Acute cauda equina syndrome secondary to iliocaval thrombosis successfully treated with thrombolysis and pharmacomechanical thrombectomy.

PURPOSE: To present two cases of lower extremity paraplegia associated with acute iliocaval thrombosis successfully treated with thrombolysis. CASE REPORTS: A 36-year-old morbidly obese woman with a history of lower extremity deep venous thrombosis (DVT), pulmonary embolism (PE), and inferior vena cava (IVC) filter placement 4 years prior presented with back pain. Imaging showed iliac vein engorgement consistent with thrombosis and common femoral vein DVT bilaterally. She was started on intravenous heparin but developed marked lower extremity weakness while anticoagulated. Given these progressive symptoms, systemic tissue plasminogen activator was administered, with subsequent improvement over 48 hours. At 6-month follow-up, she was living independently, with near normal strength and sensation in her lower extremities. While hospitalized following an assault, a 55-year-old man with a history of factor V Leiden, DVT/PE, and prior IVC filter developed marked left lower extremity swelling, which progressed to severe bilateral lower extremity edema and mottling, along with sensory and motor loss of the lower extremities. Lower extremity duplex confirmed extensive DVT extending from the level of the iliac veins down to the tibial vessels. He underwent successful pharmacomechanical thrombectomy. At 6 months, he was walking normally, with no residual neurological symptoms and no evidence of DVT.
CONCLUSION: Acute cauda equina syndrome related to iliocaval thrombosis and epidural variceal engorgement presenting with complete paraplegia has not to our knowledge been reported. Pharmacomechanical thrombectomy affords an opportunity to achieve complete iliocaval clearance in a single procedure and is well-suited to cases in which neural infarction is imminent.