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Pseudoaneurysm of the internal jugular vein after mumps: ultrasonographic evaluation
European Journal of Radiology Extra 46 (2003) 93 /96 http://intl.elsevierhealth.com/journals/ejrx
Pseudoaneurysm of the internal jugular vein after mumps: ultrasonographic evaluation Ahmet Sıg˘ırcı a,*, Sinasi Kuranel b, Ramazan Kutlu a, Alpay Alkan a, Tayfun Altınok a a
Department of Radiology, Turgut Ozal Medical Center, Ino¨nu¨ University, 44069 Malatya, Turkey b Department of Ear, Nose and Throat, State Hospital of Malatya, 44100 Malatya, Turkey Received 6 August 2002; received in revised form 7 October 2002; accepted 8 October 2002
Abstract We report a case of pseudoaneurysm following mumps infection in the left internal jugular vein with sonography and Doppler ultrasound findings. The diagnosis was confirmed during surgical exploration. To the best of our knowledge, this is the first case report of an internal jugular vein false aneurysm in the literature. # 2002 Elsevier Science Ireland Ltd. All rights reserved. Keywords: Aneurysm, false; Jugular veins; Ultrasonography, Doppler; Mumps
1. Introduction Venous false aneurysms are rarely seen [1 /4]. True venous aneurysms have been described more commonly [5]. We report a case of pseudoaneurysm following mumps infection in the left internal jugular vein with sonography and Doppler ultrasound findings, in which the diagnosis of the pseudoaneurysm and left internal jugular vein source was confirmed during the time of surgical exploration.
2. Case report A 7-year-old boy was referred to the department of radiology for Doppler ultrasound of a large, superficial mass in the left neck from another hospital. He was complaining of fever, general malaise and gradually increasing pain in the mass. He had a history of mumps and upper respiratory tract infection with severe cough 1 month ago. Approximately 1 week later, a slowly growing soft tissue mass appeared in the anterior part * Corresponding author. Tel.: /90-422-341-0660/5712; fax: /90422-341-0728 E-mail addresses: [email protected], [email protected] (A. Sıg˘ırcı).
of the left neck under the mandible with a reddened skin surface. He had no history of trauma, jugular vein cannulation or any heart disease. Physical examination revealed a superficial, soft, compressible, moderately painful mass under a hyperemic skin with a minimal palpable thrill in the anterior triangle of the left neck. The patient had high fever (39 8C) and the white blood cell count was elevated. Therefore, a mycotic aneurysm with arteriovenous fistula was considered clinically. Sonography of the mass (Fig. 1a) revealed a welllocalized, ovoid, 5 /3 cm large mass exhibiting variable echogenicity due to internal blood flow, anterior to the left common carotid and internal jugular vein. The mass was compressing the vascular structures. Color-flow Doppler ultrasound (Fig. 1b) showed a small diameter connection between the mass and the left internal jugular vein. The color changes along the swirling motion of blood within the mass were also detected. Duplex ultrasound of the patent vascular connection (Fig. 1c) revealed a turbulent and increased flow with a prominent systolic waveform. The left internal jugular vein showed no arterialized spectral flow pattern in the Duplex ultrasound. These findings suggested an aneurysm or pseudoaneurysm of the internal jugular vein. We planned to confirm the ultrasound findings with angiography, contrast enhanced computed tomography and magnetic resonance venography. These imaging methods were found invasive and expensive by the
1571-4675/03/$ - see front matter # 2002 Elsevier Science Ireland Ltd. All rights reserved. doi:10.1016/S1571-4675(03)00055-5
94
A. Sıg˘ırcı et al. / European Journal of Radiology Extra 46 (2003) 93 /96
Fig. 1. Seven-year-old boy with pseudoaneurysm of left internal jugular vein. (a) Sonogram of left neck area with a mass. Swirling motion (thin arrows) of mass material with different echogenities. Compression of carotid artery by mass (large arrows) (arrowhead, left internal jugular vein). (b) In color-Doppler ultrasound, the neck (arrowhead) between the mass and internal jugular vein could be seen. Minimal blurring image in the mass due to swirling motion (thin arrows) (large arrows, common carotid artery; IJV, internal jugular vein). (c) In Duplex ultrasound, spectral pattern in the neck of pseudoaneurysm shows turbulent flow and high systolic velocity (more than 1.5 m/s) (L CCA and large arrow, left common carotid artery; JV, jugular vein; thin arrows, turbulence or swirling motion).
