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Abstract
A 45-year-old woman with a history of depression and anxiety, treated with selective serotonin reuptake inhibitors (SSRIs), experienced acute, recurrent, and severe bifrontal headaches. Over time, she developed a left homonymous hemianopia and mental status changes. MRA revealed segmental vasoconstriction of cerebral arteries in multiple vascular distributions. She was treated with a calcium-channel blocker and magnesium, and there was resolution of her symptoms and cerebrovascular changes. Her clinical course and neuroimaging findings were consistent with reversible cerebral vasoconstriction syndrome. Although rare, this disorder frequently manifests with visual complaints. Although the prognosis is generally favorable, patients with this syndrome require prompt diagnosis and care directed to avoid complications including stroke, seizure, and subarachnoid hemorrhage.
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152
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Miller EC, Yaghi S, Boehme AK, Willey JZ, Elkind MSV, Marshall RS. Mechanisms and outcomes of stroke during pregnancy and the postpartum period: A cross-sectional study. Neurol Clin Pract 2016; 6:29-39. [PMID: 26918201 DOI: 10.1212/cpj.0000000000000214] [Citation(s) in RCA: 38] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
BACKGROUND Pregnancy-associated stroke remains incompletely characterized because of the rarity of these potentially devastating events. We investigated whether mechanism and outcome of ischemic pathophysiology stroke differ between young pregnant and nonpregnant women. METHODS We identified 135 consecutive women ages 18-40 years admitted to our center from January 2008 through June 2014 with ischemic stroke, TIA, cerebral venous thrombosis, or nonaneurysmal subarachnoid hemorrhage due to reversible cerebral vasoconstriction syndrome (RCVS). We reviewed charts for pregnancy status, demographics, medical comorbidities, stroke severity, etiology, and discharge outcomes. RESULTS There were 33 women with pregnancy-associated stroke (PAS) and 102 with non-pregnancy-associated stroke (NPAS). Among women with PAS, 73% of strokes occurred postpartum. In the PAS group, the most common cause of cerebrovascular events was RCVS (n = 12), 11 postpartum and 4 in women with preeclampsia. There were no significant differences between the groups in demographics. Women with PAS were less likely to have vascular risk factors such as hyperlipidemia and history of thromboembolism but more likely to have cerebral venous thromboses (21% vs 7%, p = 0.02). Women with PAS were more likely to have RCVS as stroke mechanism (36% vs 1%, odds ratio 57.7, 95% confidence interval 7-468, p = 0.0001). CONCLUSION Compared with nonpregnant women of the same age group, women with PAS had fewer vascular risk factors. Cerebral venous thrombosis and RCVS were more common in PAS, most of which occurred postpartum. These results provide further evidence for the unique pathophysiology of pregnancy-related stroke, raising important questions for future investigation.
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Affiliation(s)
- Eliza C Miller
- Department of Neurology (ECM, SY, AKB, JZW, MSVE, RSM), College of Physicians and Surgeons, and Department of Epidemiology (AKB, MSVE), Mailman School of Public Health, Columbia University, New York, NY
| | - Shadi Yaghi
- Department of Neurology (ECM, SY, AKB, JZW, MSVE, RSM), College of Physicians and Surgeons, and Department of Epidemiology (AKB, MSVE), Mailman School of Public Health, Columbia University, New York, NY
| | - Amelia K Boehme
- Department of Neurology (ECM, SY, AKB, JZW, MSVE, RSM), College of Physicians and Surgeons, and Department of Epidemiology (AKB, MSVE), Mailman School of Public Health, Columbia University, New York, NY
| | - Joshua Z Willey
- Department of Neurology (ECM, SY, AKB, JZW, MSVE, RSM), College of Physicians and Surgeons, and Department of Epidemiology (AKB, MSVE), Mailman School of Public Health, Columbia University, New York, NY
| | - Mitchell S V Elkind
- Department of Neurology (ECM, SY, AKB, JZW, MSVE, RSM), College of Physicians and Surgeons, and Department of Epidemiology (AKB, MSVE), Mailman School of Public Health, Columbia University, New York, NY
| | - Randolph S Marshall
- Department of Neurology (ECM, SY, AKB, JZW, MSVE, RSM), College of Physicians and Surgeons, and Department of Epidemiology (AKB, MSVE), Mailman School of Public Health, Columbia University, New York, NY
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154
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Lee WJ, Yeon JY, Jo KI, Kim JS, Hong SC. Reversible Cerebral Vasoconstriction Syndrome and Posterior Reversible Encephalopathy Syndrome Presenting with Deep Intracerebral Hemorrhage in Young Women. J Cerebrovasc Endovasc Neurosurg 2015; 17:239-45. [PMID: 26523259 PMCID: PMC4626349 DOI: 10.7461/jcen.2015.17.3.239] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/22/2015] [Revised: 07/30/2015] [Accepted: 08/19/2015] [Indexed: 11/23/2022] Open
Abstract
Reversible cerebral vasoconstriction syndrome (RCVS) is a group of syndromes characterized by reversible segmental constriction of cerebral arteries. Posterior reversible encephalopathy syndrome (PRES) is another clinical-radiologic syndrome characterized by reversible, posterior-predominant brain edema. Although the exact causes of these reversible syndromes are poorly understood, these entities may share some common pathophysiologic elements leading to hemorrhagic strokes and rarely, deep intracerebral hemorrhage (ICH). Recent studies have suggested that endothelial dysfunction is a common pathophysiologic factor associated with these syndromes. We report on two young female patients who presented with deep ICH and were later diagnosed as RCVS and PRES. Both patients suffered from vasoconstriction and delayed ischemic stroke. Early detection of distinguishing clinical-radiologic features associated with these reversible syndromes and removing triggers would facilitate successful treatment with no complications.
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Affiliation(s)
- Won Jae Lee
- Department of Neurosurgery, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Je Young Yeon
- Department of Neurosurgery, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Kyung-Il Jo
- Department of Neurosurgery, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Jong-Soo Kim
- Department of Neurosurgery, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Seung-Chyul Hong
- Department of Neurosurgery, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
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155
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Diffuse Intracranial and Extracranial Vascular Involvement in Reversible Cerebral Vasoconstriction Syndrome. Clin Neuroradiol 2015; 25:301-4. [DOI: 10.1007/s00062-014-0335-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/02/2014] [Accepted: 08/11/2014] [Indexed: 10/24/2022]
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Jacoby N, Kaunzner U, Dinkin M, Safdieh J. Diagnosing RCVS Without the CV: The Evolution of Reversible Cerebral Vasoconstriction Syndrome. Neurohospitalist 2015; 6:NP1-4. [PMID: 27366300 DOI: 10.1177/1941874415599576] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
This is a case of a 52-year-old man with a past medical history of 2 episodes of coital thunderclap headaches as well as recent cocaine, marijuana, and pseudoephedrine use, who presented with sudden, sharp, posterior headache associated with photophobia and phonophobia. His initial magnetic resonance imaging (MRI) of the brain, magnetic resonance angiography (MRA) of the head, and magnetic resonance venography (MRV) of the head were all normal as well as a normal lumbar puncture. Given the multiple risk factors for reversible cerebral vasoconstriction syndrome (RCVS), the patient was treated for suspected RCVS, despite the normal imaging. Repeat MRI brain 3 days after hospital admission demonstrated confluent white matter T2 hyperintensities most prominent in the occipital lobes, typical of posterior reversible encephalopathy syndrome (PRES). Repeat MRA of the head 1 day after discharge and 4 days after the abnormal MRI brain showed multisegment narrowing of multiple arteries. This case demonstrates that RCVS may present with PRES on MRI brain and also exemplifies the need to treat suspected RCVS even if imaging is normal, as abnormalities in both the MRI and the MRA may be delayed.
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Affiliation(s)
- Nuri Jacoby
- New York Presbyterian Weill Cornell, New York, NY, USA
| | | | - Marc Dinkin
- New York Presbyterian Weill Cornell, New York, NY, USA
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157
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Posterior reversible encephalopathy syndrome: clinical and radiological manifestations, pathophysiology, and outstanding questions. Lancet Neurol 2015; 14:914-925. [PMID: 26184985 DOI: 10.1016/s1474-4422(15)00111-8] [Citation(s) in RCA: 674] [Impact Index Per Article: 74.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/29/2014] [Revised: 04/08/2015] [Accepted: 05/27/2015] [Indexed: 12/12/2022]
Abstract
Almost two decades have elapsed since posterior reversible encephalopathy syndrome (PRES) was described in an influential case series. This usually reversible clinical syndrome is becoming increasingly recognised, in large part because of improved and more readily available brain imaging. Although the pathophysiological changes underlying PRES are not fully understood, endothelial dysfunction is a key factor. A diagnosis of PRES should be considered in the setting of acute neurological symptoms in patients with renal failure, blood pressure fluctuations, use of cytotoxic drugs, autoimmune disorders, or eclampsia. Characteristic radiographic findings include bilateral regions of subcortical vasogenic oedema that resolve within days or weeks. The presence of haemorrhage, restricted diffusion, contrast enhancement, and vasoconstriction are all compatible with a diagnosis. In most cases, PRES resolves spontaneously and patients show both clinical and radiological improvements. The range of symptoms that can comprise the syndrome might be broader than usually thought. In its mild form, this disorder might cause only one clinical symptom (headache or seizure) and radiographically might show few areas of vasogenic oedema or even normal brain imaging in some rare cases. In severe forms, PRES might cause substantial morbidity and even mortality, most often as a result of acute haemorrhage or massive posterior fossa oedema causing obstructive hydrocephalus or brainstem compression.
