. Patients with diabetes frequently have preserved left-ventricular function (a normal ejection fraction) but with a poorly compliant left ventricle that is …

PTU-114 Hepatology Specialist Nurse Led External Jugular Venepuncture; Is It Safe And Effective?

IntroductionDifficult venous access is a significant problem for a proportion of patients with chronic hepatitis C and a history of intravenous drug use. It can impede access to treatment and...

PMM.40 Peripartum cardiomyopathy (PPCM) – A rare presentation with abnormal liver function mimicking HELLP syndrome

ObjectivesTo report the rare case of a woman who was induced at term for deranged liver function, was later was recognised as secondary to cardiac dysfunction and a literature review...

Unusual site of formation of brachiocephalic vein along with multiple venous anomalies in neck and its clinical importance

AbstractNeck veins are important for various diagnostic, therapeutic and experimental procedures. So knowledge of their anatomical variation is also important. The author reports an unusual site of formation of brachiocephalic vein with multiple venous anomalies in the neck. A rare site of formation of the right brachiocephalic vein was found at the middle of neck under the right sternocleido mastoid muscle by union of right internal jugular and subclavian vein. Another observation was of facial, lingual and superior thyroid veins joined together and formed a common vein over the sternocleidomastoid muscle that drained into the external jugular vein. This unusual course of brachiocephalic vein and aberrant drainage of facial, lingual and superior thyroid veins may cause unusual bleeding during surgeries and invasive procedures. So clinicians should be aware of these variations of major neck veins to avoid complications.

Retromandibular Vein Diverticulum: Unique Imaging Findings with a Novel Therapeutic Strategy

Diverticula of the vascular system are rare. A diverticulum involving the retromandibular vein has not been described to date. We describe the imaging findings and a novel therapeutic strategy for the management of this rare diverticulum. A 25-year-old male presented with complaints of swelling behind the angle of mandible that enlarged on straining. On imaging, a retromandibular vein diverticulum was seen. The diverticulum was punctured percutaneously with the patient performing Valsalva maneuver and injected with sclerosant microfoam. There was no sclerosant reflux into the normal neck veins. At 6-month follow-up, the patient had complete resolution of his symptoms. We also have done a review of literature for patients with venous diverticula in the head and neck region treated by endovascular techniques.

Massive Pericardial Effusion and Cardiac Tamponade Due to Cholesterol Pericarditis in a Case of Subclinical Hypothyroidism: A Rare Event

![Figure][1] A 50-year-old woman presented with dyspnea, abdominal distension, and edema for 20 days. Clinical examination revealed hypotension, an engorged neck vein, and muffled heart sound with clear lung fields. Electrocardiogram demonstrated low voltage QRS complex. Chest x-ray revealed