A. Sıg˘ırcı et al. / European Journal of Radiology Extra 46 (2003) 93 /96
parents of the child. Therefore, Doppler ultrasound was repeated by another specialist who confirmed the aforementioned findings of the mass. Anticoagulation treatment was started and surgical repair planned until after stabilization of the child. At the time of surgical exploration, the diagnosis of a false aneurysm without arteriovenous fistula of the left internal jugular vein was made.
3. Discussion Venous pseudoaneurysms are rarely reported complications of various causes [1 /4]. Venous false aneurysms can occur more commonly in the arterialized vein in the patients on hemodialysis [6]. Aneurysms of internal jugular vein have been reported in the literature [7,8]. To the authors’ knowledge, this is the first reported case demonstrating ultrasound findings of a pseudoaneurysm of the left internal jugular vein that was also confirmed during surgical exploration. A pseudoaneurysm results from a tear or disruption of all layers of a vessel wall. A diagnosis of true pseudoaneurysm can theoretically only be made after resection, when histology shows that there is no vascular endothelium in the lining of the lesion [9]. It was appeared in histopathologic study after surgery that this lesion would not have a true vascular endothelial lining. Extravasated blood is contained by compressed extravascular tissue or a clot, which makes up the wall of the pseudoaneurysm. In veins, this usually does not occur because of the low pressure. In our case, the probable weakness of the vessel wall may be due to purulent adenitis after mumps. This may have lead to disruption and then the increased venous pressure due to the cough during the slow growth of the mass may have prevented the closure and thrombosis of the internal jugular vein defect with resultant pseudoaneurysm formation. Diagnosing pseudoaneurysms before they rupture and develop thrombosis with emboli is essential [10 /12]. It is probably fair to say that the risk of rupture of an arterial pseudoaneurysm is higher than a venous one, because of the high pressure in arteries. Ultrasound examination is non-invasive and a well-recognized method in the evaluation of vascular abnormalities. Hematomas exhibit variable echogenicity and internal complexity but never demonstrate internal blood flow. The demonstration of swirling motion of blood, a patent vascular connection with the injured vessel and ‘to-and-fro’ sign are important hallmarks in the diagnosis of a pseudoaneurysm [13]. In our case, swirling motion of blood was observed by sonography (Fig. 1a). Color changes due to swirling motion were detected weakly when compared with arterial pseudoaneurysm by color-flow Doppler ultrasound (Fig. 1b). This may be due to low pressure in
95
the venous pseudoaneurysm. In our case, Duplex ultrasound (Fig. 1c) showed an arterialized and turbulent flow with a prominent systolic waveform without reversed diastolic flow. Ferrer-Puchol et al. [4] revealed pulsed Doppler imaging of a pseudoaneurysm of femoral vein with arteriovenous fistula as turbulent and partially arterialized flow. Roizental et al. [3] described pulsed Doppler spectrum of pseudoaneurysm of common femoral vein as a prominent systolic waveform with reversed diastolic flow. It is clear from the aforementioned studies that the flow waveforms, peak systolic velocities and end diastolic velocities variable in the spectral pattern of pseudoaneurysms. Therefore, the other imaging methods were planned to confirm the findings of ultrasound in our case. Magnetic resonance angiography has the ability to demonstrate complicated three-dimensional anatomy in different planes [14]. This property makes the magnetic resonance angiography the ideal imaging technique in vascular lesions but it has drawbacks like longer examination time, higher cost, and inability to scan some patients with claustrophobia or unusual body habitus. Angiography and contrast enhanced computed tomography are invasive procedures. These imaging methods could not be performed in our case due to invasive potential and higher cost. Ultrasound examination repeated by another specialist confirmed our findings. Clinically, the differentiation of pseudoaneurysm from the carotid body tumor, glomus jugulare, hemangioma, lymphadenopathy, external laryngocele [7], parotid tumors may be difficult and important. Each mentioned pathology has different treatment options. Therefore, the exact diagnosis should be made either clinically or by imaging methods. The treatment of arterial pseudoaneurysms by ultrasound guided compression, thrombin injection and coil embolization [15] are known procedures. The coil embolization of an iatrogenic venous pseudoaneurysm in the antecubital fossa has recently been described as a treatment, although embolization theoretically has a higher risk of failure than surgery [16]. In our case, compression was not attempted because the nearby location of the pseudoaneurysm to carotid arteries. The patient underwent surgical exploration in which the diagnosis of an isolated pseudoaneurysm of the left internal jugular vein without any adherence to the surrounding structures was confirmed. This pseudoaneurysm was surgically excised with repair of the jugular vein. To the best of our knowledge, our case is the first reported instance of an internal jugular vein pseudoaneurysm with sonography and Doppler ultrasound findings.
