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

For a patient with cancer of the tongue who underwent modified neck dissection and now presents with vomiting, drowsiness, confusion, headache, and left internal jugular vein thrombosis, immediate anticoagulation therapy is the recommended first-line management. 1

Immediate Management

The patient's presentation with neurological symptoms (drowsiness, confusion, headache) along with vomiting in the setting of confirmed IJV thrombosis requires urgent intervention to prevent potential cerebral venous thrombosis complications. Among the options provided:

• D. Anticoagulants is the correct first-line management
• This should be initiated immediately with low-molecular-weight heparin (LMWH) as the preferred agent for cancer-associated thrombosis 1

Rationale for Anticoagulation

1. Cancer-associated thrombosis management:

   • The American Society of Hematology specifically recommends LMWH as the preferred agent for cancer-associated thrombosis 1
   • LMWH has demonstrated better efficacy than vitamin K antagonists in preventing recurrent venous thromboembolism (VTE) in cancer patients 1

2. Dosing considerations:

   • Recommended LMWH regimens include:
     • Dalteparin 200 U/kg once daily
     • Enoxaparin 1 mg/kg twice daily
     • Tinzaparin 175 U/kg once daily 1

3. Duration of therapy:

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

Why Not the Other Options?

• A. Neurosurgery consultation: While neurological symptoms are concerning, direct anticoagulation is the first step before specialty consultation
• B. CT: Imaging may be helpful as a follow-up study, but the diagnosis of IJV thrombosis is already confirmed by duplex scan
• C. Re-exploration and Thrombectomy: Surgical intervention is not first-line for cancer-associated thrombosis and carries additional risks in a recently operated patient

Special Considerations

• Monitor platelet counts carefully:

  • For platelet counts 50-100 × 10^9/L: full-dose anticoagulation can be maintained
  • For platelet counts 25-50 × 10^9/L: reduced-dose LMWH should be considered
  • For platelet counts <25 × 10^9/L: platelet transfusion may be required 1

• Cancer patients have a higher risk of recurrent thrombosis despite adequate anticoagulation 1, 2

• The neurological symptoms (headache, vomiting, drowsiness, confusion) require close monitoring as they may indicate progression to cerebral venous thrombosis 1

Follow-up Management

After initiating anticoagulation:

1. Monitor neurological status closely
2. Consider CT venography or MR venography to evaluate for extension into cerebral venous sinuses if symptoms persist or worsen
3. Continue LMWH for at least 6 months, as cancer patients have higher recurrence rates 2, 3

Pitfalls to Avoid

• Do not delay anticoagulation while waiting for additional imaging or consultations
• Do not use oral anticoagulants as first-line therapy in cancer patients; LMWH has been shown to be superior 1, 3
• Do not discontinue anticoagulation prematurely; cancer patients require extended therapy (minimum 6 months) 1, 2