1991, The British Journal of Radiology, 64, 867-868
Case of the month A pain in the neck! By R. Rajah, FRCS, FRCR, A. Boothroyd, FRCR and W. R. Lees, FRCR Department of Radiology, The Middlesex Hospital, Mortimer Street, London W1N 8AA, UK {Received April 1990)
A 36-year-old female presented with a 24 h history of constant severe pain in the left side of her neck. On clinical examination there was marked tenderness and swelling within the left anterior triangle of the neck. She had documented polycystic ovarian disease and her two previous pregnancies were induced by Clomiphene and an LHRH pump, respectively. 2 months prior to this presentation she had received 10 000 u of human chorionic gonadotrophin (HCG) and her ovaries were monitored regularly. 3 weeks later she developed abdominal distension, nausea, weight gain, pleural effusion, low blood pressure and a tachycardia. A frontal chest radiograph was taken (Fig. 1). At this stage a clinical diagnosis was made and treatment commenced. 3 weeks later she presented with neck pain and an ultrasound examination was performed (Fig. 2a & b) using 5 MHz linear probe.
What abnormalities are demonstrated on the chest radiograph and ultrasound? What is your diagnosis?
LEFT
> -4
^
.
Figure 1. A frontal chest radiograph.
Address for correspondence: R. Rajah, Department of Radiology, The Middlesex Hospital, Mortimer Street, London WIN 8AA, UK. Vol. 64, No. 765
(b) Figure 2. (a) and (b) Show ultrasound examination of the neck.
867
Case of the month
The chest radiograph revealed bilateral pleural effusions which were compatible with the hyperstimulation syndrome. Diagnosis of a pulmonary embolism was also made, but in view of the strong clinical evidence and early pregnancy an isotope ventilation/perfusion scan was not performed. The patient was heparinized for 7 days after which anticoagulation was discontinued. The ultrasound examination revealed a markedly distended left internal jugular vein. The lumen was completely occluded by echogenic material. No Doppler signals were obtained distal to this mass. The other structures in the neck and the right internal jugular vein were normal. The appearance of the left internal jugular vein was consistent with thrombosis. The appearances are those of a thrombosis of the left internal jugular vein. These thrombotic episodes are presumed to be caused by hypercoagulability secondary to ovarian hyperstimulation and pregnancy. Discussion
Thrombosis of the internal jugular vein is relatively uncommon but is most frequently associated with central venous catheterization (Krepsi et al, 1981; McNeill, 1981). The incidence is gradually rising with the increase in the use of catheters for intravenous feeding, venous pressure measurement, chemotherapy and rapid fluid administration. Spontaneous thrombosis is extremely rare but occasional cases (Witte & Lameris, 1986) have been reported. In these cases factors such as reduced blood flow (e.g. chronic heart failure) or hypercoagulability (e.g. oral contraceptives) may play a role. In this patient the hypercoagulability was associated with severe ovarian hyperstimulation, i.e. massive ovarian enlargement, ascites and pleural effusion (Painvain et al, 1987), secondary to her treatment for infertility. In the absence of recent venous catheterization the diagnosis is often not considered (Albertyn & Alcock, 1986) and a high degree of clinical suspicion is required in the presence of non-specific clinical findings. Other less frequent causes included contiguous head and neck infection (Yau & Norante, 1980) and intravenous drug abuse (Merhar et al, 1981). The diagnosis can also be made using phlebography
(Chastre et al, 1982), scintigraphy (De Navdo & De Navdo, 1977), computed tomography (Albertyn & Alcock, 1986) and magnetic resonance (Braun et al, 1985). The advantage of ultrasound is that it provides a non-invasive, accurate method of establishing the diagnosis and may exclude other causes of neck swelling. Doppler studies are valuable in demonstrating reduced or absent flow and are particularly helpful if there is a very recent thrombosis, since fresh clot has identical acoustic properties to liquid blood. References ALBERTYN, L. E. & ALCOCK, M. K., 1986. Diagnosis of internal
jugular vein thrombosis. Radiology, 162, 505-508. BRAUN, I. F., HOFFMAN, J. C , MALKO, J. A., PETTIGREW, R. I.,
DANIELS,
W. & DAVIS,
P. C ,
1985. Jugular
venous
thrombosis: MR imaging. Radiology, 157, 357-360. CHASTRE, J., CORNUD, F., BOUCHAMA, A., VIAU, F., BENACERRAF, R. & GIBERT, C , 1982. Thrombosis as a
complication of pulmonary artery catheterization via internal jugular vein: Prospective evaluation by phlebography. New England Journal of Medicine, 306, 278-281. DE
NAVDO, S. J. & D E NAVDO, G. L., 1977. Iodine 123.