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158
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Charidimou A, Linn J, Vernooij MW, Opherk C, Akoudad S, Baron JC, Greenberg SM, Jäger HR, Werring DJ. Cortical superficial siderosis: detection and clinical significance in cerebral amyloid angiopathy and related conditions. Brain 2015; 138:2126-39. [PMID: 26115675 DOI: 10.1093/brain/awv162] [Citation(s) in RCA: 257] [Impact Index Per Article: 28.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/15/2014] [Accepted: 04/17/2015] [Indexed: 01/13/2023] Open
Abstract
Cortical superficial siderosis describes a distinct pattern of blood-breakdown product deposition limited to cortical sulci over the convexities of the cerebral hemispheres, sparing the brainstem, cerebellum and spinal cord. Although cortical superficial siderosis has many possible causes, it is emerging as a key feature of cerebral amyloid angiopathy, a common and important age-related cerebral small vessel disorder leading to intracerebral haemorrhage and dementia. In cerebral amyloid angiopathy cohorts, cortical superficial siderosis is associated with characteristic clinical symptoms, including transient focal neurological episodes; preliminary data also suggest an association with a high risk of future intracerebral haemorrhage, with potential implications for antithrombotic treatment decisions. Thus, cortical superficial siderosis is of relevance to neurologists working in neurovascular, memory and epilepsy clinics, and neurovascular emergency services, emphasizing the need for appropriate blood-sensitive magnetic resonance sequences to be routinely acquired in these clinical settings. In this review we focus on recent developments in neuroimaging and detection, aetiology, prevalence, pathophysiology and clinical significance of cortical superficial siderosis, with a particular emphasis on cerebral amyloid angiopathy. We also highlight important areas for future investigation and propose standards for evaluating cortical superficial siderosis in research studies.
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Affiliation(s)
- Andreas Charidimou
- 1 Stroke Research Group, Department of Brain Repair and Rehabilitation, UCL Institute of Neurology and The National Hospital for Neurology and Neurosurgery, Queen Square, London WC1N 3BG, UK 2 Stroke Research Centre, Massachusetts General Hospital, Boston, MA, USA
| | - Jennifer Linn
- 3 Department of Neuroradiology, University Hospital Munich, Marchioninistrasse 15, 81377 Munich, Germany
| | - Meike W Vernooij
- 4 Department of Radiology and Department of Epidemiology, Erasmus MC University Medical Centre, Rotterdam, Netherlands
| | - Christian Opherk
- 5 Institute for Stroke and Dementia Research, Ludwig Maximilians University, Munich, and Department of Neurology, SLK-Kliniken, Heilbronn, Germany
| | - Saloua Akoudad
- 4 Department of Radiology and Department of Epidemiology, Erasmus MC University Medical Centre, Rotterdam, Netherlands
| | - Jean-Claude Baron
- 6 UMR 894 INSERM-Université Paris 5, Sorbonne Paris Cité, Paris, France
| | - Steven M Greenberg
- 2 Stroke Research Centre, Massachusetts General Hospital, Boston, MA, USA
| | - Hans Rolf Jäger
- 1 Stroke Research Group, Department of Brain Repair and Rehabilitation, UCL Institute of Neurology and The National Hospital for Neurology and Neurosurgery, Queen Square, London WC1N 3BG, UK 7 Lysholm Department of Neuroradiology, UCL Institute of Neurology and National Hospital for Neurology and Neurosurgery, London, UK
| | - David J Werring
- 1 Stroke Research Group, Department of Brain Repair and Rehabilitation, UCL Institute of Neurology and The National Hospital for Neurology and Neurosurgery, Queen Square, London WC1N 3BG, UK
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159
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Calic Z, Cappelen-Smith C, Zagami AS. Reversible cerebral vasoconstriction syndrome. Intern Med J 2015; 45:599-608. [DOI: 10.1111/imj.12669] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/06/2014] [Accepted: 12/06/2014] [Indexed: 12/27/2022]
Affiliation(s)
- Z. Calic
- Institute of Neurological Sciences; Prince of Wales Hospital; Sydney Australia
- Prince of Wales Clinical School; University of New South Wales; Sydney Australia
| | - C. Cappelen-Smith
- Department of Neurology and Neurophysiology; Liverpool Hospital; Sydney New South Wales Australia
- South Western Clinical School; University of New South Wales; Sydney Australia
| | - A. S. Zagami
- Institute of Neurological Sciences; Prince of Wales Hospital; Sydney Australia
- Prince of Wales Clinical School; University of New South Wales; Sydney Australia
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160
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Bourvis N, Franc J, Szatmary Z, Chabriat H, Crassard I, Ducros A. Reversible cerebral vasoconstriction syndrome in the context of recent cerebral venous thrombosis: Report of a case. Cephalalgia 2015; 36:92-7. [PMID: 25944816 DOI: 10.1177/0333102415584359] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/28/2014] [Accepted: 04/05/2015] [Indexed: 01/03/2023]
Abstract
INTRODUCTION Reversible cerebral constriction syndrome and cerebral venous thrombosis are two rare conditions. Reversible cerebral constriction syndrome affects the cerebral arteries and the pathology is still largely unknown. To date, no physiological link with cerebral venous thrombosis has been reported. CASE RESULTS We report here the case of a 24-year-old woman who presented a reversible cerebral constriction syndrome in the setting of a cerebral venous thrombosis. Cerebral venous thrombosis had developed in her left lateral venous sinus, within the stent placed one year before, in order to treat an idiopathic intracranial hypertension. DISCUSSION The co-occurrence of cerebral venous thrombosis and reversible cerebral constriction syndrome in the same patient raises the issue of a potential link between them. We discuss the potential common trigger factors in this case: recent hormonal therapy; intracranial hypotension iatrogenically induced by lumbar puncture.
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Affiliation(s)
- Nadège Bourvis
- Neurology Department, Lariboisière Hospital, Paris, France Headache Emergency Centre, Lariboisière Hospital, Paris, France
| | - Julie Franc
- Neuroradiology Department, Lariboisière Hospital, Paris, France
| | - Zoltan Szatmary
- Neuroradiology Department, Lariboisière Hospital, Paris, France
| | | | | | - Anne Ducros
- Neurology Department, Lariboisière Hospital, Paris, France Headache Emergency Centre, Lariboisière Hospital, Paris, France
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161
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Skeik N, Porten BR, Kadkhodayan Y, McDonald W, Lahham F. Postpartum reversible cerebral vasoconstriction syndrome: Review and analysis of the current data. Vasc Med 2015; 20:256-65. [DOI: 10.1177/1358863x14567976] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Postpartum reversible cerebral vasoconstriction syndrome (PPRCVS) is a rare but serious cause of headache that occurs in the early postpartum period. The rarity of this disorder has limited the current literature to single case reports and small, observational case series. The lack of familiarity with PPRCVS may contribute to mismanagement of these unique patients and lead to poor outcomes. To address current gaps in the understanding of PPRCVS, this review and data analysis characterizes the demographics, presentation, clinical course, management and prognosis of PPRCVS and provides a general review of the epidemiology, pathophysiology and diagnosis to assist clinicians who may care for patients with this rare disorder.
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Affiliation(s)
- Nedaa Skeik
- Vascular Medicine, Minneapolis Heart Institute, Abbott Northwestern Hospital, Minneapolis, MN, USA
| | | | - Yasha Kadkhodayan
- Department of Pathology, Interventional Neuroradiology, Abbott Northwestern Hospital, Minneapolis, MN, USA
| | | | - Firas Lahham
- Internal Medicine, Abbott Northwestern Hospital, Minneapolis, MN, USA
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162
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Miller TR, Shivashankar R, Mossa-Basha M, Gandhi D. Reversible Cerebral Vasoconstriction Syndrome, Part 1: Epidemiology, Pathogenesis, and Clinical Course. AJNR Am J Neuroradiol 2015; 36:1392-9. [PMID: 25593203 DOI: 10.3174/ajnr.a4214] [Citation(s) in RCA: 141] [Impact Index Per Article: 15.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/17/2023]
Abstract
Reversible cerebral vasoconstriction syndrome is a clinical and radiologic syndrome that represents a common presentation of a diverse group of disorders. The syndrome is characterized by thunderclap headache and reversible vasoconstriction of cerebral arteries, which can either be spontaneous or related to an exogenous trigger. The pathophysiology of reversible cerebral vasoconstriction syndrome is unknown, though alterations in cerebral vascular tone are thought to be a key underlying mechanism. The syndrome typically follows a benign course; however, reversible cerebral vasoconstriction syndrome may result in permanent disability or death in a small minority of patients secondary to complications such as ischemic stroke or intracranial hemorrhage.
