What is the management for a patient with a history of cancer of the tongue, who underwent modified neck dissection (MND) levels 1 on the right and 2 on the left, and now presents with vomiting, drowsiness, confusion, headache, and duplex scan showing thrombosis of the left Internal Jugular Vein (IJV)?

Management of Internal Jugular Vein Thrombosis in a Post-Neck Dissection Cancer Patient

Anticoagulation therapy is the first-line treatment for this patient with cancer-associated thrombosis presenting with neurological symptoms and confirmed left internal jugular vein thrombosis.

Clinical Assessment

This patient presents with a concerning clinical picture:

• History of tongue cancer with bilateral neck dissection
• Acute neurological symptoms (drowsiness, confusion)
• Headache and vomiting
• Duplex scan confirming left internal jugular vein (IJV) thrombosis

These symptoms strongly suggest venous outflow obstruction affecting cerebral circulation, which requires immediate intervention.

Treatment Algorithm

First-line Management:

1. Initiate anticoagulation therapy immediately

   • Low-molecular-weight heparin (LMWH) is the preferred agent for cancer-associated thrombosis 1
   • Recommended regimens:
     • Dalteparin 200 U/kg once daily
     • Enoxaparin 1 mg/kg twice daily
     • Tinzaparin 175 U/kg once daily

2. Neuroimaging evaluation

   • CT brain should be performed urgently to:
     • Rule out intracranial hemorrhage before continuing anticoagulation
     • Assess for cerebral edema or venous infarction
     • Evaluate extension of thrombosis into intracranial sinuses

3. Supportive care

   • Elevate head of bed to 30°
   • Manage symptoms (antiemetics for vomiting)
   • Monitor neurological status closely

Special Considerations:

If thrombocytopenia is present:

• For platelet counts 50-100 × 10^9/L: Full-dose anticoagulation can be maintained 1
• For platelet counts 25-50 × 10^9/L: Consider reduced-dose LMWH 1
• For platelet counts <25 × 10^9/L: Platelet transfusion may be required to safely administer anticoagulation 1

Long-term management:

• Continue LMWH for at least 6 months 1
• Extended anticoagulation may be necessary if cancer remains active 1

Rationale for Choosing Anticoagulation

1. Evidence-based approach: Multiple guidelines recommend LMWH as first-line therapy for cancer-associated thrombosis 1

2. Superior efficacy: LMWH has demonstrated better efficacy than vitamin K antagonists in preventing recurrent VTE in cancer patients 1

3. Safety profile: LMWH has a predictable dose-response and doesn't require frequent monitoring 1

4. Neurological symptoms: The patient's presentation with headache, vomiting, drowsiness and confusion indicates potential progression toward cerebral venous thrombosis, requiring urgent intervention 1

Why Not Other Options?

• Re-exploration and thrombectomy (Option C): Surgical intervention carries significant risks in this setting and is not first-line therapy for venous thrombosis. Guidelines do not recommend surgical thrombectomy as initial management 1

• Neurosurgery consultation alone (Option A): While neurosurgical input may be valuable, it should not delay initiation of anticoagulation, which is the definitive treatment

• CT alone (Option B): While imaging is important to evaluate for complications, it should not delay treatment initiation. CT should be performed concurrently with anticoagulation initiation

Potential Pitfalls and Caveats

• Bleeding risk: Cancer patients have higher bleeding risk with anticoagulation. Monitor closely for signs of bleeding, especially in surgical sites from recent neck dissection

• Heparin-induced thrombocytopenia: Monitor platelet counts regularly when initiating heparin products

• Medication interactions: Some chemotherapeutic agents may interact with anticoagulants; dose adjustments may be necessary

• Renal function: Adjust LMWH dose in patients with severe renal impairment (CrCl <30 mL/min)

• Recurrence risk: Cancer patients have higher risk of recurrent thrombosis despite adequate anticoagulation 1

This patient requires urgent anticoagulation with LMWH, along with appropriate neuroimaging to evaluate for complications of venous thrombosis. The management should focus on preventing further thrombotic complications while monitoring closely for bleeding risks.