Nutcracker Phenomenon Demonstrated by Multidetector Computed Tomography with Three-Dimensional Imaging

Satomi Kawamoto, Karen M. Horton, Elliot K. Fishman

Figure 1

Figure 2

Figure 3

A 24-year-old woman presented with gross hematuria. Multidetector computed tomography (CT) showed compression of the left renal vein between the aorta and the superior mesenteric artery (SMA) (Fig. 1) with multiple collateral veins (Fig. 2), which displaced the left proximal ureter (Fig. 3). Sagittal reformatted CT showed an abnormally steep angle of the SMA origin from the aorta (40°; normal 90° ± 10° ^{[1] and [2]}).

Symptoms of nutcracker syndrome include macroscopic or microscopic hematuria, left flank pain, pelvic congestion syndrome, and left renal-to-gonadal vein reflux resulting in lower limb varices and varicoceles in men.³ Lopatkin et al.⁴ postulated that increased pressure in the venous system could rupture the thin-walled septum between the small veins and collecting system, resulting in hematuria. Ali-El-Dein et al.² proposed sequential diagnostic tests for classic cases of nutcracker syndrome with left flank pain and hematuria. These tests include urinalysis, ultrasound and/or intravenous urography, cystoscopy, CT or magnetic resonance angiography, and renal venography/venous pressure manometry. In this patient, results on cystoscopy were negative, and no other cause for hematuria was found. Her hematuria disappeared without treatment, and she was managed conservatively. Multidetector CT enabled precise depiction of the renal vascular anatomy, as reported in previous CT studies. ^{[1], [5] and [6]}

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