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A. Sıg˘ırcı et al. / European Journal of Radiology Extra 46 (2003) 93 /96
References [1] Noon GP, Zamora JL, Pratt CM, Willingham I, Short HD. Popliteal vein pseudoaneurysm: a case report. Surgery 1984;96:942 /5. [2] Cameron SE. Venous pseudoaneurysm as a complication of shoulder arthroscopy. J Shoulder Elbow Surg 1996;5:404 /6. [3] Roizental M, Hartnell GG, Perry LJ, Kane RA. Pseudoaneurysm of the common femoral vein as a late complication of right heart catheterization. Cardiovasc Intervent Radiol 1994;17:301 /3. [4] Ferrer-Puchol MD, Esteban E, Gil J, Guijarro J. Sonographic diagnosis of a pseudoaneurysm in an intravenous drug abuser. J Clin Ultrasound 2000;28:104 /7. [5] Calligaro KD, Ahmed S, Dandora R, Dougherty MJ, Savarese RP, Doerr KJ, McAffee S, DeLaurentis DA. Venous aneurysms: surgical indications and review of the literature. Surgery 1995;117:1 /6. [6] Igidbashian VN, Mitchell DG, Middleton WD, Schwartz RA, Goldberg BB. Iatrogenic femoral arteriovenous fistula: diagnosis with color Doppler imaging. Radiology 1989;170:749 /52. [7] Mallik RC. A case of aneurysm of the internal jugular vein. J Laryngol Otol 1977;91:893 /5.
[8] Refson JS, Wolfe JH. An aneurysm of the internal jugular vein. Eur J Vasc Endovasc Surg 1996;11:371 /2. [9] Gardner D, Tweedle D. Pathology for surgeons in training, 2nd ed. London: Arnold, 1996. [10] DeLima LG, Wynands JE, Bourke ME, Walley VM. Catheterinduced pulmonary artery false aneurysm and rupture: case report and review. J Cardiothorac Vasc Anesth 1994;8:70 /2. [11] Elias M. Pulsating mass in the neck following attempted internal jugular vein catheterization. Anaesthesia 1999;54:914 /5. [12] Peces R, Navascues RA, Baltar J, Laures AS, Alvarez-Grande J. Pseudoaneurysm of the thyrocervical trunk complicating percutaneous internal jugular-vein catheterization for haemodialysis. Nephrol Dial Transplant 1998;13:1009 /11. [13] Coughlin BF, Paushter DM. Peripheral pseudoaneurysms: evaluation with duplex US. Radiology 1988;168:339 /42. [14] Finn JP, Zisk JH, Edelman RR, Wallner BK, Hartnell GG, Stokes KR, Longmaid HE. Central venous occlusion: MR angiography. Radiology 1993;187:245 /51. [15] Calton WC, Jr, Franklin DP, Elmore JR, Han DC. Ultrasoundguided thrombin injection is a safe and durable treatment for femoral pseudoaneurysms. Vasc Surg 2001;35:379 /83. [16] Chakraborty S, McGann G, Coen LD. Embolization of iatrogenic venous pseudoaneurysm. Br J Radiol 1999;72:311 /2.
