| Abstract|| |
The dural sinus thrombosis is an uncommon complication of a commonly done procedure of central venous catheterisation. We present a case of massive hemorrhagic venous infarct with gross cerebral edema due to dural sinus thrombosis along with right internal jugular vein thrombus. A 21-year-old male patient presented to the emergency department with fever and swelling of the right neck four days following discharge after his prior hospitalization two weeks ago for acute renal failure due to severe gastroenteritis, when he underwent hemodialysis through right internal jugular access. On presentation, he was conscious, with swelling on right side of the neck, which was diagnosed as right internal jugular vein occlusion. However, he rapidly deteriorated and developed signs of raised intracranial pressure despite being on treatment with heparin. He was diagnosed as having massive hemorrhagic cerebral venous infarct with gross cerebral edema complicated with shift of the ventricles to the left due to dural sinus thrombosis. Despite emergency decompressive craniotomy, he succumbed in the next two days due to coning. Asymptomatic catheter-related thrombosis is frequent in the intensive care units, but major complications like retrograde extension into dural sinus causing thrombosis is rare. A high index of suspicion is required to diagnose this major catastrophe for an early and meaningful intervention.
|How to cite this article:|
Binnani P, Bahadur M M, Dalal K. Dural sinus thrombosis - A rare manifestation of internal jugular venous occlusion. Saudi J Kidney Dis Transpl 2012;23:799-803
|How to cite this URL:|
Binnani P, Bahadur M M, Dalal K. Dural sinus thrombosis - A rare manifestation of internal jugular venous occlusion. Saudi J Kidney Dis Transpl [serial online] 2012 [cited 2020 Jan 21];23:799-803. Available from: http://www.sjkdt.org/text.asp?2012/23/4/799/98164
| Introduction|| |
Access of the central venous system has been long recognized for its associated complications of infection, thrombosis and occlusion. Although catheter-related central vein thrombosis is a well-described complication among patients on hemodialysis, cancer chemotheraphy and total parentral nutrition, its association with dural sinus thrombosis is rare. , Several conditions may predispose to dural sinus thrombosis. But, when it is accompanied by central venous thrombosis, catheter placement or stenosis of the subclavian or internal jugular veins are the most likely causes. , We report a case of dural sinus thrombosis with right internal jugular venous occlusion complicated with massive hemorrhagic venous infarct with gross cerebral edema that required intervention without success. The etiology, diagnosis and management of this uncommon complication of central venous cannulation is briefly reviewed and discussed in this Practitioner's section.
| Case Report|| |
A 21-year-old male was admitted with complaints of fever, dry cough and swelling of the right neck. In his prior hospitalization, he was admitted with history of acute renal failure following acute gastroenteritis. He required hemodialysis through a right internal jugular hemodialysis catheter and had received broad-spectrum antibiotics. His renal function gradually recovered. Hemodialysis catheter was removed on day 13 of hospitalization. He went home with serum creatinine of 3.6 mg%.
Four days later, he was readmitted with swelling on the right side of the neck, fever and generalized weakness. On examination, he was febrile and hemodynamically stable. He was conscious and alert and had no focal deficit. USG neck revealed distended right internal jugular vein with an echogenic lesion and no flow in the color Doppler study, suggesting complete thrombosis. He was treated with heparin infusion for his central venous occlusion and antibiotics to cover for possible central line-related infection with methicillin resistant staphylococcus aureus. Within four hours of hospitalization, he was found to be very restless. He was still oriented, but developed weakness of the left lower limb. Within the next hour, he developed generalized tonic-clonic convulsions and became unresponsive. He was immediately intubated and put on mechanical ventilator. His right pupil was fully dilated and fixed and the left pupil was normal sized and nonreactive. Corneal reflexes were sluggish bilaterally. His lower limbs were flaccid and areflexic. Plantars were extensor. CT scan of the brain was performed, which showed evidence of superior sagittal, transverse and sigmoid sinus thrombosis [Figure 1] and [Figure 2] and a huge hemorrhagic venous infarction in the right parieto-temporo-occipital lobes [Figure 3]. There was marked subfalcine shift of the ventricles to the left and gross cerebral edema. He was taken up for emergency craniotomy for cerebral decompression. The dura was extremely tense and blue. The brain rapidly bulged through it and then burst open as the swollen white mater tore through the cortex. The bleeding was controlled and the brain covered with sheets of gelfoam. Thrombectomy of right internal jugular vein was partially successful. The patient remained comatose for two days and then expired.