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Affiliation(s)
- T R Miller
- From the Department of Diagnostic Radiology (T.R.M., R.S., D.G.), Section of Neuroradiology, University of Maryland Medical Center, Baltimore, Maryland
| | - R Shivashankar
- From the Department of Diagnostic Radiology (T.R.M., R.S., D.G.), Section of Neuroradiology, University of Maryland Medical Center, Baltimore, Maryland
| | - M Mossa-Basha
- Department of Diagnostic Radiology (M.M.-B.), Section of Neuroradiology, University of Washington, Seattle, Washington
| | - D Gandhi
- From the Department of Diagnostic Radiology (T.R.M., R.S., D.G.), Section of Neuroradiology, University of Maryland Medical Center, Baltimore, Maryland
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Straube A, Klein M, Erbguth F, Maschke M, Klawe C, Sander D, Hilz MJ, Ziemssen T, Klucken J, Kohl Z, Winkler J, Bettendorf M, Staykov D, Berrouschot J, Dörfler A. Metabolische Störungen. NEUROINTENSIV 2015. [PMCID: PMC7175475 DOI: 10.1007/978-3-662-46500-4_36] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 12/01/2022]
Abstract
Im folgenden Kapitel werden die verschiedenen metabolischen Störungen betrachtet. Zunächst wird auf die allgemeinen und spezifischen neurologischen Komplikationen bei Organtransplantation eingegangen. Dann geht es um die metabolischen Enzephalopathien: Störungen der Gehirntätigkeit bei angeborenen und erworbenen Stoffwechselerkrankungen im engeren Sinn, Elektrolytstörungen, Hypovitaminosen, zerebrale Folgen einzelner Organdysfunktionen, zerebrale Hypoxien, Endotheliopathien und Mitochondropathien. Anschließend werden das Alkoholdelir und die Wernicke-Enzephalopathie erörtert. Bei zahlreichen akuten Erkrankungen von Gehirn, Rückenmark und peripherem Nervensystem treten typische Störungen vegetativer Systeme auf, deren Erkennung und Therapie insbesondere bei Intensivpatienten eine vitale Bedeutung haben kann: die autonomen Störungen. Bei der zentralen pontinen Myelinolyse kommt es zu einer akuten, vorwiegend fokal-symmetrischen Demyelinisierung im Hirnparenchym. Auch Basalganglienerkrankungen können intensivmedizinisch relevant werden. Und schließlich wird die akute Stressreaktion betrachtet, die aufgrund der vielfältigen metabolischen und endokrinen Veränderungen bei kritischen Erkrankungen entsteht. Gerade das RCVS als neuere Krankheitsentität und wichtige Differenzialdiagnose zur Vaskulitis des ZNS verdient einen eigenen Platz, in diesem Unterkapitel werden ebenfalls verwandte Syndrome wie die hypertensive Enzephalopathie und das PRES abgehandelt.
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164
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Choi KS, Yi HJ. Progressive manifestations of reversible cerebral vasoconstriction syndrome presenting with subarachnoid hemorrhage, intracerebral hemorrhage, and cerebral infarction. J Korean Neurosurg Soc 2014; 56:419-22. [PMID: 25535520 PMCID: PMC4273001 DOI: 10.3340/jkns.2014.56.5.419] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/12/2013] [Revised: 01/13/2014] [Accepted: 01/15/2014] [Indexed: 11/30/2022] Open
Abstract
Reversible cerebral vasoconstriction syndrome (RCVS) is characterized by sudden-onset headache with focal neurologic deficit and prolonged but reversible multifocal narrowing of the distal cerebral arteries. Stroke, either hemorrhagic or ischemic, is a relatively frequent presentation in RCVS, but progressive manifestations of subarachnoid hemorrhage, intracerebral hemorrhage, cerebral infarction in a patient is seldom described. We report a rare case of a 56-year-old woman with reversible cerebral vasoconstriction syndrome consecutively presenting as cortical subarachnoid hemorrhage, intracerebral hemorrhage, and cerebral infarction. When she complained of severe headache with subtle cortical subarachnoid hemorrhage, her angiography was non-specific. But, computed tomographic angiography showed typical angiographic features of this syndrome after four days. Day 12, she suffered mental deterioration and hemiplegia due to contralateral intracerebral hematoma, and she was surgically treated. For recurrent attacks of headache, medical management with calcium channel blockers has been instituted. Normalized angiographic features were documented after 8 weeks. Reversible cerebral vasoconstriction syndrome should be considered as differential diagnosis of non-aneurysmal subarachnoid hemorrhage, and repeated angiography is recommended for the diagnosis of this under-recognized syndrome.
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Affiliation(s)
- Kyu-Sun Choi
- Department of Neurosurgery, Hanyang University Medical Center, Seoul, Korea
| | - Hyeong-Joong Yi
- Department of Neurosurgery, Hanyang University Medical Center, Seoul, Korea
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165
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Wolff V, Armspach JP, Lauer V, Rouyer O, Ducros A, Marescaux C, Gény B. Ischaemic strokes with reversible vasoconstriction and without thunderclap headache: a variant of the reversible cerebral vasoconstriction syndrome? Cerebrovasc Dis 2014; 39:31-8. [PMID: 25547150 DOI: 10.1159/000369776] [Citation(s) in RCA: 40] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/21/2014] [Accepted: 11/10/2014] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND Reversible vasoconstriction (RV) may cause ischaemic stroke (IS) in the absence of any other defined stroke aetiology. The three objectives of our study were to evaluate the frequency of RV in a prospective series of young IS patients, to describe the detailed clinical-radiological features in the patients with RV and IS, and to compare these characteristics with those of reversible cerebral vasoconstriction syndrome (RCVS). METHODS We identified between October 2005 and December 2010, 159 consecutive young patients (<45 years) hospitalized for an acute IS confirmed by cerebral magnetic resonance imaging. An extensive diagnostic work-up was performed including toxicological urinary screening for cannabis, cocaine and amphetamines, and the usual biological, cardiac and vascular investigations for an IS in the young. We specifically studied patients with IS and RV, which was defined as multifocal intracranial arterial stenoses confirmed by intracranial arterial imaging that resolved within 3-6 months. RESULTS Out of 159 patients with IS, 21 (13%, 12 males, 9 females; mean age 32 years) had multifocal cerebral arterial stenoses that were fully reversible at 3-6 months, and no other cause for stroke. IS were located on posterior territory in 71% of cases, and vasoconstriction predominated on posterior cerebral and superior cerebellar arteries. Precipitating factors of IS and RV were the use of cannabis resin (n = 14), nasal decongestants (n = 2) and triptan (n = 1). Most cases (74%) had unusual severe headache, but none had thunderclap headache. None of 21 cases had reversible posterior leukoencephalopathy, cortical subarachnoid or intracerebral haemorrhage. CONCLUSION RV was the sole identified cause of IS in 13% of our cohort. These young patients with IS and RV may have a variant of RCVS, related to an increased susceptibility to vasoactive agents in some individuals. RV in our patients differs from the classical characteristics of RCVS by the absence of thunderclap headache, reversible brain oedema and subarachnoid or intracranial haemorrhage. Intracranial arteries should be looked for, by appropriate vascular imaging, in young patients with IS at the acute stage and during the follow-up period.
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Affiliation(s)
- Valérie Wolff
- Unité Neuro-Vasculaire, Service de Neurologie, Hôpitaux Universitaires de Strasbourg, Strasbourg, France
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166
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Chen SP, Wang YF, Huang PH, Chi CW, Fuh JL, Wang SJ. Reduced circulating endothelial progenitor cells in reversible cerebral vasoconstriction syndrome. J Headache Pain 2014; 15:82. [PMID: 25466718 PMCID: PMC4266547 DOI: 10.1186/1129-2377-15-82] [Citation(s) in RCA: 27] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/28/2014] [Accepted: 11/20/2014] [Indexed: 02/02/2023] Open
Abstract
BACKGROUND The pathophysiology of reversible cerebral vasoconstriction syndrome (RCVS) remains elusive. Endothelial dysfunction might play a role, but direct evidence is lacking. This study aimed to explore whether patients with RCVS have a reduced level of circulating circulating endothelial progenitor cells (EPCs) to repair the dysfunctional endothelial vasomotor control. METHODS We prospectively recruited 24 patients with RCVS within one month of disease onset and 24 healthy age- and sex-matched controls. Flow cytometry was used to quantify the numbers of circulating EPCs, defined as KDR+CD133+, CD34+CD133+, and CD34+KDR+ double-positive mononuclear cells. The Lindegaard index, an index of vasoconstriction, was calculated by measuring the mean flow velocity of middle cerebral arteries and distal extracranial internal carotid arteries via color-coded sonography on the same day as blood drawing. A Lindegaard index of 2 was chosen as the cutoff value for significant vasoconstriction of middle cerebral arteries based on our previous study. RESULTS Patients with RCVS had a reduced number of CD34+KDR+ cells (0.009 ± 0.006% vs. 0.014 ± 0.010%, p = 0.031) but not KDR+CD133+ cells or CD34+CD133+ EPCs, in comparison with controls. The number of CD34+KDR+ cells was inversely correlated with the Lindegaard index (rs = -0.418, p = 0.047). Of note, compared to controls, patients with a Lindegaard index > 2 (n = 13) had a reduced number of CD34+KDR+ cells (0.007 ± 0.005% vs. 0.014 ± 0.010%, p = 0.010), but those with a Lindegaard index ≤ 2 did not. CONCLUSIONS Patients with RCVS had reduced circulating CD34+KDR+ EPCs, which were correlated with the severity of vasoconstriction. Endothelial dysfunction might contribute to the pathogenesis of RCVS.
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Affiliation(s)
| | | | | | | | - Jong-Ling Fuh
- Faculty of Medicine, School of Medicine, National Yang-Ming University, Taipei, Taiwan.
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167
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Sheikh HU, Mathew PG. Reversible cerebral vasoconstriction syndrome: updates and new perspectives. Curr Pain Headache Rep 2014; 18:414. [PMID: 24658747 DOI: 10.1007/s11916-014-0414-7] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
Abstract
Reversible cerebral vasoconstriction syndrome (RCVS) is an important cause of headaches that can lead to other neurological complications, including stroke, if not recognized early. Over the past few years, there has been great progress in the recognition of this entity. However, there is still much to be learned about its pathophysiology and optimal treatment strategies. RCVS occurs mostly in middle-aged adults, and there is a female preponderance with an increased incidence during the postpartum period. A consistent, predominating feature is a sudden-onset, severe headache that is frequently recurrent, usually over the span of a week. Less common presentations include seizures or focal neurological symptoms. Important causative factors include vasoactive medications, as well as illicit drugs like marijuana and cocaine. The current underlying pathophysiology is thought to be a disturbance in cerebrovascular tone leading to vasoconstriction. The diagnosis is based on history, physical examination, and cerebrovascular imaging findings that demonstrate multifocal, segmental areas of vasoconstriction in large- and medium-sized arteries. An important criterion for making the diagnosis is the eventual reversibility of symptoms and imaging findings.