Pseudoaneurysm of the internal jugular vein after mumps: ultrasonographic evaluation Ahmet Sıg˘ırcı a,*, Sinasi Kuranel b, Ramazan Kutlu a, Alpay Alkan a, Tayfun Altınok a a
Department of Radiology, Turgut Ozal Medical Center, Ino¨nu¨ University, 44069 Malatya, Turkey b Department of Ear, Nose and Throat, State Hospital of Malatya, 44100 Malatya, Turkey Received 6 August 2002; received in revised form 7 October 2002; accepted 8 October 2002
Abstract We report a case of pseudoaneurysm following mumps infection in the left internal jugular vein with sonography and Doppler ultrasound findings. The diagnosis was confirmed during surgical exploration. To the best of our knowledge, this is the first case report of an internal jugular vein false aneurysm in the literature. # 2002 Elsevier Science Ireland Ltd. All rights reserved. Keywords: Aneurysm, false; Jugular veins; Ultrasonography, Doppler; Mumps
1. Introduction Venous false aneurysms are rarely seen [1 /4]. True venous aneurysms have been described more commonly [5]. We report a case of pseudoaneurysm following mumps infection in the left internal jugular vein with sonography and Doppler ultrasound findings, in which the diagnosis of the pseudoaneurysm and left internal jugular vein source was confirmed during the time of surgical exploration.
2. Case report A 7-year-old boy was referred to the department of radiology for Doppler ultrasound of a large, superficial mass in the left neck from another hospital. He was complaining of fever, general malaise and gradually increasing pain in the mass. He had a history of mumps and upper respiratory tract infection with severe cough 1 month ago. Approximately 1 week later, a slowly growing soft tissue mass appeared in the anterior part * Corresponding author. Tel.: /90-422-341-0660/5712; fax: /90422-341-0728 E-mail addresses: [email protected], [email protected] (A. Sıg˘ırcı).
of the left neck under the mandible with a reddened skin surface. He had no history of trauma, jugular vein cannulation or any heart disease. Physical examination revealed a superficial, soft, compressible, moderately painful mass under a hyperemic skin with a minimal palpable thrill in the anterior triangle of the left neck. The patient had high fever (39 8C) and the white blood cell count was elevated. Therefore, a mycotic aneurysm with arteriovenous fistula was considered clinically. Sonography of the mass (Fig. 1a) revealed a welllocalized, ovoid, 5 /3 cm large mass exhibiting variable echogenicity due to internal blood flow, anterior to the left common carotid and internal jugular vein. The mass was compressing the vascular structures. Color-flow Doppler ultrasound (Fig. 1b) showed a small diameter connection between the mass and the left internal jugular vein. The color changes along the swirling motion of blood within the mass were also detected. Duplex ultrasound of the patent vascular connection (Fig. 1c) revealed a turbulent and increased flow with a prominent systolic waveform. The left internal jugular vein showed no arterialized spectral flow pattern in the Duplex ultrasound. These findings suggested an aneurysm or pseudoaneurysm of the internal jugular vein. We planned to confirm the ultrasound findings with angiography, contrast enhanced computed tomography and magnetic resonance venography. These imaging methods were found invasive and expensive by the
1571-4675/03/$ - see front matter # 2002 Elsevier Science Ireland Ltd. All rights reserved. doi:10.1016/S1571-4675(03)00055-5
94
A. Sıg˘ırcı et al. / European Journal of Radiology Extra 46 (2003) 93 /96
Fig. 1. Seven-year-old boy with pseudoaneurysm of left internal jugular vein. (a) Sonogram of left neck area with a mass. Swirling motion (thin arrows) of mass material with different echogenities. Compression of carotid artery by mass (large arrows) (arrowhead, left internal jugular vein). (b) In color-Doppler ultrasound, the neck (arrowhead) between the mass and internal jugular vein could be seen. Minimal blurring image in the mass due to swirling motion (thin arrows) (large arrows, common carotid artery; IJV, internal jugular vein). (c) In Duplex ultrasound, spectral pattern in the neck of pseudoaneurysm shows turbulent flow and high systolic velocity (more than 1.5 m/s) (L CCA and large arrow, left common carotid artery; JV, jugular vein; thin arrows, turbulence or swirling motion).
