Internal Jugular Vein Thrombosis Workup
- Author: Dale K Mueller, MD; Chief Editor: Vincent Lopez Rowe, MD more...
Often, the cause of internal jugular (IJ) vein thrombosis is obvious (eg, an indwelling catheter). However, some cases call for a more in-depth investigation of the coagulation system or a more extensive search for the cause of a hypercoagulable state. Therefore, the use of laboratory studies must be individualized. Currently available assays detect only 10-20% of inherited hypercoagulable states.
Imaging studies that may be helpful include ultrasonography, computed tomography (CT) with contrast, magnetic resonance imaging (MRI), and nuclear medicine scanning.
The following deficiencies and syndromes can predispose to intravascular thrombosis:
Protein C or S deficiency
Heparin-induced thrombocytopenia and thrombosis syndrome caused by an antiheparin antibody
Lupus anticoagulant/antiphospholipid syndrome
Resistance to activated protein C (factor V Leiden)
Prothrombin G20210 polymorphism
Abnormal platelet aggregation
Elevated factor VIII, factor IX, factor XI, and antithrombin III
Often a family history or past episodes of arterial thrombosis are present.
Tests for these conditions are generally sent to a reference laboratory, requiring days to return. Warfarin therapy invalidates some of the results of these assays. They are not routinely recommended in all cases, but they should be ordered as clinically indicated.
When disseminated intravascular coagulation (DIC) is suspected on the basis of the clinical presentation, a DIC screen (ie, prothrombin time [PT], activated partial thromboplastin time [aPTT], fibrin split products, and fibrinogen) should be ordered.
Despite the significant interest in the use of a simple blood test to diagnose intravascular thrombosis, no single test currently suffices. Several published studies suggest that D-dimer results have high sensitivity and specificity for intravascular thrombosis. Caution is required in working with currently available commercial test kits. The vast majority of kits now in use in hospitals lack the diagnostic accuracy of the more sophisticated assays used in the small number of published studies.
In cases of suspected septic thrombophlebitis, sending blood cultures in an attempt to isolate the pathogenic organism is critical. Persistently positive blood culture findings are strongly suggestive of an intravascular infection, with the major differential being between a septic thrombophlebitis and endocarditis. Endocarditis can usually be identified by means of transthoracic or transesophageal echocardiography.
Ultrasonography is a safe, noninvasive, portable, and widely available test. Venous duplex ultrasonography is the first diagnostic test of choice for many with IJ vein thrombosis. Ultrasonographic findings include a dilated and incompressible vein, intraluminal clot (a late finding), and no response to the Valsalva maneuver (expected change in intraluminal volume secondary to enhanced venous return).
Ultrasonography provides very poor images beneath the clavicle and under the mandible. Doppler ultrasonography may be useful for detecting flow changes secondary to thrombus during the acute phase of clot formation.
Radiography and Computed Tomography
In the past, contrast venography was the criterion standard for confirming a diagnosis of IJ vein thrombosis. However, venography has a number of drawbacks, including exposure to contrast dye and potential dislodgment of clot, with subsequent pulmonary embolism (PE).
Contrast-enhanced CT may be useful for diagnosing suspected IJ vein thrombosis. CT findings include low-density intraluminal thrombus, a sharply defined bright vessel wall (because of contrast uptake by the vasa vasorum), soft-tissue swelling surrounding the IJ vein, and a distended IJ vein proximal to the thrombus.
MRI provides greater soft tissue contrast and sensitivity to blood flow rates than CT does, and it has the additional advantage of not requiring exposure to intravenous contrast or radiation. However, the examination is usually performed in a distant hospital location and thus is difficult and inconvenient in critically ill patients.
Nuclear medicine tests such as gallium-67 studies have unacceptably high false-positive rates, especially in patients with active malignancies. Study times often are long, and the testing must be performed in the nuclear medicine area; these are distinct disadvantages for critically ill patients.
An IJ vein clot associated with an indwelling catheter, whether located in the IJ vein or the subclavian vein, mandates culture of the catheter (after removal) to rule out infection.
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