487: Unusual Presentation of Jugular Venous & Dural Venous Thrombosis after Glossopharyngeal Nerve Block

Topic: Clinical Science
Subtopic: Pain category (ICD-11), Chronic neuropathic pain, Developing methodology/technology, Genetics and Epigenetics, Treatment/management

Background and Aims: Internal jugular vein (IJV) thrombosis is an underdiagnosed, condition, associated with suppurative thrombophlebitis, propagation of thrombus into intracranial sinuses and pulmonary embolism. Clinical presentation is often subtle and easy to miss due to varied presentation. Predisposing factors are infection, intrinsic abnormalities of coagulation, intravascular stasis, prolonged IJV catheterization. Symptomatic anterograde and retrograde extension of IJV thrombosis is rare. A research subject developed symptoms of venous stroke due to brainstem infarcts after Ultrasound Guided peristyloid Glossopharyngeal Nerve Block (GPNB).This was a rare presentation of preexisting, undiagnosed, IJV Thrombosis and Dural Sinus Thrombosis

Methods: 36 year female, presented with frequent nasal infections &multiple right sided GPN blocks in ENT outdoor. Ultrasound guided GPNB with depot steroid was planned. After informed consent & visualizing major vessels with Sonosite M turbo, 1 ml lidocaine was administered by peristyloid technique. She had pain relief but complained of dizziness, drowsiness & unconsciousness. BP was 74/46 mm Hg, HR 140/minute, 80% SpO2, tachypnoea (44 Respiratory rate). She was Intubated with ETT 7.5 mm and shifted to ICU. D-dimers, homocysteine, factor V Leiden were deranged. Diagnosis of IJV thrombosis with pulmonary embolism was made. Patient was discharged after 2 months.

Results: Tracheostomy was done in ICU. MRI venogram revealed right IJV thrombosis with narrowing of right transverse sinus. Pulmonary angiography revealed hypodense filling defects in pulmonary artery branches. Antibiotics, bronchodilators, steroids & LMWH were started. Anticoagulant therapy was continued for 6 months. GCS improved with good motor power at 3rd month but gait abnormality, nystagmus persisted. Counselling & olanzapine were given for ICU psychosis.

Repeated pressure by ultrasound transducer on thrombosed IJV compromised retrograde circulation, causing infarcts in cerebellum, pons and midbrain due to interconnected venous drainage into circle of willis. Anterograde migration of thromboembolism, explained pulmonary symptoms of tachypnea, desaturation & frothy secretions.

Conclusions: Contributing factors were nasal infection, factor V leiden mutation, hyperhomocystenemia, intimal damage by repeated blocks. Preexisting undiagnosed IJV thrombosis, in this subject, highlights, the need to, rule it out prior to neck blocks, considering patient's history .
Genetic mutation (factor V leiden) is not a routine investigation to rule out hypercoagulable states. Hence, Doppler, D dimers, homocysteine levels are recommended, prior to percutaneous neck blocks. If these investigations raise doubt of hypercoagulability, then MRI venogram is recommended.
A high degree of suspicion of dural sinus thrombosis should, also, be kept in mind if patient has the features suggestive of IJV thrombosis.

References: 1. G Saposnik, F Barinagarrementeria, RD Brown et al “Diagnosis and management of cerebral venous thrombosis: a statement for healthcare professionals from the American Heart Association/American Stroke Association,” Stroke, 2011; vol. 42, no. 4, pp. 1158–1192
2. Binnani P, Bahadur MM, Dalal K. Dural sinus thrombosis – rare manifestation of internal jugular venous occlusion: Case report. Saudi J Kidney Dis Transpl 2012;23(4):799-8032.
3. Bilateral Jugular Vein and Sigmoid Sinus Thrombosis Related to an Inherited Coagulopathy: An Unusual Presentation. Case Reports in Vascular Medicine; Hindawi Publishing Corporation; Volume 2014, Article ID 873402, 3 pages http://dx.doi.org/10.1155/2014/873402

Presenting Author: ANJU GHAI
Submitting Author: Anju Ghai

Senior Author: ANJU GHAI

IASP 2026 Global Year theme of Neuropathic Pain: Yes

• SARTHAK WADHERA: MBBS, MD MEDICINE, DM CLINICAL HEMATOLOGY - POSTGRADUATE INSTITUTE OF MEDICAL EDUCATION & RESEARCH, CHANDIGARH, PUNJAB
• AARUSHI SAHNI: MBBS, MD TRANSFUSION MEDICINE - POSTGRADUATE INSTITUTE OF MEDICAL EDUCATION AND RESEARCH, CHANDIGARH, UNJAB , INDIA
• RAMAN WADHERA: MBBS, MS ENT - Pt BD Sharma,POSTGRADUATE INSTITUTE OF MEDICAL SCIENCES, ROHTAK, HARYANA, INDIA