|Figure 2: CT scan showing incomplete visualization of superior sagittal sinus suggestive of superior sagittal sinus thrombosis.|
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|Figure 3: CT scan showing incomplete visualization of both transverse sinus thrombosis, suggestive of transverse sinus thrombosis.|
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| Discussion|| |
The incidence of catheter-related asymptomatic central venous thrombosis ranges from 10 to 40%, but it has been reported to be as high as 70% in some patient trials.  Venous thrombosis has been reported in as many as 21% of femoral vein catheterizations.  The internal jugular site has a lower occurrence rate, but the internal jugular site has a reported association with venous thrombosis approximately four-times greater than that of subclavian vein cannulation. 
The incidence of catheter-related central vein thrombosis varies with catheter composition, indication of catheterization (parenteral nutrition, hemodialysis, cancer chemotherapy, hemodynamic monitoring), fluid infused and diagnostic method for thrombus.  The clinical incidence of catheter-related central venous thrombosis is as low as 0-4%.  In these patients, the main risk factors are catheter thrombogenicity, catheter-related sepsis, lack of anticoagulation and cancer.  Three independently associated factors with catheter-related central venous thrombosis have been identified as age more than 65 years, the internal jugular route and the absence of therapeutic heparinization. 
Internal jugular venous thrombosis refers to an intraluminal thrombus occurring anywhere from the origin of the internal jugular vein in the cranium down to where it joins the sub-clavian vein to form the brachiocephalic vein. In earlier days, internal jugular venous occlusion was more common as a complication of acute oropharyngeal infection, but, now, central venous catheters are the most common underlying cause of internal jugular venous thrombosis.  While using a central venous access, the catheter itself acts as the nidus for clot formation despite being flushed with heparin. Additionally, the catheter itself may produce damage to the vessel wall and disrupt venous flow, further augmenting clot formation. ,
Major complications of catheter-related central venous thrombosis are suppurative thrombophlebitis, propagation of thrombus into superior vena cava, intracranial sinuses or intra-cranial veins and pulmonary embolism.  The reported incidence of pulmonary embolism ranges from 11 to 36% of the patient with catheter-related central venous occlusion, , while the incidence of dural sinus thrombosis is rare and therefore requires a high index of suspicion. ,,
Deterioration of conscious level in a patient with local signs of neck swelling with jugular vein thrombosis requires investigation into the possibility of dural sinus thrombosis as an extension of the internal jugular venous occlusion.  The clinical severity depends on the extent of thrombus, the vessels involved and the thrombus progression. Acute occlusion is usually not well tolerated. The development of seizures, focal neurological deficits, dysphagia, cranial nerve palsies, cerebellar incoordination and coma represents thrombosis of the deep cerebral veins with associated cerebral infarcts and edema. Magnetic resonance imaging is the method of choice for the diagnosis of dural sinus thrombosis.
In view of morbidity and mortality, early treatment with anticoagulation is preferred even with hemorrhagic venous infarct, , with surgical decompression when indicated. This treatment provides rapid reduction of the intra-dural pressures and restoration of adequate venous antegrade flow. The association of dural sinus thrombosis with catheter-associated central venous thrombosis is rare. It requires a high index of suspicion for the early diagnosis and treatment in view of the associated morbidity and mortality.
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Department of Nephrology, Jaslok Hospital and Research Centre, Mumbai - 400 026
[Figure 1], [Figure 2], [Figure 3]