case_images: PMC10825014_01
case_images: Ultrasound image of the neck at the C6-C7 segment of the patient. L, left; R, right; IJV, internal jugular vein; EJV, external jugular vein; ICA, internal carotid artery; VA, vertebral artery; LC, longus colli muscle; SA, anterior oblique muscle; SCM, sternocleidomastoid muscle; TP, transverse process.
case_images: fnins-17-1288484-g001.jpg
case_images: PMC10825014_01_fnins-17-1288484-g001.jpg
case_images: F1
case_images: C6-C7 level, while the right vertebral artery ran outside the longus colli muscle at the same level (Figure 1). Consequently, it was determined that a bilateral paracarotid approach would not be suitable for this patient. The simulated puncture distance for this approach in the present case was 2.59 cm (Supplementary Figure 1).
case_images: Position adjustment process. (A) The ultrasound image clearly displays the transverse process of C6, as well as its anterior and posterior lymph nodes, along with the anatomical relationship between the sternocleidomastoid muscle, internal jugular vein, and carotid artery in a supine position; (B) To maximize the leftward extension of the internal jugular vein, the patient's head was rotated 60  to the left or positioned with the head elevated 30  and feet lowered; (C, D) The patient was instructed to slightly open her mouth, relax the anterior neck muscles, and stay steady to allow for the planning of the puncture path using color Doppler and ultrasound guidance to avoid important structures. IJV, internal jugular vein; EJV, external jugular vein; ICA, internal carotid artery; VA, vertebral artery; LC, longus colli muscle; SA, scalenus anterior muscle; SCM, sternocleidomastoid muscle; TP, transverse process.
case_images: fnins-17-1288484-g002.jpg
case_images: PMC10825014_01_fnins-17-1288484-g002.jpg
case_images: F2
case_images: The ultrasound image clearly displayed the transverse process of C6, as well as its anterior and posterior lymph nodes, along with the anatomical relationship between the sternocleidomastoid muscle, internal jugular vein, and carotid artery (Figure 2A). Although not an issue in the presented case, in cases where the internal jugular vein remains filled to a significant extent, it may be beneficial to contemplate assuming a 30  head-up, feet-down posture, while also inclining the patient's head toward the opposite side to elongate the sternocleidomastoid muscle (Figure 2B). The patient was instructed to open her mouth slightly, relax the anterior neck muscles, and to stay steady to allow for the planning of the puncture path, which was done using color Doppler and ultrasound guidance, avoiding important structures, such as the vertebral artery, internal jugular vein, and cervical nerves (Figures 2C, D).
case_images: Ultrasonic probe adjustment method: The dashed yellow line represents the median line of the ultrasound probe and served as a guide for the puncture. IJV, internal jugular vein; ICA, internal carotid artery; LC, longus colli muscle; SCM, sternocleidomastoid muscle.
case_images: fnins-17-1288484-g003.jpg
case_images: PMC10825014_01_fnins-17-1288484-g003.jpg
case_images: F3
case_images: It is essential to record the requisite distance for the puncturing and subsequently implement the puncture on the exterior of the internal jugular vein while following the guidance delineated along the median line (Figure 3).
case_images: Differences between ultrasound-guided stellate ganglion blocks with three different access routes: Yellow dotted line: Stellate ganglion block with an out-of-plane approach adjacent to the internal jugular vein; White dotted line: Stellate ganglion block with an out-of-plane approach involving puncturing the internal jugular vein; Green dotted line: Lateral in-plane approach for stellate ganglion block. IJV, internal jugular vein; EJV, external jugular vein; ICA, internal carotid artery; VA, vertebral artery; LC, longus colli muscle; SA, scalenus anterior muscle; SCM, sternocleidomastoid muscle; TP, transverse process; VN, vagus nerve.
case_images: fnins-17-1288484-g004.jpg
case_images: PMC10825014_01_fnins-17-1288484-g004.jpg
case_images: F4
case_images: By using the out-of-plane approach, the needle was advanced along the puncture guide wire, and a saline test was performed during the procedure to verify the position of the needle tip (Figure 4).