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Logo of jnnpsycJournal of Neurology, Neurosurgery and PsychiatryVisit this articleSubmit a manuscriptReceive email alertsContact usBMJ
J Neurol Neurosurg Psychiatry. 2007 April; 78(4): 403–404.
PMCID: PMC2077784

Intracranial hypertension after unilateral neck dissection

A 32‐year‐old, otherwise healthy man with recurrent metastatic papillary thyroid carcinoma underwent total thyroidectomy with modified radical neck dissection on the right side that included removal of the internal jugular vein. On the second postoperative day, he had ipsilateral conjunctival chemosis. Three weeks later, he was referred for headache, pulse synchronous tinnitus and binocular horizontal diplopia. Examination showed bilateral chemosis (fig 11)) and papilloedema ((figsfigs 1 and 22)) with bilateral sixth cranial nerve palsies. Cranial magnetic resonance imaging was normal and post‐gadolinium contrast enhanced magnetic resonance venography1 showed a hypoplastic left transverse sinus without evidence of venous sinus thrombosis (fig 33).). Lumbar puncture showed normal cerebrospinal fluid contents, but an increased opening pressure of 460 mm of water. The patient started treatment with systemic acetazolamide and improved over the next 3 months. Of the 13 reported similar cases from the literature, 11 had right‐sided surgery.2,3,4,5 Of the two cases of left sided surgery, one had a left‐side dominant venous circulation and the other could not be determined.

figure jn101626.f1
Figure 1 (A,B) Slit lamp photograph showing bilateral conjunctival chemosis predominantly in the right eye. (C,D) Fundus photograph showing grade IV papilloedema in both eyes.
figure jn101626.f2
Figure 2 (A,B) Goldmann perimetry showing an enlarged blind spot with inferior nasal step in both eyes. (C,D) Optical coherence tomography showing thickened peripapillary nerve fibre layer thickness consistent with optic disc oedema.
figure jn101626.f3
Figure 3 Contrast‐enhanced magnetic resonance venogram showing absence of the right internal jugular vein, and numerous collateral vessels (CV). The left internal jugular vein (IJV) is normal. The right transverse sinus (TS) is dominant ...

On the basis of our case and our review of the literature, we propose that intracranial hypertension after unilateral neck dissection without venous sinus thrombosis may be due to hypoplasia or atresia of the contralateral cerebral venous sinus anatomy.2 We recommend post‐gadolinium contrast enhanced (eg, three‐dimensional auto‐triggered elliptical centric‐ordered (ATECO)) magnetic resonance venography in this setting. Head and neck surgeons and ophthalmologists should be aware that the cerebral venous drainage is usually dominant on the right side. We recommend postoperative cranial magnetic resonance with post‐gadolinium contrast enhanced (eg, ATECO) magnetic resonance venography when a patient becomes symptomatic with headache or diplopia or shows signs of orbital congestion.


Informed consent was obtained for publication of figure 1.

Competing interests: None.


1. Minghua G, Zhiyuan G, Zhun J. et al Modified functional neck dissection: a useful technique for oral cancers. Oral Oncol 2005. 41978–983.983 [PubMed]
2. Hunt M G, Lee A G, Kardon R H. et al Improvement in papilledema and visual loss after endovascular stent placement in dural sinus thrombosis. Neuroophthalmology 2001. 2685–92.92 [PubMed]
3. Lydiatt D D, Ogren F P, Lydiatt W M. et al Increased intracranial pressure as a complication of unilateral radical neck dissection in a patient with congenital absence of the transverse sinus. Head Neck 1991. 13359–362.362 [PubMed]
4. Doepp F, Schreiber S J, Benndorf G. et al Venous drainage patterns in a case of pseudotumor cerebri following unilateral radical neck dissection. Acta Otolaryngol 2003. 123994–997.997 [PubMed]
5. de Vries W A, Balm A J, Tiwari R M. Intracranial hypertension following neck dissection. J Laryngol Otol 1986. 1001427–1431.1431 [PubMed]

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