A Rare Cause of Internal Jugular Vein Thrombosis: Deep Tissue Massage

DISCUSSION

Thrombosis in the head and neck region is uncommon; the majority of cases occur in the lower extremities. Typically, internal jugular vein thrombosis associated with trauma arises from direct injury or catheter-related complications.² Jugular vein thrombosis has been reported in the absence of traditional risk factors, including a case linked to deep tissue massage that caused external jugular vein thrombosis and a case of cervical chiropractic manipulation that led to internal jugular vein thrombosis.^3,4 Another case described a presentation similar to ours in which a 35-year-old male with no thrombotic risk factors and a negative hypercoagulability workup developed internal jugular vein thrombosis following shiatsu massage.⁵ That patient waited a month after symptom onset to seek medical treatment and presented with neck swelling, while our patient sought medical treatment the day following the massage.

The cause of our patient's internal jugular vein thrombosis following neck massage can be analyzed through the Virchow triad, the factors that lead to an increased risk of thrombosis: blood stasis, endothelial injury, and a hypercoagulable state. Direct trauma to the internal jugular vein, such as from central venous catheters, can provoke local inflammation, reduce blood flow, and increase the risk of thrombus formation because of endothelial damage and cell adhesion.⁶ However, the specific mechanisms by which a neck massage could induce internal jugular vein thrombosis remain speculative. Theories suggest that massage could cause venous stasis directly or through subsequent inflammation, as noted by Pastori et al.² Dislocation of an existing clot is another possibility, but this explanation is unlikely in our patient because of the localized nature of the massage, the absence of identifiable thrombotic risk factors, and her negative hypercoagulability workup. Our patient also had no identifiable acquired risk factors such as obesity, sedentary lifestyle, or use of birth control that would increase her risk of a thrombus. Given that the patient had resolution of her thrombus and no concerning physical examination findings, further investigation into malignancy was not indicated.

This case details the importance of considering less common etiologies such as deep tissue massage in the differential diagnosis of internal jugular vein thrombosis. The case also highlights the need for increased clinical investigation and further research to determine the mechanisms by which manipulative neck therapies might elicit internal jugular vein thrombosis. This understanding is necessary for guiding treatment durations and preventing recurrent thrombotic events. Furthermore, patients should be cautious when having deep tissue massage performed and should likely avoid excessive neck manipulation.