What is the management for a patient with 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 Cancer Patient with Neurological Symptoms

Anticoagulation therapy should be initiated immediately for this patient with cancer-associated internal jugular vein thrombosis presenting with neurological symptoms.

Clinical Assessment and Diagnosis

The patient presents with:

• Cancer of the tongue (post modified neck dissection)
• Left internal jugular vein (IJV) thrombosis confirmed by duplex scan
• Neurological symptoms: headache, vomiting, drowsiness, confusion

These symptoms strongly suggest cerebral venous compromise secondary to IJV thrombosis, which requires urgent intervention to prevent further neurological deterioration.

Management Algorithm

Step 1: Immediate Management

• Start therapeutic anticoagulation immediately with low-molecular-weight heparin (LMWH) 1, 2
  • Recommended regimens: Dalteparin 200 U/kg once daily, Enoxaparin 1 mg/kg twice daily, or Tinzaparin 175 U/kg once daily 2
  • Unfractionated heparin can be used if LMWH is contraindicated 1

Step 2: Neuroimaging

• Obtain CT scan of the brain to assess for:
  • Cerebral edema
  • Extension of thrombosis into intracranial sinuses
  • Venous infarction or hemorrhage

Step 3: Further Management Based on Imaging Results

• If CT shows intracranial extension without hemorrhage:

  • Continue therapeutic anticoagulation
  • Consider neurosurgery consultation for monitoring

• If CT shows intracranial extension with hemorrhage:

  • Individualize anticoagulation approach
  • Definite neurosurgical consultation

• If CT is normal:

  • Continue therapeutic anticoagulation
  • Monitor neurological status closely

Step 4: Long-term Management

• Continue LMWH for at least 3-6 months 1
• Consider extended anticoagulation if cancer remains active 1

Rationale for Choosing Anticoagulation

1. Evidence supports anticoagulation as first-line therapy:

   • The American Society of Hematology and ISTH guidelines recommend immediate anticoagulation for cancer-associated thrombosis 1, 2
   • Anticoagulant therapy is associated with a 70% reduction in mortality rate in cancer-associated thrombosis 1

2. Neurological symptoms require urgent intervention:

   • Symptoms of headache, vomiting, drowsiness, and confusion suggest possible extension into cerebral venous sinuses 3
   • Prompt anticoagulation can prevent further thrombosis propagation and potentially fatal complications 4

3. Thrombectomy considerations:

   • Surgical thrombectomy is generally reserved for cases that fail medical management or have contraindications to anticoagulation 4
   • The risks of surgical intervention in this case outweigh the benefits as first-line therapy

4. Safety in patients with intracranial malignancies:

   • ASCO 2013 VTE Guidelines recommend treating patients with intracranial malignancies with standard anticoagulation 1
   • Small retrospective studies indicate anticoagulation can be safely used in patients with intracranial involvement, with rates of symptomatic intracranial hemorrhage between 0% and 7% 1

Important Considerations and Monitoring

• Platelet count monitoring:

  • If platelets 50-100 × 10^9/L: maintain full-dose anticoagulation
  • If platelets 25-50 × 10^9/L: consider reduced-dose LMWH
  • If platelets <25 × 10^9/L: platelet transfusion may be required 1, 2

• Neurological monitoring:

  • Regular assessment of mental status
  • Monitor for worsening headache, seizures, or focal neurological deficits

• Potential complications to watch for:

  • Intracranial hemorrhage
  • Extension of thrombosis
  • Pulmonary embolism

Conclusion

Based on the clinical presentation and available evidence, anticoagulation therapy (option D) is the most appropriate initial management for this patient with cancer-associated internal jugular vein thrombosis presenting with neurological symptoms. CT imaging should be obtained to guide further management, and neurosurgical consultation may be warranted depending on imaging findings and clinical course.