Management of New Daily Persistent Headache Using Lumbar Vein Embolization in Patients with Nutcracker Phenomenon

Monday, March 31, 2025

3:54 PM – 4:03 PM CT

Location: Music City Center, 207 AB

Presenting Author(s)

Samuel B. Ogunlade, MD

Research Trainee
Mayo Clinic, Florida, United States

Author/Co-author(s)

mohamed A K Elboraey, MD

Resident
Mayo Clinic, Florida, United States
TR

Todd Rozen, MD

Professor
Mayo Clinic, Florida, United States
AL

Andrew R. Lewis, MD

Assistant Professor
Mayo Clinic Florida, United States
Beau B. Toskich, MD, FSIR

Professor
Department of Radiology, Division of Interventional Radiology, Mayo Clinic, Jacksonville, FL 32224, United States, United States
ZD

Zlatko Devcic, MD

Assistant Professor of Radiology
Mayo Clinic Florida, United States

Purpose: Nutcracker phenomenon (NCP) can cause various congestion syndromes secondary to left renal vein (LRV) narrowing. Recent studies have shown that NCP can result in retrograde left second lumbar vein (L2LV) flow and epidural venous plexus congestion, which may cause new daily persistent headache (NDPH) due to alterations in venous-CSF pressure. Traditional surgical approaches to NCP carry risks of significant morbidity and mortality. This study aims to assess the clinical and technical outcomes of L2LV embolization in alleviating NDPH associated with NCP.

Materials and Methods: This retrospective analysis of a prospectively-maintained database included patients with Nutcracker phenomenon and NDPH (headache duration 6.4 years, range: 4–13) referred by a neurologist after failure of CSF pressure-lowering medications and other treatments. All patients had pre-embolization venography showing LRV narrowing, retrograde L2LV flow, and EVP congestion. The L2LV was embolized using microcoils or plugs. Medical records and imaging were reviewed for headache severity, venographic findings, and procedural outcomes.

Results:

Nine female patients (mean age 41, range: 19–64) were included, with a mean post-embolization follow-up of 19 months (range: 6–27). Technical success was achieved in 100%, with no retrograde flow into the L2LV or EVP post-embolization and no intra-procedural complications. Clinical success was 78%, as two patients had persistent headaches despite resolved venographic findings. The mean decrease in Visual Analogue Scale (VAS) was 5.2 (range: 0–8). Patients reported improved concentration, reduced sensitivity to light and sound, and decreased brain fog and vertigo. Six patients reduced or discontinued chronic headache medications. No flank pain, abnormal urinalysis, or pelvic congestion symptoms were observed from the procedure. One patient had an allergic reaction to the plugs, with no headache improvement, and is undergoing treatment for the allergic reaction.

Conclusion: L2LV embolization is an effective minimally invasive alternative to surgical treatment of NCP with NDPH, demonstrating high technical and clinical success rates. Most patients experienced marked relief from headaches and decreased medication usage. This is a highly selective group of patients treated in collaboration with a headache neurologist; we do not recommend routine lumbar vein embolization in the setting of NCP. The possibility of a placebo effect exists, and our team is currently enrolling patients in a formal clinical trial to rigorously study this procedure.