Reversible cerebral vasoconstriction syndrome: an important cause of acute severe headache

Review of systemic and syndromic complications of cannabis use: A review

PURPOSE OF REVIEW

Prescribed and non-prescribed cannabis use is common. Providers in specialties treating chronic pain - primary care, pain management, and neurology-will be coming across medical cannabis as a treatment for chronic pain, regardless of whether they are prescribers. It is important to be aware of the systemic and syndromic complications of acute and chronic cannabis use in the differential diagnosis of cardiac, cardiovascular, cerebrovascular, gastrointestinal, and psychiatric disorders.

RECENT FINDINGS

Medical cannabis is legal in 36 states. Studies have shown several potentially serious adverse effects associated with cannabis use.

SUMMARY

Cannabis use has the potential to cause several complications that can be easily overlooked without a preexisting high index of suspicion.

Systemic Sclerosis, Reversible Cerebral Vasoconstriction Syndrome, and NeuroMyelitis Optica in a Patient

Systemic sclerosis (SSC) is an autoimmune disease of connective tissue and microvasculature mostly caused by autoantibodies. Likewise, neuromyelitis optica (NMO) is a demyelinating disease of the central nervous system correlating with autoantibodies against aquapourin-4. Reversible cerebral vasoconstriction syndrome (RCVS) is a disorder of brain vasculature resembling Raynaud phenomena in SSC. Despite co-occurrence is not rare in autoimmune disorders, the co-occurrence of NMO and SSC is extremely rare. In this case, we report a 35-year-old female presenting with paraplegia one day after discharge from hospital following surgical carnioplasty. She had a history of scleroderma and optic neuritis for which she was treated with high dose glucocorticoids causing renal crisis and RCVS causing intracranial and intracerebral hemorrhage which required a craniotomy to be performed in February 2020. In her recent admission, magnetic resonance imaging of the spinal cord indicated longitudinally extensive transverse myelitis (LETM) and blood tests revealed a highly positive titer of NMO-IgG. Daily plasmapheresis resulted in satisfactory improvement in her condition. This case highlights the importance of evaluating neurologic manifestations in systemic sclerosis patients considering the NMO and RCVS occurrence. Additionally, in concomitant cases, the treatment strategy should be modified regarding the risk of scleroderma renal crisis.

Reversible Cerebral Vasoconstriction Syndrome Following Exposure to Oleoresin Capsicum "Pepper Spray"

OBJECTIVES

To report a case associating the use of Oleoresin Capsicum Pepper Spray (OCPS) during law enforcement training with development of Reversible Cerebral Vasoconstriction Syndrome (RCVS).

MATERIALS AND METHODS

RCVS is radiographically characterized by multifocal smooth narrowing of cerebral arteries heralded by clinical manifestations of recurrent thunderclap headaches. 70% of cases with RCVS have a clear precipitating factor and agents commonly implicated were cannabis, selective serotonin reuptake inhibitors, nasal decongestants, cocaine, postpartum state, eclampsia and strenuous physical/sexual activity.¹ RESULTS: 24-year-old female police officer with no past medical history who presented with thunderclap headaches after exposure to pepper spray to her face during work training. Neurological examination was unremarkable. CT angiogram (CTA) of the head and neck and subsequent conventional angiogram revealed multifocal mild arterial narrowing of bilateral middle cerebral arteries (MCA), bilateral posterior cerebral arteries (PCA) and left anterior cerebral artery (ACA) concerning for RCVS. Eight weeks later, she had a repeat MRA head and neck demonstrating complete resolution of the previously noted narrowing of her cerebral arteries.

CONCLUSIONS

OCPS is widely used in law enforcement training as well as by general population as a self- defense tool. It is generally assumed to be safe, although the consequences of its use can never be predicted with certainty.² As our case highlights, use of OCPS may be associated with development of RCVS and awareness needs to be raised regarding this rare but serious complication.

HaNDL Syndrome Presenting With Confusion: A Rare Case Report

HaNDL syndrome (Syndrome of Transient Headache and Neurologic Deficit with Cerebrospinal Fluid Lymphocytosis) characterized by sudden onset headache, transient neurological deficits, and cerebrospinal fluid (CSF) lymphocytosis, is a self-limited clinical entity that is rarely seen. In this article, we present a case with HaNDL syndrome in a 28-year-old male patient who presented with confusion and agitation after sudden onset of headache, right hemiparesis, and lymphocytosis pleocytosis.

Quantifying Intra-Arterial Verapamil Response as a Diagnostic Tool for Reversible Cerebral Vasoconstriction Syndrome

BACKGROUND AND PURPOSE

There is mounting evidence supporting the benefit of intra-arterial administration of vasodilators in diagnosing reversible cerebral vasoconstriction syndrome. We prospectively quantified the degree of luminal diameter dilation after intra-arterial administration of verapamil and its accuracy in diagnosing reversible cerebral vasoconstriction syndrome.

MATERIALS AND METHODS

Patients suspected of having intracranial arteriopathy on noninvasive imaging and referred for digital subtraction angiography were enrolled in a prospective registry. Intra-arterial verapamil was administered in vascular territories with segmental irregularities. The caliber difference (Caliber_post - Caliber_pre) and the proportion of caliber change ([(Caliber_post - Caliber_pre)/Caliber_pre] × 100%) were used to determine the response to verapamil. The diagnosis of reversible cerebral vasoconstriction syndrome was made on the basis of clinical and imaging features at a follow-up appointment, independent of the reversibility of verapamil. Receiver operating characteristic curve analysis was performed to determine the best threshold.

