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Edlow JA, Singhal AB, Romero JM. Case 18-2024: A 64-Year-Old Woman with the Worst Headache of Her Life. N Engl J Med 2024; 390:2108-2118. [PMID: 38865664 DOI: 10.1056/nejmcpc2402484] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 06/14/2024]
Affiliation(s)
- Jonathan A Edlow
- From the Department of Emergency Medicine, Beth Israel Deaconess Medical Center and Harvard Medical School (J.A.E.), and the Departments of Neurology (A.B.S.) and Radiology (J.M.R.), Massachusetts General Hospital and Harvard Medical School - all in Boston
| | - Aneesh B Singhal
- From the Department of Emergency Medicine, Beth Israel Deaconess Medical Center and Harvard Medical School (J.A.E.), and the Departments of Neurology (A.B.S.) and Radiology (J.M.R.), Massachusetts General Hospital and Harvard Medical School - all in Boston
| | - Javier M Romero
- From the Department of Emergency Medicine, Beth Israel Deaconess Medical Center and Harvard Medical School (J.A.E.), and the Departments of Neurology (A.B.S.) and Radiology (J.M.R.), Massachusetts General Hospital and Harvard Medical School - all in Boston
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Tentolouris-Piperas V, Lymperopoulos L, Tountopoulou A, Vassilopoulou S, Mitsikostas DD. Headache Attributed to Reversible Cerebral Vasoconstriction Syndrome (RCVS). Diagnostics (Basel) 2023; 13:2730. [PMID: 37685270 PMCID: PMC10487016 DOI: 10.3390/diagnostics13172730] [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: 07/10/2023] [Revised: 08/10/2023] [Accepted: 08/18/2023] [Indexed: 09/10/2023] Open
Abstract
Reversible cerebral vasoconstriction syndrome (RCVS) is a condition with variable outcomes presenting a new onset thunderclap headache accompanied by focal neurological symptoms or seizures. It can be idiopathic or arise secondarily to a variety of trigger factors. The condition is increasingly recognized in clinical practice, but many facets remain poorly understood. This article aims to clarify the headache characteristics in RCVS, the temporal association of angiographic findings, the potential association of the condition with SARS-CoV-2 infection, and the clinical presentation of RCVS in children and is based on a systematic PRISMA search for published analytical or large descriptive observational studies. Data from 60 studies that fulfilled specific criteria were reviewed. Most people with RCVS exhibit a typical thunderclap, explosive, or pulsatile/throbbing headache, or a similar acute and severe headache that takes longer than 1 min to peak. Atypical presentations or absence of headaches are also reported and may be an underrecognized phenotype. In many cases, headaches may persist after resolution of RCVS. Focal deficits or seizures are attributed to associated complications including transient ischemic attacks, posterior reversible encephalopathy syndrome, ischemic stroke, cerebral edema, and intracranial hemorrhage. The peak of vasoconstriction occurs usually within two weeks after clinical onset, possibly following a pattern of centripetal propagation, and tends to resolve completely within 3 months, well after symptoms have subsided. There are a few reports of RCVS occurring in relation to SARS-CoV-2 infection, but potential underlying pathophysiologic mechanisms and etiological associations have not been confirmed. RCVS occurs in children most often in the context of an underlying disease. Overall, the available data in the literature are scattered, and large-scale prospective studies and international collaborations are needed to further characterize the clinical presentation of RCVS.
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Affiliation(s)
| | | | | | | | - Dimos D. Mitsikostas
- 1st Department of Neurology, Eginition Hospital, School of Medicine, National and Kapodistrian University of Athens, 11528 Athens, Greece; (V.T.-P.); (L.L.); (A.T.); (S.V.)
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Reversible Cerebral Vasoconstriction Syndromes. Stroke 2022. [DOI: 10.1016/b978-0-323-69424-7.00037-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
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Glössmann K, Baumgartner C, Koren JP, Riederer F. Recurrent migraine aura-like symptoms in an elderly woman: symptomatic cortical spreading depression? BMJ Case Rep 2021; 14:e241479. [PMID: 34226251 PMCID: PMC8258541 DOI: 10.1136/bcr-2020-241479] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/11/2021] [Indexed: 11/04/2022] Open
Abstract
Cortical spreading depression (CSD) has been directly observed in humans with malignant stroke, traumatic brain injury and subarachnoid haemorrhage and is also considered to be the correlate of migraine aura. We report on a 76-year-old woman with new-onset episodes of headache, paraesthesia, hemiparesis and dysarthria, in whom a small cortical subarachnoid haemorrhage was diagnosed with MRI. Repeated diffusion-weighted MRI scans shortly after transient focal neurological episodes as well as diagnostic workup were normal, which makes recurrent transient ischaemic attacks unlikely. Ictal electroencephalogram recordings showed no epileptic activity. Long-term follow-up revealed a diagnosis of probable cerebral amyloid angiopathy. We propose that CSD could be a pathophysiological correlate of transient focal neurological deficits in patients with cortical bleeding.
