SUPERIOR VENA CAVA SYNDROME CAUSING RECURRENT INTRACRANIAL HEMORRHAGE BY VENOUS CONGESTION (P1.293)

Objective: Report a case of Superior Vena Cava Syndrome (SVCS) causing cerebral venous infarcts and hemorrhage likely from venous congestion; and review literature on intracranial hemorrhage (ICH) in SVCS.

Background: SVCS causes increased venous pressure which can cause intracerebral manifestations including headaches, papilledema and rarely, cerebral edema. The literature on SVCS causing increased intracranial pressure (ICP) resulting in ICH is sparse.

Design/Methods: Retrospective chart review.

Results: 85 year old gentleman known to have atrial fibrillation on Apixaban with a pacemaker presented with dyspnea, headache and malignant hypertension. CT head (CTH) demonstrated ICH in the superior right parietal lobe with surrounding vasogenic edema, without any vascular malformations. CTA chest showed pulmonary embolus and incidental goiter with mild tracheal compression. Three months later, he presented with new left arm weakness, dysarthria and headache. Though normotensive, CTH showed a new ipsilateral ICH with surrounding vasogenic edema. He developed abrupt respiratory failure with marked head/neck swelling and purplish discoloration. Repeat CT chest demonstrated marked tracheal compression and vascular compromise from known goiter necessitating urgent thyroidectomy for SVCS.

Abnormal upper limb venous collaterals were noted on both CTAs of the chest, with bilateral subclavian vein occlusion by the goiter, leading to a SVCS with Pemberton Sign. The ICHs were more consistent with a venous infarction etiology given significant vasogenic edema, making venous congestion from SVCS a plausible etiology. Animal models have shown that SVC occlusion can cause elevated ICP and hemorrhagic infarcts secondary to venous congestion. Rare cases of ICH have been described in SVCS, but not conclusively linked to venous congestion due to the presence of confounding factors like anticoagulation and traumatic brain injury, until now.

Conclusions: SVCS is an important cause of raised ICP. Patients with SVCS on anticoagulation have increased incidence of ICH, which could also be due to venous congestion.

Disclosure: Dr. Attar has nothing to disclose. Dr. Mathur Kumaraswamy has nothing to disclose. Dr. Miller has nothing to disclose. Dr. De Georgia has nothing to disclose.