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Affiliation(s)
- Huma U Sheikh
- Brigham and Women's Hospital, Department of Neurology, John R. Graham Headache Center, Harvard Medical School, 1153 Centre Street, Suite 4970, Boston, MA, 02130, USA,
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Komatsu T, Kimura T, Yagishita A, Takahashi K, Koide R. A case of reversible cerebral vasoconstriction syndrome presenting with recurrent neurological deficits: Evaluation using noninvasive arterial spin labeling MRI. Clin Neurol Neurosurg 2014; 126:96-8. [DOI: 10.1016/j.clineuro.2014.08.023] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/11/2013] [Revised: 08/18/2014] [Accepted: 08/22/2014] [Indexed: 10/24/2022]
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Pezzella FR, Santalucia P, Vadalà R, Giugni E, Zedde ML, Sessa M, Anticoli S, Caso V. Women Stroke Association Statement on Stroke. Int J Stroke 2014; 9:20-27. [PMID: 28051365 DOI: 10.1111/ijs.12110] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
We describe the current and future objectives of the Women Stroke Association, a nonprofit multidisciplinary organization promoting research awareness on medical, psychological, and social issues concerning women affected by cerebrocardiovascular disease. In this paper, we deal with only cerebrovascular disease, whereas cardiovascular disorders will be addressed in a future paper. Gender differences in the clinical presentation of cerebrovascular diseases have been repeatedly suggested, and some treatment options may not be as effective and safe in men and women. For many years, women have either been underrepresented or excluded from randomized clinical trials, and the majority of therapeutic research has been carried on predominantly male populations. Furthermore, gender differences have been shown to contribute to different responses to cerebrovascular drugs in women when compared with men, regarding pharmacokinetics, pharmacodynamics, and physiology. In this statement, we discuss main research fields relevant to Women Stroke Association's mission and commitment, highlighting opportunities and critical from the women's health perspective. Future directions and goals of the Women Stroke Association arise from these considerations and represent the association's commitment to combating stroke.
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Affiliation(s)
| | - Paola Santalucia
- 2 Direzione Scientifica and U.O. Medicina d'Urgenza, Fondazione IRCCS Cà Granda, Ospedale Maggiore Policlinico, Milan, Italy
| | - Rita Vadalà
- 3 NeuroRadiology, IRCCS Fondazione S Lucia, Rome, Italy
| | | | - Maria Luisa Zedde
- 5 Neurology Department, Arcispedale Santa Maria Nuova, Reggio nell'Emilia, Italy
| | - Maria Sessa
- 6 Stroke Unit - Department of Neurology and Neurophysiology, San Raffaele Scientific Institute, Milan, Italy
| | - Sabrina Anticoli
- 1 Stroke Unit - Department of Emergency Medicine, AO S Camillo Forlanini, Rome, Italy
| | - Valeria Caso
- 7 Stroke Unit, University of Perugia, Santa Maria della Misericordia Hospital, Perugia, Italy
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171
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Wilson D, Marshall CR, Solbach T, Watkins L, Werring DJ. Intraventricular hemorrhage in reversible cerebral vasoconstriction syndrome. J Neurol 2014; 261:2221-4. [PMID: 25240397 PMCID: PMC4221649 DOI: 10.1007/s00415-014-7499-0] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/17/2014] [Revised: 09/06/2014] [Accepted: 09/08/2014] [Indexed: 11/01/2022]
Affiliation(s)
- Duncan Wilson
- Stroke Research Group, Department of Brain Repair and Rehabilitation, UCL Institute of Neurology, London, UK
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172
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Abstract
Etoricoxib is a newer cyclooxygenase (COX)-2 inhibitor anti-inflammatory drug with a favorable safety profile. However, several randomized trials have provided evidence of an increased risk for acute myocardial infarction associated with the use of COX-2 inhibitors. Fewer data are available concerning the risk for ischemic stroke associated with COX-2 inhibitors. Although sporadic classes of drug-induced reversible cerebral vasoconstriction syndrome (RCVS) have been reported, this was not the case for etoricoxib. We report a patient who developed thunderclap headache, reversible cerebral arterial vasoconstriction, high blood pressure, and ischemic stroke (ie, RCVS) with recent exposure to etoricoxib. Although the association is hypothetical, the authors suggest consideration of RCVS in hypertensive patients presenting with headache, focal deficits, and evidence of cerebral ischemia during COX-2 inhibitors use.
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173
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Mehdi A, Hajj-Ali RA. Reversible Cerebral Vasoconstriction Syndrome: a Comprehensive Update. Curr Pain Headache Rep 2014; 18:443. [DOI: 10.1007/s11916-014-0443-2] [Citation(s) in RCA: 27] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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175
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Glover RL, Vollbracht S, Robbins MS. Acute Postpartum Headache. Headache 2014; 54:1073-84. [DOI: 10.1111/head.12385] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/21/2014] [Indexed: 01/18/2023]
Affiliation(s)
- Robert L. Glover
- Department of Neurology; Albert Einstein College of Medicine; Bronx NY USA
| | - Sarah Vollbracht
- Department of Neurology; Albert Einstein College of Medicine; Bronx NY USA
- Montefiore Headache Center; Albert Einstein College of Medicine; Bronx NY USA
| | - Matthew S. Robbins
- Department of Neurology; Albert Einstein College of Medicine; Bronx NY USA
- Montefiore Headache Center; Albert Einstein College of Medicine; Bronx NY USA
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176
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Coenen F, Duprez T, Hantson P. Concomitant occurrence of posterior reversible encephalopathy syndrome and non-convexal subarachnoid haemorrhage in a renal transplant patient. Acta Neurol Belg 2014; 114:159-61. [PMID: 24190279 DOI: 10.1007/s13760-013-0259-6] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/11/2013] [Accepted: 10/26/2013] [Indexed: 10/26/2022]
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Maaijwee NAMM, Rutten-Jacobs LCA, Schaapsmeerders P, van Dijk EJ, de Leeuw FE. Ischaemic stroke in young adults: risk factors and long-term consequences. Nat Rev Neurol 2014; 10:315-25. [PMID: 24776923 DOI: 10.1038/nrneurol.2014.72] [Citation(s) in RCA: 219] [Impact Index Per Article: 21.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
Abstract
Contrary to trends in most other diseases, the average age of ischaemic stroke onset is decreasing, owing to a rise in the incidence of stroke among 'young' individuals (under 50 years of age). This Review provides a critical overview of the risk factors and aetiology of young ischaemic stroke and addresses its long-term prognosis, including cardiovascular risk, functional outcome and psychosocial consequences. We highlight the diminishing role of 'rare' risk factors in the pathophysiology of young stroke in light of the rising prevalence of 'traditional' vascular risk factors in younger age groups. Long-term prognosis is of particular interest to young patients, because of their long life expectancy and major responsibilities during a demanding phase of life. The prognosis of young stroke is not as favourable as previously thought, with respect either to mortality or cardiovascular disease or to psychosocial consequences. Therefore, secondary stroke prevention is probably a life-long endeavour in most young stroke survivors. Due to under-representation of young patients in past trials, new randomized trials focusing on this age group are needed to confirm the benefits of long-term secondary preventive medication. The high prevalence of poor functional outcome and psychosocial problems warrants further study to optimize treatment and rehabilitation for these young patients.
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Affiliation(s)
- Noortje A M M Maaijwee
- Department of Neurology, Radboud University Nijmegen Medical Centre, Donders Institute for Brain, Cognition and Behaviour, Centre for Neuroscience, PO Box 9101, 6500 HB, Nijmegen, Netherlands
| | - Loes C A Rutten-Jacobs
- Department of Neurology, Radboud University Nijmegen Medical Centre, Donders Institute for Brain, Cognition and Behaviour, Centre for Neuroscience, PO Box 9101, 6500 HB, Nijmegen, Netherlands
| | - Pauline Schaapsmeerders
- Department of Neurology, Radboud University Nijmegen Medical Centre, Donders Institute for Brain, Cognition and Behaviour, Centre for Neuroscience, PO Box 9101, 6500 HB, Nijmegen, Netherlands
| | - Ewoud J van Dijk
- Department of Neurology, Radboud University Nijmegen Medical Centre, Donders Institute for Brain, Cognition and Behaviour, Centre for Neuroscience, PO Box 9101, 6500 HB, Nijmegen, Netherlands
| | - Frank-Erik de Leeuw
- Department of Neurology, Radboud University Nijmegen Medical Centre, Donders Institute for Brain, Cognition and Behaviour, Centre for Neuroscience, PO Box 9101, 6500 HB, Nijmegen, Netherlands
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Obusez EC, Hui F, Hajj-Ali RA, Cerejo R, Calabrese LH, Hammad T, Jones SE. High-resolution MRI vessel wall imaging: spatial and temporal patterns of reversible cerebral vasoconstriction syndrome and central nervous system vasculitis. AJNR Am J Neuroradiol 2014; 35:1527-32. [PMID: 24722305 DOI: 10.3174/ajnr.a3909] [Citation(s) in RCA: 189] [Impact Index Per Article: 18.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Abstract
BACKGROUND AND PURPOSE High-resolution MR imaging is an emerging tool for evaluating intracranial artery disease. It has an advantage of defining vessel wall characteristics of intracranial vascular diseases. We investigated high-resolution MR imaging arterial wall characteristics of CNS vasculitis and reversible cerebral vasoconstriction syndrome to determine wall pattern changes during a follow-up period. MATERIALS AND METHODS We retrospectively reviewed 3T-high-resolution MR imaging vessel wall studies performed on 26 patients with a confirmed diagnosis of CNS vasculitis and reversible cerebral vasoconstriction syndrome during a follow-up period. Vessel wall imaging protocol included black-blood contrast-enhanced T1-weighted sequences with fat suppression and a saturation band, and time-of-flight MRA of the circle of Willis. Vessel wall characteristics including enhancement, wall thickening, and lumen narrowing were collected. RESULTS Thirteen patients with CNS vasculitis and 13 patients with reversible cerebral vasoconstriction syndrome were included. In the CNS vasculitis group, 9 patients showed smooth, concentric wall enhancement and thickening; 3 patients had smooth, eccentric wall enhancement and thickening; and 1 patient was without wall enhancement and thickening. Six of 13 patients had follow-up imaging; 4 patients showed stable smooth, concentric enhancement and thickening; and 2 patients had resoluton of initial imaging findings. In the reversible cerebral vasoconstriction syndrome group, 10 patients showed diffuse, uniform wall thickening with negligible-to-mild enhancement. Nine patients had follow-up imaging, with 8 patients showing complete resolution of the initial findings. CONCLUSIONS Postgadolinium 3T-high-resolution MR imaging appears to be a feasible tool in differentiating vessel wall patterns of CNS vasculitis and reversible cerebral vasoconstriction syndrome changes during a follow-up period.
