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Wang C, Iftekharuddin A, Fipps DC. Management of Psychiatric Diagnoses in Reversible Cerebral Vasoconstriction Syndrome: The Dangers of Worsening Pathology with Serotonergic Medications: A Case Report and Literature Review. J Psychiatr Pract 2024; 30:379-384. [PMID: 39357021 DOI: 10.1097/pra.0000000000000811] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/04/2024]
Abstract
Reversible cerebral vasoconstriction syndrome (RCVS) represents a group of conditions that show reversible multifocal narrowing or constriction of the cerebral arteries that supply blood to the brain. The initial manifestation of RCVS often includes a "thunderclap" headache that is sudden, severe, and often disabling. Stimulants, selective serotonin reuptake inhibitors, serotonin-norepinephrine reuptake inhibitors, and antipsychotics with serotonergic activity can alter the cerebral arterial tone, trigger vasoconstriction, and place patients at risk of a cerebrovascular accident. Thus, psychiatric medications are commonly discontinued on admission for RCVS, and psychiatry is often consulted for input on acute medication management and longitudinal treatment options. Currently, there is a dearth of literature on managing psychiatric medications in RCVS, resulting in variable practice patterns that place patients at risk of withdrawal, decompensation, and relapse. In this article, we provide a case example and aim to consolidate the limited data surrounding the management of psychiatric illness with comorbid RCVS in our discussion. There is a clear concern about worsening and even potentially lethal consequences due to serotonin or stimulant-induced vasospasm both during an acute episode and in long-term management of RCVS. We discuss the underlying pathophysiologic mechanisms proposed for serotonergic-, noradrenergic-, and dopaminergic-induced cerebral vasospasm and how this correlates with the clinical management of patients on psychiatric medications. These data will then be organized to create a risks versus benefits outline to equip psychiatrists to make decisions about when to stop and when to restart psychiatric medications in the setting of RCVS.
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Affiliation(s)
- Chris Wang
- Department of Psychiatry and Psychology, Mayo Clinic College of Medicine and Science, Rochester, MN
| | | | - David C Fipps
- Department of Psychiatry and Psychology, Mayo Clinic College of Medicine and Science, Rochester, MN
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Collins L, Lam L, Kleinig O, Proudman W, Zhang R, Bagster M, Kovoor J, Gupta A, Goh R, Bacchi S, Schultz D, Kleinig T. Verapamil in the treatment of reversible cerebral vasoconstriction syndrome: A systematic review. J Clin Neurosci 2023; 113:130-141. [PMID: 37267876 DOI: 10.1016/j.jocn.2023.05.013] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/11/2023] [Revised: 05/19/2023] [Accepted: 05/20/2023] [Indexed: 06/04/2023]
Abstract
INTRODUCTION Extrapolating from efficacy in subarachnoid haemorrhage (SAH), nimodipine has been used as a treatment for reversible cerebral vasoconstriction syndrome (RCVS). However, 4-hourly dosing is a practical limitation and verapamil has been proposed as an alternative. The potential efficacy, adverse effects, preferred dosing and formulation of verapamil for RCVS have not been systematically reviewed previously. METHOD A systematic review was conducted of the databases PubMed, EMBASE, and the Cochrane Library from inception to July 2022 for peer-reviewed articles describing the use of verapamil for RCVS. This systematic review adheres to the PRISMA guidelines and was registered on PROSPERO. RESULTS There were 58 articles included in the review, which included 56 patients with RCVS treated with oral verapamil and 15 patients treated with intra-arterial verapamil. The most common oral verapamil dosing regimen was controlled release 120 mg once daily. There were 54/56 patients described to have improvement in headache following oral verapamil and one patient who died from worsening RCVS. Only 2/56 patients noted possible adverse effects with oral verapamil, with none requiring discontinuation. There was one case of hypotension from combined oral and intra-arterial verapamil. Vascular complications including ischaemic and haemorrhagic stroke were recorded in 33/56 patients. RCVS recurrence was described in 9 patients, with 2 cases upon weaning oral verapamil. CONCLUSIONS While no randomised studies exist to support the use of verapamil in RCVS, observational data support a possible clinical benefit. Verapamil appears well tolerated in this setting and represents a reasonable treatment option. Randomised controlled trials including comparison with nimodipine are warranted.
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Affiliation(s)
- Luke Collins
- Flinders Medical Centre, Bedford Park, SA 5042, Australia.
| | - Lydia Lam
- University of Adelaide, Adelaide, SA 5005, Australia
| | | | | | - Ruyi Zhang
- Flinders Medical Centre, Bedford Park, SA 5042, Australia
| | - Michelle Bagster
- University of Adelaide, Adelaide, SA 5005, Australia; Lyell McEwin Hospital, Elizabeth Vale, SA 5112, Australia
| | - Joshua Kovoor
- University of Adelaide, Adelaide, SA 5005, Australia; Royal Adelaide Hospital, Adelaide, SA 5000, Australia
| | - Aashray Gupta
- University of Adelaide, Adelaide, SA 5005, Australia
| | - Rudy Goh
- Lyell McEwin Hospital, Elizabeth Vale, SA 5112, Australia
| | - Stephen Bacchi
- Flinders Medical Centre, Bedford Park, SA 5042, Australia; University of Adelaide, Adelaide, SA 5005, Australia; Royal Adelaide Hospital, Adelaide, SA 5000, Australia
| | - David Schultz
- Flinders Medical Centre, Bedford Park, SA 5042, Australia
| | - Timothy Kleinig
- University of Adelaide, Adelaide, SA 5005, Australia; Royal Adelaide Hospital, Adelaide, SA 5000, Australia
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Tryptophan Metabolism and Gut-Brain Homeostasis. Int J Mol Sci 2021; 22:ijms22062973. [PMID: 33804088 PMCID: PMC8000752 DOI: 10.3390/ijms22062973] [Citation(s) in RCA: 171] [Impact Index Per Article: 57.0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/12/2021] [Revised: 03/10/2021] [Accepted: 03/11/2021] [Indexed: 02/06/2023] Open
Abstract
Tryptophan is an essential amino acid critical for protein synthesis in humans that has emerged as a key player in the microbiota-gut-brain axis. It is the only precursor for the neurotransmitter serotonin, which is vital for the processing of emotional regulation, hunger, sleep, and pain, as well as colonic motility and secretory activity in the gut. Tryptophan catabolites from the kynurenine degradation pathway also modulate neural activity and are active in the systemic inflammatory cascade. Additionally, tryptophan and its metabolites support the development of the central and enteric nervous systems. Accordingly, dysregulation of tryptophan metabolites plays a central role in the pathogenesis of many neurologic and psychiatric disorders. Gut microbes influence tryptophan metabolism directly and indirectly, with corresponding changes in behavior and cognition. The gut microbiome has thus garnered much attention as a therapeutic target for both neurologic and psychiatric disorders where tryptophan and its metabolites play a prominent role. In this review, we will touch upon some of these features and their involvement in health and disease.
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