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Affiliation(s)
| | - Christoph Baumgartner
- Department of Neurology, Clinic Hietzing, Wien, Austria
- Karl Landsteiner Institute for Clinical Epilepsy Research and Cognitive Neurology, Vienna, Austria
- Sigmund Freud Private University, Vienna, Austria
| | - Johannes Peter Koren
- Department of Neurology, Clinic Hietzing, Wien, Austria
- Karl Landsteiner Institute for Clinical Epilepsy Research and Cognitive Neurology, Vienna, Austria
| | - Franz Riederer
- Department of Neurology, Clinic Hietzing, Wien, Austria
- University of Zurich, Zurich, Switzerland
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Smith EE, Charidimou A, Ayata C, Werring DJ, Greenberg SM. Cerebral Amyloid Angiopathy-Related Transient Focal Neurologic Episodes. Neurology 2021; 97:231-238. [PMID: 34016709 PMCID: PMC8356377 DOI: 10.1212/wnl.0000000000012234] [Citation(s) in RCA: 38] [Impact Index Per Article: 12.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/08/2020] [Accepted: 04/19/2021] [Indexed: 12/22/2022] Open
Abstract
Transient focal neurologic episodes (TFNEs) are brief disturbances in motor, somatosensory, visual, or language functions that can occur in patients with cerebral amyloid angiopathy (CAA) and may be difficult to distinguish from TIAs or other transient neurologic syndromes. They herald a high rate of future lobar intracerebral hemorrhage, making it imperative to differentiate them from TIAs to avoid potentially dangerous use of antithrombotic drugs. Cortical spreading depression or depolarization triggered by acute or chronic superficial brain bleeding, a contributor to brain injury in other neurologic diseases, may be the underlying mechanism. This review discusses diagnosis, pathophysiology, and management of CAA-related TFNEs.
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Affiliation(s)
- Eric E Smith
- From the Department of Clinical Neurosciences (E.E.S.), Hotchkiss Brain Institute, University of Calgary, Canada; Hemorrhagic Stroke Research Program (A.C., S.M.G.), Department of Neurology, Massachusetts General Hospital Stroke Research Center, Harvard Medical School; Stroke Service and Neurovascular Research Lab (C.A.), Department of Neurology, Massachusetts General Hospital, Boston; and Stroke Research Centre (D.J.W.), University College London Queen Square Institute of Neurology, UK.
| | - Andreas Charidimou
- From the Department of Clinical Neurosciences (E.E.S.), Hotchkiss Brain Institute, University of Calgary, Canada; Hemorrhagic Stroke Research Program (A.C., S.M.G.), Department of Neurology, Massachusetts General Hospital Stroke Research Center, Harvard Medical School; Stroke Service and Neurovascular Research Lab (C.A.), Department of Neurology, Massachusetts General Hospital, Boston; and Stroke Research Centre (D.J.W.), University College London Queen Square Institute of Neurology, UK
| | - Cenk Ayata
- From the Department of Clinical Neurosciences (E.E.S.), Hotchkiss Brain Institute, University of Calgary, Canada; Hemorrhagic Stroke Research Program (A.C., S.M.G.), Department of Neurology, Massachusetts General Hospital Stroke Research Center, Harvard Medical School; Stroke Service and Neurovascular Research Lab (C.A.), Department of Neurology, Massachusetts General Hospital, Boston; and Stroke Research Centre (D.J.W.), University College London Queen Square Institute of Neurology, UK
| | - David J Werring
- From the Department of Clinical Neurosciences (E.E.S.), Hotchkiss Brain Institute, University of Calgary, Canada; Hemorrhagic Stroke Research Program (A.C., S.M.G.), Department of Neurology, Massachusetts General Hospital Stroke Research Center, Harvard Medical School; Stroke Service and Neurovascular Research Lab (C.A.), Department of Neurology, Massachusetts General Hospital, Boston; and Stroke Research Centre (D.J.W.), University College London Queen Square Institute of Neurology, UK
