septic internal jugular vein - sigmoid sinus thrombosis is a rare condition that complicates local and regional infectious inflammatory processes occurring in the head and neck .
these include deep neck infections , lemierre syndrome , and central venous catheterization ( cvc ) or cannulation17 ) .
this is a life - threatening condition and prompt management is essential to decrease the potential for thrombosis - related morbidity and mortality .
we report a case of internal jugular vein - sigmoid sinus thrombosis due to a misplaced central venous catheter .
a 52-year - old woman presented with a severe bursting headache , vomiting , and a drowsy mentality .
brain computed tomography ( ct ) scan revealed subarachnoid hemorrhage in the basal cistern with a small amount of hematoma at the left sylvian fissure ( fig .
we identified an aneurysmal rupture of the middle cerebral artery on the left side by cerebral catheter angiography ( fig .
postoperative chest x - ray was normal except for malposition of the central venous catheter in the right internal jugular vein ( fig .
ten days later , the patient developed a fever , elevated white blood cell count to 227000 , and elevated c - reactive protein to 33.6 .
the central venous catheter was removed , and antibiotics were administrated through a different intravenous route . despite these managements , the patient was stupor the next day .
brain ct scan revealed cerebral infarction with hemorrhagic transformation in the right temporal lobe , and ct angiography did not identify vasospasm ( fig .
retrospective analysis of the contrast - enhanced ct scan and ct angiography showed an " empty delta sign " and absence of venous flow within the right internal jugular vein - sigmoid sinus that was sufficient for diagnosis of sinus thrombosis ( fig .
results of central venous catheter tip and blood culture was reported staphylococcus epidermidis and methicillin - resistant staphylococcus aureus , respectively .
we could not start systemic heparinization due to hemorrhagic transformation of the cerebral infarction in the right temporal lobe .
we administrated mannitol and steroids to manage increased intracranial pressure ; however , the patient died from severe pneumonia due to septic emboli after one week ( fig . 2c ) .
indications for a cvc are the intravenous administration of drugs , parenteral nutrition , hemodialysis , and hemodynamic monitoring13 ) . at many institutions , cvc
is routinely inserted before undergoing major surgery or treating patients with critical illnesses or cancer .
the most frequently available anatomical sites for cvc are the subclavian and internal jugular veins .
these procedures carry a substantial risk of mechanical lesions , such as arterial puncture , pneumothorax , cardiac tamponade , nerve lesions , or thrombotic or septic complications13 ) .
malpositioning of the catheter tip may happen more often in the subclavian vein than the internal jugular vein .
the reported incidence of primary misplacement of the catheter tip after infraclavicular subclavian vein catheterization varies from 5% to 24% even when inserted by experienced clinicians7 ) .
inadvertent catheterization of the ipsilateral internal jugular vein is one of the most common misplacements , with a reported incidence of around 7%15 ) .
the positioning of catheter tips within the cardiac silhouette is associated with increased risk of cardiac tamponade6 ) .
also , positioning of the catheter tip in the subclavian vein is associated with a high risk of thrombus formation and vessel occlusion2 ) .
the risk of thrombosis may increase when hyperosmolar parenteral nutrition fluid is administered through a misplaced central venous catheter into a internal jugular vein3,15 ) .
moreover , malpositioned catheter tips can damage the endothelium and precipitate the formation of thrombi17 ) .
when a cvc causes thrombosis , the risk of catheter - related sepsis may increase . in patients with a cvc
, the risk of catheter - related infection was reported to range between 1% and 10%1 ) .
contamination of a thrombus from the skin puncture site may result in septic endophlebitis , and occasional blood - borne infections may also contaminate the thrombus .
embolic septic thrombi may involve the lungs and , less frequently , the joints , viscera , and brain17 ) .
subclavian or internal jugular vein thrombosis associated with indwelling catheters will propagate into other vessels , but extension into the intracranial sinuses and veins is rare .
three reports describe an association between cerebral venous sinus thrombosis and central venous hyperalimentation due to placement of the catheter tip in the internal jugular vein3,15,16 ) .