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Affiliation(s)
- E C Obusez
- From the Department of Diagnostic Radiology (E.C.O., S.E.J.), Imaging Institute
| | - F Hui
- Cerebrovascular Center (F.H.)
| | - R A Hajj-Ali
- Department of Neurology (R.A.H., R.C.), Neurological Institute
| | - R Cerejo
- Department of Neurology (R.A.H., R.C.), Neurological Institute
| | - L H Calabrese
- Department of Rheumatology (L.H.C., T.H.), Orthopaedic and Rheumatology Institute, Cleveland Clinic, Cleveland, Ohio
| | - T Hammad
- Department of Rheumatology (L.H.C., T.H.), Orthopaedic and Rheumatology Institute, Cleveland Clinic, Cleveland, Ohio
| | - S E Jones
- From the Department of Diagnostic Radiology (E.C.O., S.E.J.), Imaging Institute
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179
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Calic Z, Choong H, Schlaphoff G, Cappelen-Smith C. Reversible cerebral vasoconstriction syndrome following indomethacin. Cephalalgia 2014; 34:1181-6. [PMID: 24723675 DOI: 10.1177/0333102414530526] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND Reversible cerebral vasoconstriction syndrome (RCVS) is characterized by severe thunderclap headaches and transient segmental cerebral arterial vasoconstriction. Precipitating factors, including the postpartum state and exposure to vasoactive substances are identified in approximately 50% of cases. Non-steroidal anti-inflammatory drugs have rarely been associated with RCVS. CASE DESCRIPTION We report a case of a 51-year-old female with RCVS after administration of indomethacin given to relieve pain caused by renal colic. Cerebral imaging showed non-aneurysmal cortical subarachnoid hemorrhage, and formal angiography demonstrated widespread multifocal segmental narrowing of medium-sized cerebral arteries. These changes resolved on repeat angiography at 3 weeks. DISCUSSION Indomethacin is a commonly used drug for treatment of certain primary headache disorders. To date, its mechanism of action remains unclear. A well described side effect of indomethacin is headache, which may be secondary to its vasoconstrictive effects. In our case, we postulate indomethacin, either alone or in combination with emotional stress from pain, triggered or exacerbated an underlying predisposition to RCVS.
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Affiliation(s)
- Zeljka Calic
- Department of Neurology and Neurophysiology, Liverpool Hospital, Australia South Western Sydney Clinical School, University of New South Wales, Australia
| | - Ho Choong
- Department of Neurology and Neurophysiology, Liverpool Hospital, Australia South Western Sydney Clinical School, University of New South Wales, Australia
| | | | - Cecilia Cappelen-Smith
- Department of Neurology and Neurophysiology, Liverpool Hospital, Australia South Western Sydney Clinical School, University of New South Wales, Australia
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180
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Berlit P, Kraemer M. Cerebral vasculitis in adults: what are the steps in order to establish the diagnosis? Red flags and pitfalls. Clin Exp Immunol 2014; 175:419-24. [PMID: 24117125 DOI: 10.1111/cei.12221] [Citation(s) in RCA: 71] [Impact Index Per Article: 7.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/04/2013] [Indexed: 12/29/2022] Open
Abstract
Cerebral vasculitis is a rare cause of juvenile stroke. It may occur as primary angiitis of the central nervous system (PACNS) or as CNS manifestation in the setting of systemic vasculitis. Clinical hints for vasculitis are headache, stroke, seizures, encephalopathy and signs of a systemic inflammatory disorder. Diagnostic work-up includes anamnesis, whole body examination, laboratory and cerebral spinal fluid (CSF) studies, magnetic resonance imaging (MRI), angiography and brain biopsy. Due to the rarity of the disease, exclusion of more frequent differential diagnoses is a key element of diagnostic work -up. This review summarizes the steps that lead to the diagnosis of cerebral vasculitis and describes the red flags and pitfalls. Despite considering the dilemma of angiography-negative vasculitis and false-negative brain biopsy in some cases, it is important to protect patients from 'blind' immunosuppressive therapy in unrecognized non-inflammatory differential diagnosis.
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Affiliation(s)
- P Berlit
- Department of Neurology, Alfried Krupp Hospital, Essen, Germany
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181
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Chen SP, Wang SJ. Hyperintense vessels: an early MRI marker of reversible cerebral vasoconstriction syndrome? Cephalalgia 2014; 34:1038-9. [PMID: 24715501 DOI: 10.1177/0333102414529193] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Affiliation(s)
- Shih-Pin Chen
- Faculty of Medicine, School of Medicine, National Yang-Ming University, Taiwan Department of Neurology, Neurological Institute, Taipei Veterans General Hospital, Taiwan Brain Research Center, National Yang-Ming University, Taiwan
| | - Shuu-Jiun Wang
- Faculty of Medicine, School of Medicine, National Yang-Ming University, Taiwan Department of Neurology, Neurological Institute, Taipei Veterans General Hospital, Taiwan Brain Research Center, National Yang-Ming University, Taiwan Institute of Brain Science, National Yang-Ming University, Taiwan
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182
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Nakajima M, Inatomi Y, Yonehara T, Hirano T, Ando Y. Nontraumatic convexal subarachnoid hemorrhage concomitant with acute ischemic stroke. J Stroke Cerebrovasc Dis 2014; 23:1564-70. [PMID: 24630829 DOI: 10.1016/j.jstrokecerebrovasdis.2013.12.046] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/26/2013] [Revised: 12/23/2013] [Accepted: 12/25/2013] [Indexed: 12/18/2022] Open
Abstract
BACKGROUND Nontraumatic convexal subarachnoid hemorrhage (cSAH) rarely occurs subsequent to acute ischemic stroke. The incidence, clinical background characteristics, and outcomes in acute ischemic stroke patients with cSAH were investigated. METHODS Our stroke center database was reviewed to identify patients with acute ischemic stroke/transient ischemic attack (TIA) who demonstrated acute cSAH within 14 days of admission between 2005 and 2011. Background characteristics, clinical course, and outcomes at discharge and 3 months after onset were investigated in these patients. RESULTS Of 4953 acute stroke/TIA patients, cSAH was observed in 8 (.14%) patients (7 men, mean age 71 years): 7 were detected incidentally, and the other was found immediately after a convulsion. Two patients died during their hospital stay, 1 died after discharge, and 3 were dependent at 3 months. Major artery occlusion or severe stenosis was observed in 5 patients. Two patients subsequently developed subcortical hemorrhage. On gradient echo imaging, lobar cerebral microbleeds were observed in 2 patients, and chronic superficial siderosis was observed in 2 patients. CONCLUSIONS In this retrospective review of cases with ischemic stroke and cSAH, over half of patients had occlusion of major arteries. Cerebral amyloid angiopathy was suggested by magnetic resonance imaging findings and subsequent events in 3 patients. The overall outcome was unfavorable although the causal relationship with cSAH was unclear.
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Affiliation(s)
- Makoto Nakajima
- Department of Neurology, Stroke Center, Saiseikai Kumamoto Hospital, Kumamoto, Japan.
| | - Yuichiro Inatomi
- Department of Neurology, Stroke Center, Saiseikai Kumamoto Hospital, Kumamoto, Japan
| | - Toshiro Yonehara
- Department of Neurology, Stroke Center, Saiseikai Kumamoto Hospital, Kumamoto, Japan
| | - Teruyuki Hirano
- Department of Neurology and Neuromuscular Disorder, Oita University Faculty of Medicine, Yufu, Japan
| | - Yukio Ando
- Department of Neurology, Graduate School of Medical Sciences, Kumamoto University, Kumamoto, Japan
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183
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Dou YH, Fuh JL, Chen SP, Wang SJ. Reversible cerebral vasoconstriction syndrome after blood transfusion. Headache 2014; 54:736-44. [PMID: 24628283 DOI: 10.1111/head.12319] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 12/27/2013] [Indexed: 12/27/2022]
Abstract
OBJECTIVES To report 2 cases of reversible cerebral vasoconstriction syndrome (RCVS) with posterior reversible encephalopathy syndrome (PRES) after blood transfusion for severe anemia. BACKGROUND RCVS is presented with recurrent thunderclap headache and reversible constriction of cerebral arteries. PRES is a known complication of RCVS. Blood transfusion for severe anemia could be a cause for PRES in few cases; however, it is seldom mentioned as an etiology for RCVS. METHODS We report a case series. RESULTS We report 2 women presented with RCVS with PRES after blood transfusion for anemia, and reviewed another 4 similar cases reported in the literature. Our 2 patients were middle-aged women, with severe chronic anemia (average hemoglobin: 1.45 g/dL), and received multiple blood transfusions (average: 3250 mL) over a period of 5-7 days. They developed thunderclap headache and other symptoms about 1 week after the last blood transfusion. Cerebral vasoconstrictions were demonstrated by magnetic resonance angiography and transcranial color-coded sonography. PRES was found in both of them using magnetic resonance imaging, and one of them also had cytotoxic edema on diffusion weighted image. CONCLUSIONS RCVS with PRES is one complication of blood transfusion in patients under chronic severe anemia (especially when hemoglobin level increased for more than 5 g/dL), particularly in Asian women with menorrhagia. Blood pressure surge and the occurrence of severe headaches or other neurological symptoms should be aggressively monitored within 10 days after the last blood transfusion.