A. Sıg˘ırcı et al. / European Journal of Radiology Extra 46 (2003) 93 /96
parents of the child. Therefore, Doppler ultrasound was repeated by another specialist who confirmed the aforementioned findings of the mass. Anticoagulation treatment was started and surgical repair planned until after stabilization of the child. At the time of surgical exploration, the diagnosis of a false aneurysm without arteriovenous fistula of the left internal jugular vein was made.
3. Discussion Venous pseudoaneurysms are rarely reported complications of various causes [1 /4]. Venous false aneurysms can occur more commonly in the arterialized vein in the patients on hemodialysis [6]. Aneurysms of internal jugular vein have been reported in the literature [7,8]. To the authors’ knowledge, this is the first reported case demonstrating ultrasound findings of a pseudoaneurysm of the left internal jugular vein that was also confirmed during surgical exploration. A pseudoaneurysm results from a tear or disruption of all layers of a vessel wall. A diagnosis of true pseudoaneurysm can theoretically only be made after resection, when histology shows that there is no vascular endothelium in the lining of the lesion [9]. It was appeared in histopathologic study after surgery that this lesion would not have a true vascular endothelial lining. Extravasated blood is contained by compressed extravascular tissue or a clot, which makes up the wall of the pseudoaneurysm. In veins, this usually does not occur because of the low pressure. In our case, the probable weakness of the vessel wall may be due to purulent adenitis after mumps. This may have lead to disruption and then the increased venous pressure due to the cough during the slow growth of the mass may have prevented the closure and thrombosis of the internal jugular vein defect with resultant pseudoaneurysm formation. Diagnosing pseudoaneurysms before they rupture and develop thrombosis with emboli is essential [10 /12]. It is probably fair to say that the risk of rupture of an arterial pseudoaneurysm is higher than a venous one, because of the high pressure in arteries. Ultrasound examination is non-invasive and a well-recognized method in the evaluation of vascular abnormalities. Hematomas exhibit variable echogenicity and internal complexity but never demonstrate internal blood flow. The demonstration of swirling motion of blood, a patent vascular connection with the injured vessel and ‘to-and-fro’ sign are important hallmarks in the diagnosis of a pseudoaneurysm [13]. In our case, swirling motion of blood was observed by sonography (Fig. 1a). Color changes due to swirling motion were detected weakly when compared with arterial pseudoaneurysm by color-flow Doppler ultrasound (Fig. 1b). This may be due to low pressure in
95
the venous pseudoaneurysm. In our case, Duplex ultrasound (Fig. 1c) showed an arterialized and turbulent flow with a prominent systolic waveform without reversed diastolic flow. Ferrer-Puchol et al. [4] revealed pulsed Doppler imaging of a pseudoaneurysm of femoral vein with arteriovenous fistula as turbulent and partially arterialized flow. Roizental et al. [3] described pulsed Doppler spectrum of pseudoaneurysm of common femoral vein as a prominent systolic waveform with reversed diastolic flow. It is clear from the aforementioned studies that the flow waveforms, peak systolic velocities and end diastolic velocities variable in the spectral pattern of pseudoaneurysms. Therefore, the other imaging methods were planned to confirm the findings of ultrasound in our case. Magnetic resonance angiography has the ability to demonstrate complicated three-dimensional anatomy in different planes [14]. This property makes the magnetic resonance angiography the ideal imaging technique in vascular lesions but it has drawbacks like longer examination time, higher cost, and inability to scan some patients with claustrophobia or unusual body habitus. Angiography and contrast enhanced computed tomography are invasive procedures. These imaging methods could not be performed in our case due to invasive potential and higher cost. Ultrasound examination repeated by another specialist confirmed our findings. Clinically, the differentiation of pseudoaneurysm from the carotid body tumor, glomus jugulare, hemangioma, lymphadenopathy, external laryngocele [7], parotid tumors may be difficult and important. Each mentioned pathology has different treatment options. Therefore, the exact diagnosis should be made either clinically or by imaging methods. The treatment of arterial pseudoaneurysms by ultrasound guided compression, thrombin injection and coil embolization [15] are known procedures. The coil embolization of an iatrogenic venous pseudoaneurysm in the antecubital fossa has recently been described as a treatment, although embolization theoretically has a higher risk of failure than surgery [16]. In our case, compression was not attempted because the nearby location of the pseudoaneurysm to carotid arteries. The patient underwent surgical exploration in which the diagnosis of an isolated pseudoaneurysm of the left internal jugular vein without any adherence to the surrounding structures was confirmed. This pseudoaneurysm was surgically excised with repair of the jugular vein. To the best of our knowledge, our case is the first reported instance of an internal jugular vein pseudoaneurysm with sonography and Doppler ultrasound findings.