the authors warn of the potential for thrombosis due to retrograde infusion into the valveless internal jugular - dural sinus system but also suggest that the small caliber of the vein may predispose to thrombosis . in our case ,
we found the malpositioned catheter tip in the internal jugular vein on follow - up chest x - ray , but it was ignored .
all intravenous fluids ( e.g. , total parenteral nutrition , mannitol , antibiotics ) were administered through the misplaced catheter .
the patient 's condition worsened , leading to thrombosis of the internal jugular vein secondary to sigmoid sinus thrombosis . since the advent of antibiotics
fever , chills , otalgia , tenderness to percussion over the mastoid emissary vein , headache and vomiting are common but not pathognomonic features8,18 ) .
occasionally , neurologic symptoms are related to increased intracranial pressure or infarct and present as deteriorating mental status , lethargy , seizures , hemiplegia , and coma , and may lead to death .
rarely , remote septic conditions such as pneumonia are the presenting symptoms9 ) . because of the nonspecific signs and symptoms of disease and the masking effects of antibiotics , diagnosis is difficult .
the diagnosis of sigmoid sinus thrombosis can be confirmed by ct , magnetic resonance imaging , or angiography .
contrast - enhanced ct scans demonstrate multiple intraluminal filling defects and nonvisualization of the sinus18 ) .
in addition , low density lumen , sharply defined dense vessel wall , or distension of the thrombosed vein , such as the " empty delta sign " , are positive signs for sinus thrombosis19 ) .
vascular imaging with cerebral angiography is highly specific for the recognition of sinus thrombosis because it can detect the lack of blood flow in thrombosed cerebral veins and dural sinuses .
chest x - rays may also demonstrate septic embolic pleura - pulmonary complications , which are often bilateral , by revealing nodular infiltrates with pleural effusion17 ) .
retrospectively , we confirmed that contrast - enhanced brain ct scans revealed a low density lumen surrounding a sharply enhanced dense vessel wall at the sigmoid sinus on the right side .
also , the right internal jugular vein and sigmoid sinus were not visualized on ct angiography .
treatment consists of aggressive antimicrobial therapy , heparinization , anticoagulation , and decreasing intracranial pressure .
antibiotic selections is directed toward the causative pathogen cultured at the initial site of infection .
recent studies have shown heparinization to be safe and beneficial , despite the possibility of an increased risk of hemorrhage4,10,16 ) . currently , heparin is recommended as the initial drug of choice for cerebral venous sinus thrombosis followed by long - term anticoagulation with warfarin5,10,12 ) .
although these procedures allow for rapid clot removal and reduction of venous hypertension , hemorrhagic complications can occur , leading to be high morbidity and mortality14 ) .
occlusion of the cerebral veins due to thrombosis may induce localized brain edema and venous infarction resulting in elevated intracranial pressure .
finally , death frequently results from increased intracranial pressure caused by obstruction of venous and cerebrospinal outflow11 ) . in our case
culture results of the subclavian catheter tip and blood were confirmed as staphylococcus epidermidis and methicillin - resistant staphylococcus aureus , respectively , and we switched from broad - spectrum antibiotics to vancomycin .
unfortunately , we could not start heparinization due to concurrent cerebral hemorrhage of being transformed from cerebral infarction .
severe pneumonia due to septic emboli eventually developed in both lung fields , and the patient died .
diagnosis of internal jugular vein - sigmoid sinus thrombosis is challenging due to vague clinical features . therefore ,
if patients with malpositioned cvcs present with symptoms of fever , chills , headache , vomiting , increased intracranial pressure , mental deterioration , and focal neurologic deficits , intracranial sinus thrombosis should be considered .
even vague symptoms may need to be investigated radiologically to discover a thrombosis early , when it can be treated .
 septic internal jugular vein - sigmoid sinus thrombosis ( ijv - sst ) associated with a malpositioned central venous catheter is a rare condition . 
 it is potentially life - threatening and necessitates early diagnosis and rapid administration of appropriate medications . 
 unfortunately , it is difficult to diagnose due to vague clinical presentations . 
 several studies such as ct , mri , and cerebral angiography should be performed and carefully examined to help make the diagnosis . 
 we report a case of septic ijv - sst due to a malpositioned central venous catheter . 
INTRODUCTION
CASE REPORT
DISCUSSION
CONCLUSION