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Affiliation(s)
- Yi-Hsuan Dou
- Department of Neurology, Neurological Institute, Taipei Veterans General Hospital, Taipei, Taiwan; Faculty of Medicine, National Yang-Ming University School of Medicine, Taipei, Taiwan
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184
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Cheng YC, Kuo KH, Lai TH. A common cause of sudden and thunderclap headaches: reversible cerebral vasoconstriction syndrome. J Headache Pain 2014; 15:13. [PMID: 24580731 PMCID: PMC3973996 DOI: 10.1186/1129-2377-15-13] [Citation(s) in RCA: 28] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/13/2013] [Accepted: 02/19/2014] [Indexed: 01/19/2023] Open
Abstract
Background Thunderclap headache (TCH) is a sudden headache (SH) with accepted criteria of severe intensity and onset to peak within one minute. It is a well-known presentation for subarachnoid hemorrhage (SAH) but most patients with TCH or SH run a benign course without identifiable causes. Reversible cerebral vasoconstriction syndrome (RCVS), a recently recognized syndrome characterized by recurrent TCH attacks, has been proposed to account for most of these patients. Methods We recruited consecutive patients presenting with SH at our headache clinic. Computed tomography and/or magnetic resonance imaging with angiography were performed to exclude structural causes and to identify vasoconstriction. Catheter angiography and lumbar puncture were performed with patients consent. Reversibility of vasoconstriction was confirmed by follow-up study. Results From July 2010 to June 2013, 31 patients with SH were recruited. Twenty-four (72.7%) of these SH patients exhibited headache fulfilling the TCH criteria. The diagnosis of RCVS was confirmed in 14 (45.2%) of patients with SH and 11 (45.8%) of patients with TCH. Other diagnoses were as follows: primary headaches (SH: 41.9%, TCH: 45.8%) and other secondary causes (SH: 12.9%, TCH: 8.3%). Compared with non-RCVS patients, patients with RCVS were older (50.8 ± 9.3 years vs. 40.8 ± 10.0 years, P = 0.006) and less likely to experience short headache duration of < 1 hour (23.1% vs. 78.6%, P = 0.007). Patients with RCVS were more likely to cite bathing (42.9% vs. 0%, P = 0.004) and less likely to cite exertion (0% vs. 29.4%, P = 0.048) as headache triggers. Conclusions Reversible cerebral vasoconstriction syndrome is a common cause of SH and TCH. Considering the potential mortality and morbidity of RCVS, systemic examination of cerebral vessels should be performed in these patients.
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Affiliation(s)
| | | | - Tzu-Hsien Lai
- Section of Neurology, Department of Internal Medicine, Far Eastern Memorial Hospital, No, 21, Sec, 2, Nanya S, Rd,, Ban-Chiao Dist,, New Taipei City 220, Taiwan.
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Mathur D, Lim LFM, Mathur M, Sng BL. Pituitary apoplexy with reversible cerebral vasoconstrictive syndrome after spinal anaesthesia for emergency caesarean section: an uncommon cause for postpartum headache. Anaesth Intensive Care 2014; 42:99-105. [PMID: 24471671 DOI: 10.1177/0310057x1404200118] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Pituitary apoplexy is a rare condition involving pituitary necrosis following either pituitary haemorrhage or infarction. Similarly, reversible cerebral vasoconstrictive syndrome is a cerebrovascular disorder characterised by diffuse, multifocal narrowing of cerebral arteries. Both may present with an acute, intense headache and associated neurological deficits. In postpartum women, these conditions should be considered in the differential diagnosis of post-dural puncture headache following regional anaesthesia, as serious morbidity may ensue if they are left untreated. We report the case of a patient who developed pituitary apoplexy during an emergency caesarean section under spinal anaesthesia. It was further complicated by the development of reversible cerebral vasoconstriction syndrome and stroke.
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Affiliation(s)
- D Mathur
- Department of Women's Anaesthesia, KK Women's and Children's Hospital, Singapore
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186
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Reversible cerebral vasoconstriction syndromes: what the cardiologist should know. CURRENT TREATMENT OPTIONS IN CARDIOVASCULAR MEDICINE 2014; 16:290. [PMID: 24500680 DOI: 10.1007/s11936-013-0290-1] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
Abstract
OPINION STATEMENT Over the past decade, the reversible cerebral vasoconstriction syndromes (RCVS) have emerged as a group of conditions with easily recognizable clinical-angiographic features and a usually benign prognosis. The RCVS affect young individuals, mostly women, and the majority present with recurrent, severe, 'thunderclap' headaches. Vascular imaging studies show dynamic and reversible narrowing and dilatation of multiple intracerebral arteries. Brain imaging usually shows no parenchymal lesions, however, approximately one-third of patients develop ischemic or hemorrhagic strokes or reversible brain edema. The etiopathogenesis of this syndrome remains unclear. It has been associated with diverse conditions such as pregnancy, vasoconstrictive drug use, and neurovascular procedures. Recent studies characterizing RCVS have made it relatively easy to exclude mimics such as aneurysmal subarachnoid hemorrhage and primary angiitis of the central nervous system. There is no proven treatment, although calcium channel blockers may help to reduce the intensity of headaches. Empiric glucocorticoid treatment should be avoided. Since most patients do well with simple observation alone, invasive strategies such as pharmacologically-induced hypertension, balloon angioplasty, and direct intra-arterial vasodilator infusion should be reserved for patients showing clear clinical progression.
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187
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Hammad TA, Hajj-Ali RA. Primary angiitis of the central nervous system and reversible cerebral vasoconstriction syndrome. Curr Atheroscler Rep 2014; 15:346. [PMID: 23793732 DOI: 10.1007/s11883-013-0346-4] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
Primary angiitis of the central nervous system (PACNS) is one of the most devastating pathologic processes that affect the central nervous system (CNS). It results in exclusive inflammation and destruction of CNS blood vessels. Progressive debilitating unexplained neurological deficit associated with abnormal cerebrospinal fluid (CSF) analysis findings is the typical picture of the disease. CNS biopsy is the gold standard diagnostic test. Immunosuppressive therapy is the core treatment. Reversible cerebral vasoconstriction syndrome (RCVS) is a main mimic of PACNS. RCVS is characterized clinically by recurrent thunderclap headache with or without neurological deficit and normal CSF analysis findings and angiographically by reversible diffuse segmental vasospasm of intracranial vessels. A stepwise diagnostic approach should be followed to differentiate PACNS from RCVS and exclude the other clinical, radiographic, and angiographic mimics.
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Affiliation(s)
- Tariq A Hammad
- Orthopedic and Rheumatologic Institute, Rheumatologic and Immunologic, Cleveland Clinic Foundation, 9500 Euclid Avenue, Cleveland, OH 44195, USA.
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Mathon B, Ducros A, Bresson D, Herbrecht A, Mirone G, Houdart E, Saint-Maurice JP, Di Emidio P, George B, Chibbaro S. Subarachnoid and intra-cerebral hemorrhage in young adults: rare and underdiagnosed. Rev Neurol (Paris) 2014; 170:110-8. [PMID: 24411684 DOI: 10.1016/j.neurol.2013.07.032] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/05/2013] [Revised: 06/03/2013] [Accepted: 07/19/2013] [Indexed: 10/25/2022]
Abstract
OBJECTIVES Convexity subarachnoid and intra-cerebral hemorrhages, in patients aged<50 years, are always a diagnostic challenge. This condition is characterized by acute headaches with or without neurological symptoms and/or seizures, and by the radiological demonstration of subarachnoid and/or intra-cerebral hemorrhages and, more rarely, by the association of ischemic events. PATIENTS AND METHODS In a prospective series of 30 consecutive patients (median age 31 years; 22 women) with a subarachnoid and intra-cerebral hemorrhages, 19 were diagnosed with reversible cerebral vasoconstriction syndrome (RCVS), 7 with cerebral venous sinus thrombosis (CVST), and 4 with a bleeding mycotic aneurysm (MA). RESULTS RCVS appeared spontaneously in 16 patients and was related to the postpartum period in three cases. Subarachnoid hemorrhage (SAH) was demonstrated in 24 patients as follows: 18 cases were in cortical areas, 4 were in the polygon of Willis, one was inter-hemispheric, and one was inter-hemispheric/intra-cerebral. A convexity pure intra-cerebral hemorrhage (ICH) was recorded in 6 cases. Among the 7 patients suffering from CVST, the superior sagittal sinus was involved in 4 cases, the transverse sinuses (TS) in 2, and the TS plus sigmoid sinus (SS) in one. CONCLUSION The three most common causes in this series were RCVS, followed by CVST and bleeding from MA. Because of atypical clinical or radiological presentations, this large spectrum of etiologies can cause diagnostic difficulties. Therefore, careful analysis is needed to ensure correct and prompt diagnosis and to avoid any dangerous delays in management.
