Acute IJ Thrombus

This week’s image is brought to us by Dr. Alex Moore.  It is a short axis view of the right internal jugular and carotid with evidence of acute IJ thrombus.  

The patient presented to the emergency department for pain in her neck at the site of a central line placement one week previously.  The image was obtained by standing at the head of the patient’s bed, placing the probe with the indicator towards the left shoulder as if one were placing an ultrasound guided central line. 

Gentle pressure was applied in an attempt to compress the IJ. 

With normal anatomy the carotid is located just medial to the IJ. With gentle compression of the probe the IJ should collapse fully. The carotid will not compress and its pulsations will become more prominent.  The lumens of both vessels should appear black without internal echoes. If color doppler is applied you should see evidence of flow in both the IJ and the carotid.  In this image the application of gentle pressure DID NOT collapse the IJ.  Note how the lumen of the IJ is filled with internal echoes representing clot.   Color flow is seen within the carotid lumen, but there is extremely diminished flow in the IJ. This is the classic appearance of an acute DVT.  

We can also apply this scanning technique when placing central lines. It is useful to scan through the entire IJ to look for compressibility/clot prior to prepping your site for central line placement. Many patients particularly those with malignancy, prior longstanding central access (ports, dialysis catheters), or pacemakers will develop chronic, occluding DVTs that may impede you abilty to thread the wire and place your line. If a patient tells you other doctors have had problems with central access in the past this can also be a tip off.  It can be a huge time saver to make this diagnosis prior to initiating the procedure.