Correspondence  |   June 2004
Patient Positioning and Ultrasound Guidance Are Important in Bilateral Cannulation of Internal Jugular Veins
Author Affiliations & Notes
  • Wolfram Schummer, M.D.
  • Claudia Schummer, M.D.
  • * Friedrich-Schiller University of Jena, Jena, Germany.
Article Information
Correspondence   |   June 2004
Patient Positioning and Ultrasound Guidance Are Important in Bilateral Cannulation of Internal Jugular Veins
Anesthesiology 6 2004, Vol.100, 1624-1625. doi:
Anesthesiology 6 2004, Vol.100, 1624-1625. doi:
To the Editor:—  We congratulate Stocchetti et al.  1 on their interesting case report and the favorable outcome of the patient. We agree with the authors that bilateral cannulation of internal jugular veins may worsen intracranial hypertension. Nevertheless, we wish to make some comments:
For internal jugular vein cannulation, their patient’s head and torso were placed in a flat position, and the head was even slightly rotated. All these procedures are known to increase intracranial pressure in patients with reduced intracranial compliance. 2 In the context of increased intracranial pressure, we wonder why the internal jugular vein route was preferred for the insertion of the 8-French introducer and Swan-Ganz catheter to the subclavian or external jugular vein route.
In our opinion, Doppler or B-mode ultrasound guidance should always be used in these patients. Recently, we were able to demonstrate the safe cannulation even of the internal jugular veins in patients with reduced intracranial compliance under Doppler guidance without the need for change in body position. 3 
Following the arguments of Stocchetti et al.  that the introducer itself was responsible for the obstructed cerebral venous drainage, a B-mode ultrasound image of the left internal jugular vein should have shown a small-sized vessel. With regard to the high thrombogenicity of large-bore catheters in small-sized veins, another access route would have been preferred. 4 In this context, we refer to a fatal incident of intracranial hypertension we encountered after tracheostomy. 5 During neck extension, the patient experienced brain herniation due to obstruction of the accessory brain drainage pathway (vertebral venous plexus) in the context of unrecognized bilateral internal jugular vein obstruction (left: thrombosis after central venous cannulation; right: hypoplastic vein).
Blood drains from the brain by two major routes: the internal jugular veins and the vertebral venous plexus. 6,7 Valdueza et al.  8 have shown that predominance of the jugular veins in cerebrovenous drainage is limited to the supine position. When outflow through the internal jugular veins is compromised, the vertebral system becomes the major channel for blood leaving the cranium. 6 
Various clinical implications, such as bilateral neck dissection, or metastatic spread of tumors, including the controversies about head positioning in increased intracranial pressure, underline the importance of a postural influence on cerebrovenous drainage. 8 
In patients at risk, such as patients with reduced intracranial compliance, central venous access procedures should be performed under ultrasound guidance. 3 
Stocchetti N, Longhi L, Valeriani V: Bilateral cannulation of internal jugular veins may worsen intracranial hypertension. Anesthesiology 2003; 99:1017–8
Mavrocordatos P, Bissonnette B, Ravussin P: Effects of neck position and head elevation on intracranial pressure in anaesthetized neurosurgical patients: Preliminary results. J Neurosurg Anesthesiol 2000; 12:10–4
Schummer W, Schummer C, Niesen WD, Gerstenberg H: Doppler-guided cannulation of internal jugular vein, subclavian vein and innominate (brachiocephalic) vein: A case-control comparison in patients with reduced and normal intracranial compliance. Intensive Care Med 2003; 29:1535–40
Chastre J, Cornud F, Bouchama A, Viau F, Benacerraf R, Gibert C: Thrombosis as a complication of pulmonary-artery catheterization via the internal jugular vein: Prospective evaluation by phlebography. N Engl J Med 1982; 306:278–81
Schummer W, Schummer C, Niesen WD: Unrecognized internal jugular vein obstruction: Cause of fatal intracranial hypertension after tracheostomy? J Neurosurg Anesthesiol 2002; 14:313–5
Andeweg J: Consequences of the anatomy of deep venous outflow from the brain. Neuroradiology 1999; 41:233–41
Epstein HM, Linde HW, Crampton AR, Ciric IS, Eckenhoff JE: The vertebral venous plexus as a major cerebral venous outflow tract. Anesthesiology 1970; 32:332–7
Valdueza JM, von Munster T, Hoffman O, Schreiber S, Einhaupl KM: Postural dependency of the cerebral venous outflow. Lancet 2000; 355:200–1