96
A. Sıg˘ırcı et al. / European Journal of Radiology Extra 46 (2003) 93 /96
References [1] Noon GP, Zamora JL, Pratt CM, Willingham I, Short HD. Popliteal vein pseudoaneurysm: a case report. Surgery 1984;96:942 /5. [2] Cameron SE. Venous pseudoaneurysm as a complication of shoulder arthroscopy. J Shoulder Elbow Surg 1996;5:404 /6. [3] Roizental M, Hartnell GG, Perry LJ, Kane RA. Pseudoaneurysm of the common femoral vein as a late complication of right heart catheterization. Cardiovasc Intervent Radiol 1994;17:301 /3. [4] Ferrer-Puchol MD, Esteban E, Gil J, Guijarro J. Sonographic diagnosis of a pseudoaneurysm in an intravenous drug abuser. J Clin Ultrasound 2000;28:104 /7. [5] Calligaro KD, Ahmed S, Dandora R, Dougherty MJ, Savarese RP, Doerr KJ, McAffee S, DeLaurentis DA. Venous aneurysms: surgical indications and review of the literature. Surgery 1995;117:1 /6. [6] Igidbashian VN, Mitchell DG, Middleton WD, Schwartz RA, Goldberg BB. Iatrogenic femoral arteriovenous fistula: diagnosis with color Doppler imaging. Radiology 1989;170:749 /52. [7] Mallik RC. A case of aneurysm of the internal jugular vein. J Laryngol Otol 1977;91:893 /5.
[8] Refson JS, Wolfe JH. An aneurysm of the internal jugular vein. Eur J Vasc Endovasc Surg 1996;11:371 /2. [9] Gardner D, Tweedle D. Pathology for surgeons in training, 2nd ed. London: Arnold, 1996. [10] DeLima LG, Wynands JE, Bourke ME, Walley VM. Catheterinduced pulmonary artery false aneurysm and rupture: case report and review. J Cardiothorac Vasc Anesth 1994;8:70 /2. [11] Elias M. Pulsating mass in the neck following attempted internal jugular vein catheterization. Anaesthesia 1999;54:914 /5. [12] Peces R, Navascues RA, Baltar J, Laures AS, Alvarez-Grande J. Pseudoaneurysm of the thyrocervical trunk complicating percutaneous internal jugular-vein catheterization for haemodialysis. Nephrol Dial Transplant 1998;13:1009 /11. [13] Coughlin BF, Paushter DM. Peripheral pseudoaneurysms: evaluation with duplex US. Radiology 1988;168:339 /42. [14] Finn JP, Zisk JH, Edelman RR, Wallner BK, Hartnell GG, Stokes KR, Longmaid HE. Central venous occlusion: MR angiography. Radiology 1993;187:245 /51. [15] Calton WC, Jr, Franklin DP, Elmore JR, Han DC. Ultrasoundguided thrombin injection is a safe and durable treatment for femoral pseudoaneurysms. Vasc Surg 2001;35:379 /83. [16] Chakraborty S, McGann G, Coen LD. Embolization of iatrogenic venous pseudoaneurysm. Br J Radiol 1999;72:311 /2.