Daily Persistent Headache with Nutcracker Physiology and Spinal Epidural Venous Congestion: Treatment with Lumbar Vein Embolization

Introduction, Objectives, and/or Purpose: Nutcracker phenomenon (NCP) can cause various congestion syndromes secondary to the superior mesenteric artery (SMA) compressing the left renal vein (LRV) resulting in venous reflux. It has recently been suggested that reflux into the lumbar vein (LV) and epidural venous plexus (EVP) may cause headaches in some patients with NCP. This report illustrates an example of a patient with refractory headaches and imaging findings suggestive of NCP that underwent treatment with percutaneous LV embolization.

Methods: The patient is a 60-year-old female with daily persistent headaches for five years that failed numerous headache preventative medications. Time-resolved magnetic resonance angiography demonstrated NCP with reflux and congestion of the LV and EVP. Catheter-based venography confirmed these findings and the patient was treated with percutaneous embolization of the LV using multiple microcoils. At the completion of the procedure there was complete resolution of spinal EVP congestion. A written informed consent was obtatined from the patient and this case report is compliant with HIPAA regulations.

Results: This is the first reported case in which LV embolization is used to prevent EVP reflux and treat daily headaches due to NCP. The patient’s headache resolved the next day and she has been headache-free for 3 months. These findings support prior data suggesting that NCP can cause retrograde LV flow, EVP congestion, and elevated cerebrospinal fluid pressures leading to daily persistent headaches.

Conclusion(s): Percutaneous embolization of the LV may be a minimally invasive treatment option for refractory headaches in patients with NCP, retrograde LV flow, and EVP congestion.