RESULTS

Twenty-six patients were included, and 9 (34.6%) were diagnosed with reversible cerebral vasoconstriction syndrome. A total of 213 vascular segments were assessed on diagnostic angiography. Every patient with a final diagnosis of reversible cerebral vasoconstriction syndrome responded to intra-arterial verapamil. The maximal proportion of change (P < .001), mean proportion of change (P = .002), maximal caliber difference (P = .004), and mean caliber difference (P = .001) were statistically different between patients with reversible cerebral vasoconstriction syndrome and other vasculopathies. A maximal proportion of change  ≥32% showed a sensitivity of 100% and a specificity of 88.2% to detect reversible cerebral vasoconstriction syndrome (area under the curve = 0.951). The Reversible Cerebral Vasoconstriction Syndrome-2 score of  ≥5 points achieved a lower area under the curve (0.908), with a sensitivity of 77.8% and a specificity of 94.1%.

CONCLUSIONS

Objective measurement of the change in the arterial calibers after intra-arterial verapamil is accurate in distinguishing reversible cerebral vasoconstriction syndrome from other vasculopathies. A proportion of change  ≥32% has the best diagnostic performance.

Basi-parallel anatomical scanning-magnetic resonance imaging for the diagnosis of reversible cerebral vasoconstriction syndrome of the basilar artery: a case report

Case

Reversible cerebral vasoconstriction syndrome (RCVS) is an increasingly recognized and important cause of thunderclap headache. Delays in diagnosis may cause deterioration of symptoms and concomitant unnecessary investigations. However, the diagnosis of RCVS in the acute stage remains difficult.

A 41‐year‐old man was admitted to the emergency department for severe, recurrent occipital headaches. The results of initial computed tomography and magnetic resonance imaging (MRI) of the brain and cerebrospinal fluid analysis were normal. Magnetic resonance angiography (MRA) showed multisegmental luminal stenosis of the basilar artery. Basi‐parallel anatomical scanning (BPAS)‐MRI, illustrating the outer contour of the vertebrobasilar artery, also showed multisegmental stenosis.

Outcome

The patient was speculated as having RCVS and was treated with oral lomerizine hydrochloride. Repeat MRA and BPAS‐MRI 2 months later showed resolution, confirming RCVS.

Conclusion

Combined with MRA, BPAS‐MRI is an effective and non‐invasive imaging method for diagnosis of RCVS of the basilar artery.

Atypical presentation of posterior reversible encephalopathy syndrome: Clinical and radiological characteristics in eclamptic patients

Posterior reversible encephalopathy syndrome (PRES) is an obstetric emergency frequently occurring in a pregnant or puerperal woman, manifested with an acute headache, consciousness impairment, seizures, and visual deficits and is associated with white matter changes predominantly affecting the posterior parietal and occipital lobes of the brain. Apart from the above-described typical location of the changes, the most common atypical location involves the brain stem and basal ganglia. Since magnetic resonance imaging (MRI) is more sensitive and specific imaging technique compared to computerized tomography, establishing the diagnosis and follow-up in patients with PRES is based mainly on MRI findings. It is particularly important not to exclude PRES as a possible diagnosis when we have the appropriate clinical presentation accompanied by the atypical radiological findings, since this clinical-radiological syndrome can often be manifested with an atypical MRI image.

Reversible cerebral vasoconstriction syndrome - A narrative revision of the literature

Reversible Cerebral Vasoconstriction Syndrome (RCVS) is a not very well known clinical-imaging entity; it is characterized by thunderclap headache, which mimics an aneurysmal subarachnoid haemorrhage, and a diffuse and segmental constriction of cerebral arteries, that resolves spontaneously within 3 months. The pathophysiology remains unknown. The female gender is the more affected and more than half of cases occur in the puerperium or after exposure to vasoactive substances. Typically, RCVS is self-limited and has a benign course, although it may have more serious complications with permanent neurologic sequelae and death. Treatment is predominantly supportive and directed to the symptoms.

Syndrome of Headache Accompanied with Transient Neurologic Deficits and Cerebrospinal Fluid Lymphocytosis

The syndrome of headache accompanied with transient neurologic deficits and cerebrospinal fluid lymphocytosis (HaNDL), is a rare, benign and self limiting syndrome. In the 2nd Edition of the International Classification of Headache Disorders, HaNDL syndrome was defined in secondary headache group as "Headache attributed to non-vascular intracranial disorder". The etiology of HaNDL is still unknown. In recent years, some authors have shown that ion channel autoimmunity might at least partially contribute to HaNDL pathogenesis. In this paper, the definition of HaNDL syndrome, clinical picture and epidemiology of HaNDL syndrome, etiopathogenesis, differential diagnosis and treatment will be reviewed with the recent literature.

Call-Fleming syndrome: headache in a 16-year-old girl

BACKGROUND

Call-Fleming syndrome, also known as reversible cerebral vasoconstriction syndrome, is an important cause of severe headache characterized by segmental constriction of cerebral arteries in multiple vascular distributions. It is commonly described in adults, with a female predominance.

PATIENT

We report a case of a 16-year-old girl with history of anxiety, attention deficit hyperactivity disorder, and migraines on several medications presenting with 2 weeks of worsening headaches.

RESULTS

Cranial computed tomography was normal, but magnetic resonance imaging revealed cortical subarachnoid hemorrhage. Follow-up imaging demonstrated extensive vasoconstriction of small- to medium-sized cerebral arteries. Sertraline and methylphenidate were discontinued, and nifedipine was started. Symptoms rapidly improved, and repeat angiography at 2 months showed no vasoconstriction.

CONCLUSIONS

Call-Fleming syndrome is an important cause of thunderclap headache and should be considered in the pediatric population, especially in the setting of certain medication usage and other known risk factors.