Cerebral Hemisphere Hypoperfusion with Ipsilateral Internal Jugular Vein and Upper Extremity Deep Vein Thrombosis in Lung Carcinoma on 18F-Fluorodeoxyglucose Positron Emission Tomography/Contrast-enhanced Computed Tomography.

Sir,

We present the case of a 55-year-old woman with the history of antitubercular treatment for pulmonary tuberculosis having gradually worsening breathlessness (New York Heart Association Grade II) of 3-month duration, cough and fever, progressive functional impairment in right half of the body, and memory loss for 15 days. The routine hematological and biochemical examinations were within normal limits. Contrast-enhanced computed tomography (CECT) chest showed a nodule in the right lung upper lobe with patchy consolidation in the bilateral lung parenchyma. Image-guided biopsy from the lung lesion demonstrated adenocarcinoma. 18F-fluorodeoxyglucose positron emission tomography (18F-FDG-PET) done for staging revealed abnormal tracer uptake in the right thoracic region in maximum intensity projection image [Figure 1a]. The transaxial CECT and fused images [Figure 1b–e] showed intensely tracer avid nodular lesion with patchy consolidation in the right lung upper lobe, mediastinal lymph node, and nodular lesion in the lateral limb of the left adrenal gland. In addition, coronal, sagittal, and transaxial CECT and corresponding fused images [Figure 2a–f] revealed filling defect with low-grade FDG uptake (maximum standardized uptake value [SUVmax] 1.1) in brachiocephalic, left internal jugular, left subclavian and left axillary veins (arrowhead) in venous phase, suggestive of thrombosis. The low-grade FDG uptake in the thrombus was suggestive of a bland thrombus. Brain PET images were acquired in same sitting and reconstructed with the help of available Cortex ID software in view of memory loss and presence of internal jugular vein (IJV) thrombosis and upper extremity deep venous thrombosis (UEDVT). Sagittal brain PET images revealed decreased metabolic activity in the left cerebral parenchyma compared to the right side [Figure 2g and h]. Duplex ultrasound of arm and neck region confirmed the presence of IJV thrombosis and UEDVT. The patient was put on anticoagulation therapy. She expired due to respiratory failure before initiation of chemotherapy.

Figure 1

18F-fluorodeoxyglucose positron emission tomography/contrast-enhanced computed tomography maximum intensity projection image (a), transaxial contrast-enhanced computed tomography and fused images showing intensely tracer avid nodular lesion with patchy consolidation in the right lung upper lobe, mediastinal lymph node ([b and c] arrows), and nodular lesion in the lateral limb of left adrenal gland ([d and e] arrow)

Figure 2

Coronal, sagittal, and transaxial contrast-enhanced computed tomography and fused images (a-f) showing filling defect with low-grade fluorodeoxyglucose uptake (maximum standardized uptake value 1.1) in brachiocephalic, left internal jugular, left subclavian, and left axillary veins (arrowhead) in venous phase, suggestive of thrombosis. Sagittal brain positron emission tomography images revealing decreased metabolic activity in the left cerebral parenchyma compared to the right side (g and h)

IJV thrombosis is mostly seen in patients with malignancy (lung cancer or lymphoma/leukemia), central venous catheters, and ovarian hyperstimulation syndrome.[123] Concurrent involvement of subclavian/axillary/brachial veins along with IJV thrombosis is seen in around 70%–75% of patients.[2] The presence of IJV thrombosis and UEDVT is a significant risk indicator for malignancy and half of the patients may show concomitant diagnosis of cancer and DVT.[1] The patients with malignancy have shown an 18-fold increased risk of UEDVT in comparison to those without malignancy.[4] IJV thrombosis and UEDVT should be kept as a possibility in elderly aged females with a known malignancy, painless swelling of affected body parts, and nonspecific pain and paresthesia in upper extremities. Duplex ultrasound examination is the first diagnostic investigation with high sensitivity and specificity.[3] CECT and magnetic resonance imaging help in the diagnosis of IJV thrombosis, UEDVT, and possible concomitant pathologies such as unsuspected malignancy. 18F-FDG-PET/CECT in the index case showed its utility in identifying the IJV thrombosis, UEDVT, their underlying pathology, stage of the disease, and decreased metabolic activity in the ipsilateral cerebral hemisphere. The low-grade FDG avidity of the thrombus also helped in its characterization as a bland thrombus. As reported by Sharma et al., the cutoff SUVmax of 3.63 can be used to differentiate between bland and tumor thrombi with a sensitivity and specificity of 72% and 90%, respectively.[5] Tumor pulmonary embolism and postthrombotic syndromes are the main complications of IJV thrombosis and UEDVT.[4] The pulmonary embolism might have led to respiratory failure in our case. This is the first case report where 18F-FDG-PET/CT has shown lung malignancy and probable involvement of adrenal gland associated with IJV thrombosis, UEDVT, and ipsilateral cerebral hemisphere hypoperfusion.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given her consent for her images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

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Conflicts of interest

There are no conflicts of interest.