Internal Jugular Vein Thrombosis Workup

  • Author: Dale K Mueller, MD; Chief Editor: Vincent Lopez Rowe, MD   more...
 
Updated: Aug 2, 2011
 

Laboratory Studies

  • Often, the cause of the internal jugular (IJ) thrombosis is obvious (eg, indwelling catheter). However, some cases require 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.
  • Protein C, protein S, heparin-induced thrombocytopenia and thrombosis syndrome caused by an antiheparin antibody, lupus anticoagulant/antiphospholipid syndrome, resistance to activated protein C (factor V Leiden), hyperhomocysteinemia, prothrombin G20210 polymorphism, defective fibrinolysis, dysfibrinogenemia, lipoprotein, abnormal platelet aggregation, elevated factor VIII, factor IX, factor XI, and antithrombin III are as follows:
    • Deficiencies of the coagulation cascade or these syndromes predispose the patient to spontaneous intravascular thrombosis. However, often a family history and/or past episodes of arterial thrombosis are present.
    • These tests are generally sent to a reference laboratory, requiring days to return. Coumadin 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.
  • Order a disseminated intravascular coagulation (DIC) screen (ie, prothrombin time [PT], activated partial thromboplastin time [aPTT], fibrin split products, fibrinogen) when DIC is suspected on the basis of clinical presentation.
  • D-dimer is as follows:
    • 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.
    • Use caution when working with currently available commercial test kits. The vast majority of kits now in use in hospitals do not have the diagnostic accuracy of the more sophisticated assays used in the small number of published studies.
  • Blood cultures are as follows:
    • 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 on transthoracic or transesophageal echocardiography.
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Imaging Studies

  • Contrast venography
    • In the past, the criterion standard for confirming a diagnosis was contrast venography.
    • Venography has a number of drawbacks, including exposure to contrast dye and potential dislodgement of clot, with subsequent pulmonary embolism.
  • Ultrasonography
    • Ultrasonography is a safe, noninvasive, portable, and widely available test that is the test of choice for many with IJ 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.
  • Contrast-enhanced CT scanning
    • CT scanning with intravenous contrast is considered by some to be the study of choice for suspected IJ thrombosis.
    • CT scan 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
    • MRI provides greater soft tissue contrast and sensitivity to blood flow rates when compared to CT scanning.
    • It does not require exposure to intravenous contrast or radiation. The examination is usually performed in a distant hospital location, making it difficult and inconvenient in critically ill patients.
  • Nuclear medicine scanning
    • 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, both of which are distinct disadvantages for critically ill patients.
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Other Tests

  • Catheter tip and intradermal culture: IJ clot associated with an indwelling catheter, whether located in the IJ or subclavian vein, mandates culture of the catheter (once removed) to rule out infection.
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Contributor Information and Disclosures
Author

Dale K Mueller, MD  Clinical Associate Professor of Surgery, Section Chief, Department of Surgery, University of Illinois College of Medicine; Co-Medical Director, Thoracic Center of Excellence, Vice-Chair, Department of Cardiovascular Medicine and Surgery, OSF St Francis Medical Center; Director, Adult ECMO, Cardiovascular and Thoracic Surgeon, HeartCare Midwest, SC

Dale K Mueller, MD is a member of the following medical societies: American College of Chest Physicians, American College of Surgeons, American Medical Association, American Medical Writers Association, Chicago Medical Society, Illinois State Medical Society, and Society of Thoracic Surgeons

Disclosure: Nothing to disclose.

Coauthor(s)

Michael J Dacey, MD  Consulting Staff, Department of Internal Medicine, Division of Critical Care, Kent County Hospital

Disclosure: Nothing to disclose.

Specialty Editor Board

Richard M Stillman†, MD, FACS  Honorary Medical Staff, Northwest Medical Center; Former Chief of Staff and Medical Director, Wound Healing Center, Department of Surgery, Northwest Medical Center

Richard M Stillman†, MD, FACS is a member of the following medical societies: American College of Angiology, American College of Surgeons, Association for Academic Surgery, and Society of University Surgeons

Disclosure: Nothing to disclose.

Francisco Talavera, PharmD, PhD  Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: Medscape Salary Employment

Vincent Lopez Rowe, MD  Associate Professor of Surgery, Department of Surgery, Division of Vascular Surgery, University of Southern California Medical Center

Vincent Lopez Rowe, MD is a member of the following medical societies: American College of Surgeons, American Heart Association, Pacific Coast Surgical Association, Peripheral Vascular Surgery Society, Society for Clinical Vascular Surgery, Society for Vascular Surgery, and Western Vascular Surgical Society

Disclosure: Nothing to disclose.

Paolo Zamboni, MD  Professor of Surgery, Chief of Day Surgery Unit, Chair of Vascular Diseases Center, University of Ferrara, Italy

Paolo Zamboni, MD is a member of the following medical societies: American Venous Forum and New York Academy of Sciences

Disclosure: Nothing to disclose.

Chief Editor

Vincent Lopez Rowe, MD  Associate Professor of Surgery, Department of Surgery, Division of Vascular Surgery, University of Southern California Medical Center

Vincent Lopez Rowe, MD is a member of the following medical societies: American College of Surgeons, American Heart Association, Pacific Coast Surgical Association, Peripheral Vascular Surgery Society, Society for Clinical Vascular Surgery, Society for Vascular Surgery, and Western Vascular Surgical Society

Disclosure: Nothing to disclose.

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