A 64-year-old woman with a history of diabetes, hypertension, and lymphoma was admitted to the hospital with a dull headache, conjunctival congestion, and slight dyspnea. Her pulse rate was 96 beats per minute; blood pressure, 146/68 mm Hg; and respiration rate, 22 breaths per minute. She also had increased jugular venous distention; cardiovascular and chest examination findings were normal. Edema of both arms and dilated blood vessels on the anterior chest wall were noted.
A CT scan of the chest demonstrated superior vena cava thrombosis and a right-sided pleural effusion. Anticoagulation therapy with warfarin and radiation therapy to the chest partially ameliorated the symptoms.
Drs Sonia Arunabh and K. Rauhilla of Flushing, NY, write that superior vena cava thrombosis is usually caused by malignancies, such as tumors of the lung, lymphoma, and metastatic tumors, that involve the superior vena cava in the chest. Benign causes include thyroid enlargement, aortic aneurysm, and fibrosing mediastinitis. Common findings in superior vena cava thrombosis are upper chest and neck engorgement, dilated veins, facial swelling, cyanosis, periorbital edema, papilledema, and changes in mental status; a right-sided pleural effusion develops in some patients. Laryngeal and cerebral edema are among the life-threatening complications that can occur.
A CT scan of the chest currently is the best noninvasive technique for evaluating the superior vena cava and its collateral blood flow. This modality demonstrates the source of the obstruction, which may be either intraluminal or secondary to an extrinsic cause; identifies the surrounding structures; facilitates guidance for percutaneous biopsies; monitors response to radiotherapy; and provides information about the pathology.
Radiation therapy is the primary treatment for superior vena cava syndrome caused by solid malignancies. Patients with severe unrelenting symptoms may benefit from thrombolysis, balloon angioplasty, or stent placement. Surgical bypass grafting can be performed in selected patients.