Fibrinogen Scintigraphy. Seminars in Nuclear Medicine, 7, 245-252. KREPSI,
Y.
P.,
KOMISAR,
A.
&
LUCENTE,
F.
E., 1981.
Complications of internal jugular vein catheterization. Archives of Otolaryngology, 107, 310-312. MCNEILL, R., 1981. Internal jugular vein thrombosis. Head Neck Surgery, 3, 247. »• MERHAR, G. L., COLLEY, D. P., CLARK, R. A. & HERWIG, S. R.,
1981. Computed tomographic demonstration of cervical abscess and jugular vein thrombosis. A complication of intravenous drug abuse in the neck. Archives of Otolaryngology, 107, 313-315. PAINVAIN, E., BARLESE, M. G., MASTROJANNI, F., BOLZANO GAGLIONE, R., DRAGONE, L., FERRAROTT, M. & TARAMANNI,
C, 1987. Ultrasound evaluation of the ovarian hyperstimulation syndrome. Acta Europaea Fertilitatis, 18, 39-43. WITTE, R. DE B. & LAMERIS, J. S., 1986. Real-time ultrasound
diagnosis of internal jugular vein thrombosis. Journal of Clinical Ultrasound, 14, 712-717. YAU, P. C. & NORANTE, J. D., 1980. Thrombophlebitis of the
internal jugular vein secondary to pharyngitis. Archives of Otolaryngology, 106, 507-508.
Keywords: Jugular vein thrombosis, Ultrasound
868
The British Journal of Radiology, September 1991
Case of the month A pain in the neck! By R. Rajah, FRCS, FRCR, A. Boothroyd, FRCR and W. R. Lees, FRCR Department of Radiology, The Middlesex Hospital, Mortimer Street, London W1N 8AA, UK {Received April 1990)
A 36-year-old female presented with a 24 h history of constant severe pain in the left side of her neck. On clinical examination there was marked tenderness and swelling within the left anterior triangle of the neck. She had documented polycystic ovarian disease and her two previous pregnancies were induced by Clomiphene and an LHRH pump, respectively. 2 months prior to this presentation she had received 10 000 u of human chorionic gonadotrophin (HCG) and her ovaries were monitored regularly. 3 weeks later she developed abdominal distension, nausea, weight gain, pleural effusion, low blood pressure and a tachycardia. A frontal chest radiograph was taken (Fig. 1). At this stage a clinical diagnosis was made and treatment commenced. 3 weeks later she presented with neck pain and an ultrasound examination was performed (Fig. 2a & b) using 5 MHz linear probe.
What abnormalities are demonstrated on the chest radiograph and ultrasound? What is your diagnosis?
LEFT
> -4
^
.
Figure 1. A frontal chest radiograph.
Address for correspondence: R. Rajah, Department of Radiology, The Middlesex Hospital, Mortimer Street, London WIN 8AA, UK. Vol. 64, No. 765
(b) Figure 2. (a) and (b) Show ultrasound examination of the neck.