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Affiliation(s)
- B Mathon
- Service de neurochirurgie, CHU Lariboisière, 2, rue Ambroise-Paré, 75475 Paris cedex 10, France.
| | - A Ducros
- Service de neurologie, CHU Lariboisière, 2, rue Ambroise-Paré, 75475 Paris cedex 10, France
| | - D Bresson
- Service de neurochirurgie, CHU Lariboisière, 2, rue Ambroise-Paré, 75475 Paris cedex 10, France
| | - A Herbrecht
- Service de neurochirurgie, CHU Lariboisière, 2, rue Ambroise-Paré, 75475 Paris cedex 10, France
| | - G Mirone
- Service de neurochirurgie, CHU Lariboisière, 2, rue Ambroise-Paré, 75475 Paris cedex 10, France
| | - E Houdart
- Service de neuroradiologie interventionnelle, CHU Lariboisière, 2, rue Ambroise-Paré, 75475 Paris cedex 10, France
| | - J-P Saint-Maurice
- Service de neuroradiologie interventionnelle, CHU Lariboisière, 2, rue Ambroise-Paré, 75475 Paris cedex 10, France
| | - P Di Emidio
- Service de neurochirurgie, CHU Lariboisière, 2, rue Ambroise-Paré, 75475 Paris cedex 10, France
| | - B George
- Service de neurochirurgie, CHU Lariboisière, 2, rue Ambroise-Paré, 75475 Paris cedex 10, France
| | - S Chibbaro
- Service de neurochirurgie, CHU Lariboisière, 2, rue Ambroise-Paré, 75475 Paris cedex 10, France
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189
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Nouh A, Ruland S, Schneck MJ, Pasquale D, Biller J. Reversible Cerebral Vasoconstriction Syndrome with Multivessel Cervical Artery Dissections and a Double Aortic Arch. J Stroke Cerebrovasc Dis 2014; 23:e141-3. [DOI: 10.1016/j.jstrokecerebrovasdis.2013.08.013] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/06/2013] [Revised: 08/20/2013] [Accepted: 08/21/2013] [Indexed: 11/24/2022] Open
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Dramatic intracerebral hemorrhagic presentations of reversible cerebral vasoconstriction syndrome: three cases and a literature review. Case Rep Neurol Med 2014; 2014:782028. [PMID: 24707417 PMCID: PMC3965932 DOI: 10.1155/2014/782028] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/24/2013] [Accepted: 10/10/2013] [Indexed: 12/17/2022] Open
Abstract
Reversible cerebral vasoconstriction syndrome (RCVS) refers to a number of disorders characterized by severe and sudden-onset (“thunderclap”) headaches and angiographic features of reversible, segmental, multifocal vasoconstriction of cerebral arteries. Although RCVS generally resolves without significant sequelae, a rare and possibly underrecognized hemorrhagic presentation has a worse potential course. We report three cases of hemorrhagic RCVS and review the literature. Three females (42, 54, and 33 years old, resp.) presented with severe headache, neurological deficits, and dramatic intracerebral hemorrhage (ICH). Patient 1 presented comatose with a 9 × 4 × 6.6 cm left deep intraparenchymal hemorrhage (IPH) and 1 cm midline shift. She underwent emergent surgical intervention. Patient 2 had a 3.3 × 1.5 cm left superior frontal IPH that enlarged to 4 × 2.5 cm within 12 hours with worsening headache and neurological deficits. She was successfully managed nonoperatively. Patient 3, after uncomplicated pregnancy and delivery, presented with a 1.5 cm left superior parietal IPH on postpartum day 7. Two days later, she acutely developed right hemiplegia. Repeat CT demonstrated a new 3.3 × 1.7 cm left frontal IPH. She was also successfully managed nonoperatively. Many diverse conditions are grouped within the category of RCVS. Dramatic ICH remains a rare and possibly underrecognized presenting feature. Prompt diagnosis and management are essential for obtaining the best outcome.
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191
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Abstract
Reversible cerebral vasoconstriction syndrome is characterized by severe headaches with or without focal neurologic deficits and/or seizures, and segmental constriction of cerebral arteries that resolves within 3 months. This increasingly recognized syndrome is supposedly due to a transient disturbance in the control of cerebral vascular tone with sympathetic overactivity. It can cause stroke in the young. It affects mainly middle-aged women. More than half the cases occur after exposure to vasoactive substances or during postpartum. The manifestations have a monophasic course, without new clinical symptom after 4 weeks, and range from pure cephalalgic forms with recurrent thunderclap headaches over 1-2 weeks to rare catastrophic forms with multiple hemorrhagic and ischemic strokes, brain edema and death. Diagnosis may be hampered by the dynamic nature of clinicoradiological features. Convexity subarachnoid hemorrhage or stroke may occur a few days after initial normal imaging, and cerebral vasoconstriction is maximal on angiography 2-3 weeks after clinical onset. Symptomatic treatment includes rest and removal of vasoactive substances. Nimodipine has been proposed to reduce thunderclap headaches within 48 hours, but has no proven effect on the hemorrhagic and ischemic complications.
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Affiliation(s)
- Anne Ducros
- Department of Neurology, Hôpital Gui de Chauliac, Montpellier, France.
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192
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Oderich GS, Pereira AA, Rabinstein AA, Mendes BC, Pulido JN. Posterior reversible encephalopathy syndrome from induced hypertension during endovascular thoracoabdominal aortic aneurysm repair. J Vasc Surg 2013; 61:1062-5. [PMID: 24365121 DOI: 10.1016/j.jvs.2013.10.052] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/21/2013] [Revised: 10/02/2013] [Accepted: 10/03/2013] [Indexed: 11/30/2022]
Abstract
Endovascular repair of thoracoabdominal aortic aneurysm has been increasingly performed using fenestrated and branched endografts. Spinal cord injury is a complication of complex endovascular aortic repair, especially in patients with extensive aortic involvement. Maneuvers commonly used to avoid spinal cord injury include cerebrospinal fluid drainage and induced hypertension. Posterior reversible encephalopathy syndrome is associated with abnormal cerebral autoregulation through endothelial and blood-brain barrier dysfunction; the pathophysiology involves vasogenic edema, and severe hypertension is a recognized trigger. We report on a patient who developed posterior reversible encephalopathy syndrome associated with induced hypertension used to prevent spinal cord injury during endovascular repair of a type II thoracoabdominal aortic aneurysm using fenestrated and branched stent grafts.
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Affiliation(s)
- Gustavo S Oderich
- Gonda Vascular Center, Division of Vascular and Endovascular Surgery, Mayo Clinic, Rochester, Minn.
| | - Alexandre A Pereira
- Gonda Vascular Center, Division of Vascular and Endovascular Surgery, Mayo Clinic, Rochester, Minn
| | | | - Bernardo C Mendes
- Gonda Vascular Center, Division of Vascular and Endovascular Surgery, Mayo Clinic, Rochester, Minn
| | - Juan N Pulido
- Department of Anesthesiology, Mayo Clinic, Rochester, Minn
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193
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Chen SP, Yang AC, Fuh JL, Wang SJ. Autonomic dysfunction in reversible cerebral vasoconstriction syndromes. J Headache Pain 2013; 14:94. [PMID: 24274860 PMCID: PMC4177393 DOI: 10.1186/1129-2377-14-94] [Citation(s) in RCA: 32] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/07/2013] [Accepted: 11/19/2013] [Indexed: 12/22/2022] Open
Abstract
Background Autonomic imbalance may play an important role in the pathogenesis of reversible cerebral vasoconstriction syndromes (RCVS). This study aimed to assess the autonomic function by analyzing heart rate variability (HRV) in patients with RCVS. Methods Patients with RCVS and age- and gender-matched controls were consecutively recruited. All patients (both ictal and remission stage) and controls underwent 24-hour ambulatory electrocardiographic (ECG) recordings. HRV measures covering time and frequency domains were used to assess autonomic functioning. Results Thirty-nine patients with RCVS and 39 controls completed the study. Compared to the controls, RCVS patients during the ictal stage showed reductions in parasympathetic-related indices, including the root mean square of difference of consecutive interbeat intervals (RMSSD) (22.1 ± 7.0 vs. 35.2 ± 14.2, p < 0.001), the percentage of adjacent intervals that varied by more than 50 ms (pNN50) (3.7 ± 3.4 vs. 10.6 ± 8.1, p < 0.001), and high-frequency power (HF) (5.82 ± 0.73 vs. 6.77 ± 0.74; p < 0.001), and increased low-frequency/high-frequency (LF/HF) ratio (index of sympathovagal balance) (3.38 ± 1.32 vs. 2.48 ± 1.07; p =0.001). These HRV indices improved partially but remained significantly different from controls during remission. Conclusions Decreased parasympathetic modulations and accentuated sympathetic activity might be a biological trait in patients with RCVS.
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Affiliation(s)
- Shih-Pin Chen
- Faculty of Medicine, National Yang-Ming University School of Medicine, Taipei, Taiwan.