| | - Steven M Greenberg
- From the Department of Clinical Neurosciences (E.E.S.), Hotchkiss Brain Institute, University of Calgary, Canada; Hemorrhagic Stroke Research Program (A.C., S.M.G.), Department of Neurology, Massachusetts General Hospital Stroke Research Center, Harvard Medical School; Stroke Service and Neurovascular Research Lab (C.A.), Department of Neurology, Massachusetts General Hospital, Boston; and Stroke Research Centre (D.J.W.), University College London Queen Square Institute of Neurology, UK
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Han J, Cao D, Wang H, Ji Y, Kang Z, Zhu J. Spinal dural arteriovenous fistula presenting with subarachnoid hemorrhage: A case report. Medicine (Baltimore) 2018; 97:e0513. [PMID: 29668636 PMCID: PMC5916701 DOI: 10.1097/md.0000000000010513] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/19/2022] Open
Abstract
RATIONALE Subarachnoid hemorrhage (SAH) is a common and serious disease and one of the most important differential diagnoses in the emergency department. PATIENT CONCERNS A 39-year-old female patient with a 12 years' history of migraine, presented with a sudden headache combined with motor aphasia. Physical examination suggested probable positive neck resistance. SAH was confirmed by magnetic resonance imaging. In addition, spinal digital subtraction angiography and spinal vascular computed tomography angiography indicated spinal arteriovenous malformation (SAVM). DIAGNOSES The final diagnosis was spinal dural arteriovenous fistula presenting with SAH. INTERVENTIONS Following diagnosis, appropriate drugs were administered, but the therapeutic effect was poor. Then the patient was then transferred to a superior hospital where she was treated with interventional embolization. OUTCOMES Through 2 years of follow-up, intermittent migraine was found in the patient, but the symptoms of occipital pain, nausea, and vomiting did not occur again. LESSONS For patients who have been diagnosed with SAH but have no definite cause, we should pay attention to the etiological screening of SAH, and the possibility of the spinal cord SAH should be vigilant. The pain in the chest and back and the signs of spinal cord may be an important breakthrough in patients with spinal cord SAH, and medical history and physical examination are particularly important.
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Affiliation(s)
| | | | | | | | - Zhilei Kang
- Department of Magnetic Resonance, Harrison International Peace Hospital, Hengshui, Hebei, China
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Mao DQ, Addess D, Valsamis H. A report of nontraumatic cortical subarachnoid hemorrhage and subsequent management. FUTURE NEUROLOGY 2017; 11:231-235. [PMID: 28757807 PMCID: PMC5480783 DOI: 10.2217/fnl-2016-0016] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/10/2016] [Accepted: 09/29/2016] [Indexed: 11/21/2022]
Abstract
Aim: Report a case of cortical subarachnoid hemorrhage (cSAH) and discuss its management. Patient & methods: A 66-year-old woman presents with acute onset left arm numbness and weakness. Initial head CT shows small hyperdensity in sulci typical for cSAH. Extensive workup with MRI, lumbar puncture and blood tests is performed. No signs of infection, vascular malformations, thrombosis or cancer are found. At outpatient follow-up, she is diagnosed with cSAH secondary to amyloid angiopathy. She is treated with gabapentin. Results & conclusion: Diagnosis of cSAH is challenging given its subtle findings, and management is empiric as there are only a few case series in literature.
