Follow up to PCP/GP:
This is a letter of followup to describe the recent care of your patient, Melissa xxxxx. As you are aware, Melissa is a 32-year-old woman with a history of multiple sclerosis. She works as a geneticist at xxxxxxx, and was diagnosed in August of 2007, following an episode of double vision involving the left eye, and arm greater than leg fatigue. Since then, she has been on a number of therapies, but symptoms of fatigue, extreme heat sensitivity, and constipation persist.
On July 6, 2009, she underwent magnetic resonance imaging and magnetic resonance venography, performed at Stanford University Hospital. The results demonstrated demyelinating lesions in the brain, consistent with her diagnosis of multiple sclerosis. In addition, the right jugular vein was dominant, but both jugular vessels had moderate stenoses apparent at the cervical vertebral levels 2 and 3. Of note, prominent vertebral and epidural veins were observed, with relatively slow flow within the paraspinal venous sinuses.
Subsequently, on July 7, 2009, she was taken to the cath/angio laboratories at Stanford University Hospital, where bilateral jugular venography and azygous venography were performed. The jugular veins had an appearance similar to that noted on the prior MRV. The azygous vein appeared normal. Pressure gradients across the mid-jugular narrowings at the C4 level, demonstrated bilateral 3 mmHg pressure drop-offs. Subsequently, a 12 mm x 40 mm long self-expanding stent was placed in the right jugular, bridging the lesion. Following this, a 7 mm diameter x 40 mm long self-expanding stent was placed in the left jugular at approximately the same level as the one on the right. Following stent placement, completion venography demonstrated complete obliteration of the narrowings. This correlated with obliteration of the previously noted pressure gradients. The patient was then recovered without difficulty, and she stayed in the hospital overnight.
She was loaded with 300 mg of Plavix, and will be maintained for the first 2 months on 75 mg p.o. daily. She started Coumadin at a dose of 5 mg a day, and she will continue this dose until she sees you for testing and recalibration, to ensure that she maintains an INR within the range of 2 to 3. Aspirin 81 mg per day was also commenced. In addition, nonsteroidal anti-inflammatory therapy with ibuprofen 400 mg q.6 h. was prescribed for the first 4-5 days.
It is anticipated that within 2 months Melissa will have repeat MRI and MRV. If the venography appears normal, it is most likely that her Coumadin and Plavix will be discontinued, and she will be maintained only on aspirin 81 mg daily. I anticipate she will be contacting you in the near future to arrange for a PT/PTT, so that you may adjust her Coumadin dose, to maintain the INR range previously noted.