Isolated phrenic nerve injury after apparently atraumatic puncture of the internal jugular vein

Abstract

Vascular lesions due to subclavian and internal jugular vein puncture may result in hematomas, which are usually clinically evident. While mostly benign, some of these hematomas can cause compression of the surrounding structures. When the hematoma is obvious, straightforward correlation can be made between the symptoms, for instance nerve compression, and the clinical signs. We present a case where we missed the diagnosis of phrenic nerve paralysis, which occurred after an unsuccessful, but apparently atraumatic attempt to puncture the internal jugular vein, prior to cardiac surgery. At the time the diagnosis was made (8 days post-op), the radiographic appearance of the neck was normal, and further investigation (i.e., CT-scan) had become pointless. A retrospective study of serial chest X-rays disclosed a space occupying lesion in the right lateral neck that displaced the nasogastric tube. This abnormality could only be seen on the first film and disappeared on the following. Since phrenic nerve paralysis is extremely rare in our institution, even after cardiac surgery, and as there was no clinical evidence of hematoma, our attention was not been drawn to the only definite sign that could have led to an early diagnosis.

Phrenic nerve palsy: a rare complication of indwelling subclavian vein catheter

“…In other instances the patient may be asymptomatic and the condition detected on chest roentgenogram [6]. Phrenic nerve paralysis is usually reversible in cases resulting from compression caused by hematoma [6,13] and infiltration of local anesthetic agent [7]. In contrast, direct injury to the phrenic nerve may cause irreversible paralysis [11].…”

Internal jugular central venous catheterization: a focus on the procedure

“…Neck hematoma is a common complication site-specific to the IJ CVC but easy to be discovered and controlled. Several neurologic complications are reported, as phrenic nerve damage, iatrogenic Horner syndrome, brachial plexus injury, and inadvertent CVC into the spinal canal thecal space (17)(18)(19). Valve incompetence may occur, of uncertain clinical importance (20).…”

Central venous catheterization—An anatomical review of a clinical skill, Part 2: Internal jugular vein via the supraclavicular approach

“…Although mostly benign, some of these hematomas may cause compression of the surrounding structures, i.e. the phrenic nerve (Depierraz et al, 1989).…”