867
Case of the month
The chest radiograph revealed bilateral pleural effusions which were compatible with the hyperstimulation syndrome. Diagnosis of a pulmonary embolism was also made, but in view of the strong clinical evidence and early pregnancy an isotope ventilation/perfusion scan was not performed. The patient was heparinized for 7 days after which anticoagulation was discontinued. The ultrasound examination revealed a markedly distended left internal jugular vein. The lumen was completely occluded by echogenic material. No Doppler signals were obtained distal to this mass. The other structures in the neck and the right internal jugular vein were normal. The appearance of the left internal jugular vein was consistent with thrombosis. The appearances are those of a thrombosis of the left internal jugular vein. These thrombotic episodes are presumed to be caused by hypercoagulability secondary to ovarian hyperstimulation and pregnancy. Discussion
Thrombosis of the internal jugular vein is relatively uncommon but is most frequently associated with central venous catheterization (Krepsi et al, 1981; McNeill, 1981). The incidence is gradually rising with the increase in the use of catheters for intravenous feeding, venous pressure measurement, chemotherapy and rapid fluid administration. Spontaneous thrombosis is extremely rare but occasional cases (Witte & Lameris, 1986) have been reported. In these cases factors such as reduced blood flow (e.g. chronic heart failure) or hypercoagulability (e.g. oral contraceptives) may play a role. In this patient the hypercoagulability was associated with severe ovarian hyperstimulation, i.e. massive ovarian enlargement, ascites and pleural effusion (Painvain et al, 1987), secondary to her treatment for infertility. In the absence of recent venous catheterization the diagnosis is often not considered (Albertyn & Alcock, 1986) and a high degree of clinical suspicion is required in the presence of non-specific clinical findings. Other less frequent causes included contiguous head and neck infection (Yau & Norante, 1980) and intravenous drug abuse (Merhar et al, 1981). The diagnosis can also be made using phlebography
(Chastre et al, 1982), scintigraphy (De Navdo & De Navdo, 1977), computed tomography (Albertyn & Alcock, 1986) and magnetic resonance (Braun et al, 1985). The advantage of ultrasound is that it provides a non-invasive, accurate method of establishing the diagnosis and may exclude other causes of neck swelling. Doppler studies are valuable in demonstrating reduced or absent flow and are particularly helpful if there is a very recent thrombosis, since fresh clot has identical acoustic properties to liquid blood. References ALBERTYN, L. E. & ALCOCK, M. K., 1986. Diagnosis of internal
jugular vein thrombosis. Radiology, 162, 505-508. BRAUN, I. F., HOFFMAN, J. C , MALKO, J. A., PETTIGREW, R. I.,
DANIELS,
W. & DAVIS,
P. C ,
1985. Jugular
venous
thrombosis: MR imaging. Radiology, 157, 357-360. CHASTRE, J., CORNUD, F., BOUCHAMA, A., VIAU, F., BENACERRAF, R. & GIBERT, C , 1982. Thrombosis as a
complication of pulmonary artery catheterization via internal jugular vein: Prospective evaluation by phlebography. New England Journal of Medicine, 306, 278-281. DE
NAVDO, S. J. & D E NAVDO, G. L., 1977. Iodine 123.
Fibrinogen Scintigraphy. Seminars in Nuclear Medicine, 7, 245-252. KREPSI,
Y.
P.,
KOMISAR,
A.
&
LUCENTE,
F.
E., 1981.
Complications of internal jugular vein catheterization. Archives of Otolaryngology, 107, 310-312. MCNEILL, R., 1981. Internal jugular vein thrombosis. Head Neck Surgery, 3, 247. »• MERHAR, G. L., COLLEY, D. P., CLARK, R. A. & HERWIG, S. R.,
1981. Computed tomographic demonstration of cervical abscess and jugular vein thrombosis. A complication of intravenous drug abuse in the neck. Archives of Otolaryngology, 107, 313-315. PAINVAIN, E., BARLESE, M. G., MASTROJANNI, F., BOLZANO GAGLIONE, R., DRAGONE, L., FERRAROTT, M. & TARAMANNI,
C, 1987. Ultrasound evaluation of the ovarian hyperstimulation syndrome. Acta Europaea Fertilitatis, 18, 39-43. WITTE, R. DE B. & LAMERIS, J. S., 1986. Real-time ultrasound
diagnosis of internal jugular vein thrombosis. Journal of Clinical Ultrasound, 14, 712-717. YAU, P. C. & NORANTE, J. D., 1980. Thrombophlebitis of the
internal jugular vein secondary to pharyngitis. Archives of Otolaryngology, 106, 507-508.
Keywords: Jugular vein thrombosis, Ultrasound
868
The British Journal of Radiology, September 1991
