Saccular Aneurysm of Internal Jugular Vein in a Young Patient

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To the Editor: A venous aneurysm is defined as an isolated zone of venous dilatation that communicates with a main venous structure by a single channel.1 Unrelated to either age or gender, it can affect any vein but due to low pressure in the vena cava system, aneurysms of cervical veins are rare. Saccular aneurysms of the internal jugular vein in young ages are extremely rare.2 Internal jugular venous aneurysms usually present as a painless neck swelling that is a common symptom in various diseases of children. Therefore, it may pose a diagnostic dilemma. In this report, we presented a young patient with saccular internal jugular venous aneurysm.
A 4-year-old female presented with a 9-month history of a painless swelling at right neck region. On physical examination, a soft, painless mass starting from right submandibular region and extending toward right supraclavicular region, 6 × 4 cm in diameter was observed. An ultrasonography revealed a cystic mass that is suspected to be a branchial cleft cyst. A magnetic resonance imaging of the neck was performed which revealed a macrolobulated cystic mass starting from inferior of right parotid gland extending toward supraclavicular region through posterior of sternocleidomastoid muscle, 7 × 5 × 5 cm in diameter. The mass was hyperintens in T2-weighted images and iso-hyperintens in T1-weighted images (Fig. 1). An operation for excision of the mass was planned. During the operation it was observed that the mass was bluish-gray in color. Careful dissection of the mass revealed a connection between the mass and internal jugular vein. The mass was diagnosed as saccular aneurysm of internal jugular vein. In association with cardiovascular surgery, the mass was fully excised. The histopathological evaluation confirmed the diagnosis of saccular aneurysm. The postoperative period was uneventful.
Saccular aneurysm of internal jugular vein is extremely rare with only a few reports in English literature.2 Because of the presence of all 3 layers of a normal vein, they are also called true aneurysms.3 They may be congenital, traumatic, or acquired but the main etiology is still unknown. Studies about the pathogenesis of the lesion concluded a significant decrease in the number of muscle cells and elastic fibers in the wall of affected region which causes thinning of elastic and muscular layers.4,5
The main symptom of an aneurysm of jugular vein is a compressible, painless swelling at lateral neck region that increases in size with straining, crying, sneezing, or Valsava maneuver.1 As neck masses during childhood are not uncommon, it is important to establish a correct diagnosis. Radiologic examinations are important in diagnosis of the disease. Ultrasonography can assist in making the correct diagnosis.3 Computerized tomography and gadolinium enhanced magnetic resonance imaging techniques are other useful methods.5 The differential diagnosis includes most of lateral cystic lesions such as cystic higroma, thyroglossal duct cysts, dermoid cysts, branchial cleft cysts, or laryngocele.1,3
The treatment of saccular aneurysms of jugular vein is controversial because of the lower number of patients. The possible complications of a venous aneurysm include thromboembolic events, rupture, venous obstruction, and compression of adjacent tissues.6 First 2 of these complications are not reported in saccular aneurysms of jugular vein in the literature. Because of this, the first treatment option is observation.1,7 The surgical treatment may be performed when the aneurysm is symptomatic, enlarging, or disfiguring.1,3,8 Cosmetic problems, the fear of patient for carrying a tumor and undefined masses, are other reasons for surgery.
Surgical treatment of a saccular aneurysm is excision of the aneurismal segment. Simple clipping, lateral venorraphy, plication with mattress sutures, replacement with autologous venous graft are other surgical techniques.1 In our patient, excision of the aneurysm was performed.
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