SHM Converge Scientific Abstract ePoster Gallery-The Perfect Storm: An Unusual Case of Syncope

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A 66-year-old man with recently resected left frontal glioblastoma multiforme (GBM), radiation, and temozolomide presented with chest pain and was found to have bilateral subsegmental pulmonary emboli and a right lower extremity DVT. Because he also had a small intraparenchymal hemorrhage in the surgical cavity, anticoagulation was stopped and an infrarenal IVC filter was placed.  <br /><br />After several days, warfarin was started without heparin bridging. About 36 hours later, the patient had syncope while standing for orthostatic vital signs, with systolic blood pressures in the 70s, and improved quickly with IV fluids. He then had recurrent syncopal episodes while walking, despite continued fluid resuscitation. Cardiac workup, including telemetry and echocardiography, was unrevealing. Further history revealed lower abdominal pressure before episodes.  <br /><br />CT abdomen/pelvis showed extensive thrombosis above and below the IVC filter extending into both iliofemoral veins. Because his INR was still subtherapeutic, heparin was restarted. Interventional radiology performed thrombectomy of over one liter of clot, removed the filter, and placed a new suprarenal IVC filter. Active re-thrombosis was seen during the procedure, requiring additional thrombectomy the next day. Hematology was consulted, and the patient was transitioned to apixaban. His orthostatic hypotension resolved and no further syncope occurred.  <br /><br />This case highlights a rare cause of syncope: massive IVC filter thrombosis causing impaired venous return, reduced preload, orthostatic hypotension, and cerebral hypoperfusion. It also underscores the hypercoagulable risk associated with GBM and the potential risk of starting warfarin without bridging.

Asset Subtitle

Devesh Kumar

Meta Tag

Author List Ali Syed, Devesh Kumar, Devin Madernberg, Hamsitha Karra, Krystal Almazan

Category Clinical Vignettes

Concept Inferior Vena Cava Filter

Concept Thrombosis

Concept Venous Return

Concept Orthostatic Hypotension

Concept Syncope

Distinguished Non-Finalist

Presenter Organization Medical College of Wisconsin

Presenting Author Devesh Kumar

Track Adult

Keywords

glioblastoma multiforme

pulmonary embolism

deep vein thrombosis

inferior vena cava filter

IVC filter thrombosis

syncope

orthostatic hypotension

warfarin

thrombectomy

hypercoagulable state

Inferior Vena Cava Filter

Thrombosis

Venous Return

Orthostatic Hypotension

Syncope