O-167 - CASE REPORT: COMPLETE RESOLUTION OF CAUDA EQUINA SYNDROME AFTER THROMBOLYSIS AND VENOUS STENTING FOR EXTENSIVE ILIOCAVAL THROMBOSIS.

TOPIC:
Case Reports
AUTHORS:
Bakas J. (Erasmus University Medical Center ~ Rotterdam ~ Netherlands) , Bijdevaate D. (Erasmus University Medical Center ~ Rotterdam ~ Netherlands) , Lauw M. (Erasmus University Medical Center ~ Rotterdam ~ Netherlands) , Van Veelen - Vincent M. (Erasmus University Medical Center ~ Rotterdam ~ Netherlands) , Van Rijn M.J. (Erasmus University Medical Center ~ Rotterdam ~ Netherlands)
Introduction:
The cauda equine syndrome (CES) is a rare condition affecting less than 1 in 100,000 patients annually (1). It is challenging to diagnose CES because of its rare incidence, potentially subtle presentation and various underlying causes (2). Vascular causes, such as inferior vena cava (IVC) thrombosis, are uncommon but should be considered (3). Epidural vein engorgement was revealed by magnetic resonance imaging (MRI) in patients with deep vein thrombosis (DVT) or compression of the IVC, causing a radicular syndrome by spinal cord or nerve root compression (4). Timely recognition of DVT as a cause of CES can avoid irreversible neurological damage.
Methods:
We describe a 30-year-old male who presented with CES due to an extensive iliocaval DVT, successfully treated with thrombolysis and venous stents.
Results:
The patient's medical history reported a pyloromyotomy and orchidopexy. He presented with a partial CES. Computed tomography angiography (CTa) showed an extensive iliocaval DVT (figure 1a), and direct nerve root compression caused by venous congestion was revealed on MRI with decreased venous outflow of the nerve roots itself (figure 1b). Large amounts of clots were removed by thrombosuction from the IVC and both iliac veins. A venous stent was placed in the IVC because of a remaining mid-caval stenosis. Collaterals at the level of the renal veins indicated that this stenosis and the iliocaval DVT was likely to be chronic. Anticoagulation was initiated with unfractionated heparin, followed by treatment with low-molecular-weight heparin based on therapeutic anti-Xa levels, and eventually a vitamin K antagonist (INR range 2-3). Patent venous stents were visualized on CT-imaging after 6 months of follow-up (figure 2). Symptoms and signs of CES and DVT completely resolved with patent stents, and very mild post-thrombotic complaints (Villalta 2) until the last date of duplex ultrasound follow-up (1 year). Broad molecular, infectious, and hematological laboratory tests did not reveal any underlying disease for the thrombotic event, particularly no hereditary or acquired thrombophilia. We hypothesize that the mid-caval stenosis may be the most likely cause of DVT in this patient, leading to epidural vein engorgement and provoked CES in our patient.
Conclusion:
This is the first case report of CES caused by an extensive iliocaval DVT successfully treated with thrombolysis and venous stenting with good resolution of DVT and symptoms. Timely recognition of venous thrombosis as a cause of CES is essential.
References:
1. Hoeritzauer I, Wood M, Copley PC, Demetriades AK, Woodfield J. What is the incidence of cauda equina syndrome? A systematic review. J Neurosurg Spine. 2020:1-10. 2. Barraclough K. Cauda equina syndrome. BMJ. 2021;372:n32. 3. McNamee J, Flynn P, O'Leary S, Love M, Kelly B. Imaging in cauda equina syndrome--a pictorial review. Ulster Med J. 2013;82(2):100-8. 4. Paksoy Y, Gormus N. Epidural venous plexus enlargements presenting with radiculopathy and back pain in patients with inferior vena cava obstruction or occlusion. Spine (Phila Pa 1976). 2004;29(21):2419-24.
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