Unrecognized internal jugular vein obstruction: cause of fatal intracranial hypertension after tracheostomy?

We report an unusual case of fatal intracranial hypertension following tracheostomy due to the obstruction of the internal jugular veins (left side: thrombosis after central venous cannulation, right side: hypoplastic vein) and their collaterals. Principal cerebral outflow through the internal jugular veins can be substituted by the internal and external vertebral vein plexus because blood drains from the brain by two major routes: the internal jugular veins and the vertebral venous plexus. We suggest transcranial color-coded duplex sonography as a simple bedside method to detect patients with significant reduction of venous drainage who are at risk of developing massive cerebral venous congestion as a result of reduced intracranial elastance.