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Affiliation(s)
- David Qiyuan Mao
- SUNY Downstate Medical Center, Department of Neurology, 450 Clarkson Avenue, Brooklyn, NY 11203, USA.,SUNY Downstate Medical Center, Department of Neurology, 450 Clarkson Avenue, Brooklyn, NY 11203, USA
| | - Daniel Addess
- SUNY Downstate Medical Center, Department of Neurology, 450 Clarkson Avenue, Brooklyn, NY 11203, USA.,SUNY Downstate Medical Center, Department of Neurology, 450 Clarkson Avenue, Brooklyn, NY 11203, USA
| | - Helen Valsamis
- Kings County Hospital Center, Department of Neurology, 451 Clarkson Ave, Brooklyn, NY 11203, USA.,Kings County Hospital Center, Department of Neurology, 451 Clarkson Ave, Brooklyn, NY 11203, USA
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Spontaneous convexity subarachnoid haemorrhage: Clinical series of 3 patients with associated cerebral amyloid angiopathy. NEUROLOGÍA (ENGLISH EDITION) 2017. [DOI: 10.1016/j.nrleng.2015.11.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
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Graff-Radford J, Fugate JE, Klaas J, Flemming KD, Brown RD, Rabinstein AA. Distinguishing clinical and radiological features of non-traumatic convexal subarachnoid hemorrhage. Eur J Neurol 2016; 23:839-46. [PMID: 26910197 DOI: 10.1111/ene.12926] [Citation(s) in RCA: 28] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/10/2015] [Accepted: 11/04/2015] [Indexed: 12/29/2022]
Abstract
BACKGROUND AND PURPOSE The full spectrum of causes of convexal subarachnoid hemorrhage (cSAH) requires further investigation. Therefore, our objective was to describe the spectrum of clinical and imaging features of patients with non-traumatic cSAH. METHODS A retrospective observational study of consecutive patients with non-traumatic cSAH was performed at a tertiary referral center. The underlying cause of cSAH was characterized and clinical and imaging features that predict a specific etiology were identified. The frequency of future cSAH or intracerebral hemorrhage (ICH) was determined. RESULTS In all, 88 patients [median age 64 years (range 25-85)] with non-traumatic cSAH were identified. The most common causes were reversible cerebral vasoconstriction syndrome (RCVS) (26, 29.5%), cerebral amyloid angiopathy (CAA) (23, 26.1%), indeterminate (14, 15.9%) and endocarditis (9, 10.2%). CAA patients commonly presented at an older age than RCVS patients (75 years versus 51 years, P < 0.0001). Thirteen patients (14.7%) had recurrent cSAH, and 12 patients (13.6%) had a subsequent ICH. However, the risk was high amongst those with CAA compared to those caused by RCVS, with recurrent cSAH in 39.1% and subsequent lobar ICH in 43.5% of CAA cases. CONCLUSIONS Our study demonstrates the clinical diversity of cSAH. Older age, sensorimotor dysfunction and stereotyped spells suggest CAA as the underlying cause. Younger age and thunderclap headache predict RCVS. Yet, various other causes also need to be considered in the differential diagnosis.
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Affiliation(s)
| | - J E Fugate
- Department of Neurology, Mayo Clinic, Rochester, MN, USA
| | - J Klaas
- Department of Neurology, Mayo Clinic, Rochester, MN, USA
| | - K D Flemming
- Department of Neurology, Mayo Clinic, Rochester, MN, USA
| | - R D Brown
- Department of Neurology, Mayo Clinic, Rochester, MN, USA
| | - A A Rabinstein
- Department of Neurology, Mayo Clinic, Rochester, MN, USA
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Spontaneous convexity subarachnoid haemorrhage: Clinical series of 3 patients with associated cerebral amyloid angiopathy. Neurologia 2016; 32:213-218. [PMID: 26778730 DOI: 10.1016/j.nrl.2015.11.004] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/13/2015] [Revised: 10/27/2015] [Accepted: 11/04/2015] [Indexed: 11/24/2022] Open
Abstract
INTRODUCTION Convexity subarachnoid haemorrhage (cSAH) is a rare type of spontaneous, non-traumatic, and nonaneurysmal SAH characterised by blood collections in one or more cortical sulci in the convexity of the brain; the aetiology varies. We report a clinical case series of 3 patients with cSAH associated with probable cerebral amyloid angiopathy (CAA) who presented with focal sensory seizures and responded well to corticosteroid treatment. PATIENTS Case 1 was a 67-year-old man reporting right-sided paroxysmal sensory episodes with Jacksonian progression, cheiro-oral symptoms, and motor dysphasia. Case 2 was a 79-year-old man reporting left-sided paroxysmal episodes with cheiro-oral signs and dysarthria. Case 3 was a 71-year-old woman also reporting recurrent left cheiro-oral signs and dysarthria. None of the patients had headache or clinical dementia. Aneurysms were ruled out using MR angiography. RESULTS Brain CT scan detected an isolated hyperintensity in a sulcus of the frontal convexity; brain gradient echo T2-weighted MRI sequences showed meningeal haemosiderosis and microbleeds. However, no atrophy was identified in medial temporal lobes including the hippocampal formation. All patients had low levels of beta-amyloid in CSF, low values on the Hulstaert index and high levels of phosphorylated tau protein. Patients were initially treated with prednisone and levetiracetam, but symptoms recurred in 2 patients after prednisone was discontinued. CONCLUSIONS We present a series of 3 patients with cSAH associated with CAA, characterised by a stereotypical syndrome responding well to corticoid treatment; there were no cases of headache or clinical dementia.
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Singhal AB. Reversible Cerebral Vasoconstriction Syndromes. Stroke 2016. [DOI: 10.1016/b978-0-323-29544-4.00037-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
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