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194
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Robert T, Kawkabani Marchini A, Oumarou G, Uské A. Reversible cerebral vasoconstriction syndrome identification of prognostic factors. Clin Neurol Neurosurg 2013; 115:2351-7. [DOI: 10.1016/j.clineuro.2013.08.014] [Citation(s) in RCA: 30] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/29/2013] [Revised: 08/10/2013] [Accepted: 08/14/2013] [Indexed: 10/26/2022]
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195
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John S, Donnelly M, Uchino K. Catastrophic reversible cerebral vasoconstriction syndrome associated with serotonin syndrome. Headache 2013; 53:1482-7. [PMID: 24001215 DOI: 10.1111/head.12202] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/08/2013] [Indexed: 11/30/2022]
Abstract
OBJECTIVES To report fulminant cases of reversible cerebral vasoconstriction syndrome (RCVS) in the setting of serotonin syndrome. BACKGROUND RCVS is characterized by acute onset of severe headaches, with or without neurologic deficit, with evidence of reversible cerebral vasoconstriction. It is often benign, and prognosis is generally considered favorable. In the largest prospective study on RCVS, only 4% of patients were disabled from strokes and there were no fatalities. METHODS We report a case series. RESULTS We report 2 women with history of depression on selective serotonin re-uptake inhibitors who presented with thunderclap headache and dizziness, respectively. Through the course of hospitalization, both patients developed rigidity, diaphoresis, fever, tachycardia with labile blood pressures and clonus on examination. Since there was a recent addition/increase in a known serotonergic agent, they met criteria for serotonin syndrome. Cerebrovascular imaging in both patients revealed severe multi-focal vessel narrowing. The first patient developed large bi-hemispheric ischemic infarcts and increased intra-cranial pressure that was refractory to management, and she eventually expired. The second patient developed bilateral parieto-occipital strokes and decerebrate posturing. Her course slowly stabilized, and she was eventually discharged with residual left-sided hemiparesis. Repeat cerebrovascular imaging 1 month later showed normal vessels. In both patients, intra-arterial nicardipine infusion improved angiographic appearance of stenoses, consistent with RCVS. CONCLUSIONS Both cases satisfied the Sternbach criteria for serotonin syndrome. Fatality in case 1 prevents demonstration of reversal of cerebral vasoconstriction, but improvement of arterial diameters with intra-arterial calcium channel blockers in both cases suggests that both had RCVS. Serotonergic agents are known triggers of RCVS, but the concurrent presence of serotonin syndrome likely precipitated the malignant course in our patients. Severe clinical and angiographic manifestations should be considered as part of the spectrum of RCVS.
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Affiliation(s)
- Seby John
- Department of Neurology, Cleveland Clinic, Cleveland, OH, USA
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196
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Bruno VA, Lereis VP, Hawkes M, Ameriso SF. Nontraumatic subarachnoid hemorrhage of the convexity. Curr Neurol Neurosci Rep 2013; 13:338. [PMID: 23423536 DOI: 10.1007/s11910-013-0338-3] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Affiliation(s)
- Verónica Andrea Bruno
- Institute for Neurological Research FLENI, Montañeses 2325, CABA (1428), Buenos Aires, Argentina
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197
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Chen SP, Chung YT, Liu TY, Wang YF, Fuh JL, Wang SJ. Oxidative stress and increased formation of vasoconstricting F2-isoprostanes in patients with reversible cerebral vasoconstriction syndrome. Free Radic Biol Med 2013; 61:243-8. [PMID: 23608464 DOI: 10.1016/j.freeradbiomed.2013.04.022] [Citation(s) in RCA: 37] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/13/2013] [Revised: 03/28/2013] [Accepted: 04/13/2013] [Indexed: 10/26/2022]
Abstract
The pathophysiology of reversible cerebral vasoconstriction syndrome (RCVS) is unknown. Oxidative stress is detrimental to endothelial function and vascular reactivity. We hypothesized that the oxidative stress marker 8-iso-prostaglandin F2α, which is also a potent vasoconstrictor, might contribute to the pathogenesis of RCVS. Recruited participants included 103RCVS patients, 53 patients with primary headache with acute severe attacks, and 54 healthy controls. Subjects recruited prior to 2009 were discovery cohort, whereas those after 2009, replication cohort. Urine samples were obtained from all patients at registration and from 79 patients with RCVS again at remission stage. Urine 8-iso-prostaglandin F2α was analyzed by liquid chromatography-tandem mass spectrometry. Patients with RCVS received magnetic resonance angiography and transcranial color-coded sonography. In RCVS patients, the urine 8-iso-prostaglandin F2α level was higher than that in the other groups in discovery, replication, and combined cohorts (RCVS, 0.29±0.18; primary headache with acute severe attacks, 0.21±0.19; control, 0.18±0.09ng/mg creatinine; P<0.001), and it was positively correlated with the flow velocities of major intracranial arteries, especially within the first week of disease onset (middle cerebral artery, Spearman's correlation coefficient [rs]=0.580, P=0.002; anterior cerebral artery, rs=0.472, P=0.042; posterior cerebral artery, rs=0.457, P=0.022; basilar artery, rs= 0.530, P=0.002). The 8-iso-prostaglandin F2α level decreased from the ictalto remission stage in RCVS patients (0.31±0.21 vs 0.16±0.10ng/mg creatinine, P<0.001). 8-Iso-prostaglandin F2α was higher in patients with RCVS and correlated with the severity of vasoconstrictions. Further studies are required to explore its potential pathogenic role.
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Affiliation(s)
- Shih-Pin Chen
- Department of Neurology, Neurological Institute, Taipei Veterans General Hospital, Taipei, Taiwan; Faculty of Medicine, National Yang-Ming University School of Medicine, Taipei, Taiwan; Brain Research Center, National Yang-Ming University, Taipei, Taiwan.
| | - Yu-Ting Chung
- Institute of Environmental and Occupational Health Sciences, National Yang-Ming University School of Medicine, Taipei, Taiwan; Department of Medical Research & Education, Taipei Veterans General Hospital, Taipei, Taiwan.
| | - Tsung-Yun Liu
- Institute of Environmental and Occupational Health Sciences, National Yang-Ming University School of Medicine, Taipei, Taiwan; Department of Medical Research & Education, Taipei Veterans General Hospital, Taipei, Taiwan; Department and Institute of Pharmacology, School of Medicine, National Yang-Ming University, Taipei.
| | - Yen-Feng Wang
- Department of Neurology, Neurological Institute, Taipei Veterans General Hospital, Taipei, Taiwan; Faculty of Medicine, National Yang-Ming University School of Medicine, Taipei, Taiwan; Brain Research Center, National Yang-Ming University, Taipei, Taiwan.
| | - Jong-Ling Fuh
- Department of Neurology, Neurological Institute, Taipei Veterans General Hospital, Taipei, Taiwan; Faculty of Medicine, National Yang-Ming University School of Medicine, Taipei, Taiwan; Brain Research Center, National Yang-Ming University, Taipei, Taiwan; Institute of Brain Science, National Yang-Ming University, Taipei, Taiwan.
| | - Shuu-Jiun Wang
- Department of Neurology, Neurological Institute, Taipei Veterans General Hospital, Taipei, Taiwan; Faculty of Medicine, National Yang-Ming University School of Medicine, Taipei, Taiwan; Brain Research Center, National Yang-Ming University, Taipei, Taiwan; Institute of Brain Science, National Yang-Ming University, Taipei, Taiwan.
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198
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Velez A, McKinney JS. Reversible cerebral vasoconstriction syndrome: a review of recent research. Curr Neurol Neurosci Rep 2013; 13:319. [PMID: 23250764 DOI: 10.1007/s11910-012-0319-y] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/06/2023]
Abstract
Reversible cerebral vasoconstriction syndrome (RCVS) is a collective term used for transient noninflammatory, nonatherosclerotic segmental constriction of cerebral arteries. The angiopathies of RCVS have previously been defined by several nomenclatures. Current opinion favors the unification of these pathophysiologically related angiopathies because of their similar angiographic features and clinical course. RCVS typically presents acutely as headache, delirium, seizure, cerebral ischemia, and/or hemorrhage. The angiographic features make RCVS an important mimic of CNS vasculitides. In contrast to CNS vasculitis, RCVS is typically a transient condition with relatively good clinical outcomes. Although a complete understanding of the etiological and pathological features of RCVS has not yet been achieved, alterations in vascular tone lead to the observed arterial changes. In this review, we aim to provide a summary of RCVS and provide insight into current perspectives of the underlying pathophysiological processes, diagnosis, and treatment.
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Affiliation(s)
- Arnaldo Velez
- Department of Neurology, Robert Wood Johnson Medical School, University of Medicine and Dentistry of New Jersey, New Brunswick, NJ 08901, USA.
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199
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Affiliation(s)
- Richard P. Goddeau
- Department of Neurology; University of Massachusetts Medical School; Worcester; MA; USA
| | - Adel Alhazzani
- Department of Medicine; King Khalid University; Aseer Central Hospital; Abha; Saudi Arabia
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200
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Probert R, Saunders DE, Ganesan V. Reversible cerebral vasoconstriction syndrome: rare or underrecognized in children? Dev Med Child Neurol 2013; 55:385-9. [PMID: 23066702 DOI: 10.1111/j.1469-8749.2012.04433.x] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
Reversible cerebral vasoconstriction syndrome (RCVS) is a clinicoradiological diagnosis comprising 'thunderclap' headaches and reversible segmental vasoconstriction of cerebral arteries, occasionally complicated by ischaemic or haemorrhagic stroke. We report a case of RCVS in a 13-year-old male with severe thunderclap headaches and no focal neurological signs. Brain imaging showed multiple posterior circulation infarcts; cerebral computed tomography, magnetic resonance imaging, and catheter angiography showed multifocal irregularity and narrowing, but in different arterial segments. Laboratory studies did not support a diagnosis of vasculitis. Symptoms resolved over 3 weeks; magnetic resonance angiography 3 months later was normal and remained so after 2 years. We highlight the typical clinical features of RCVS in this case and suggest that the diagnosis should be considered in children with thunderclap headaches or stroke syndromes where headache is a prominent feature, especially if cerebrovascular imaging studies appear to be evolving or discrepant.
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Affiliation(s)
- Rebecca Probert
- Neurosciences Unit, University College London Institute of Child Health, London, UK.
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