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Montarello NL, Irvine I, Warner V, Hare J, Kaye D, Cloud GC. Reversible cerebral vasoconstriction syndrome post-cardiac transplantation: a therapeutic dilemma: case report. BMC Neurol 2024; 24:277. [PMID: 39123195 PMCID: PMC11312223 DOI: 10.1186/s12883-024-03780-3] [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] [Received: 12/27/2023] [Accepted: 07/25/2024] [Indexed: 08/12/2024] Open
Abstract
BACKGROUND Reversible cerebral vasoconstriction syndrome (RCVS) is characterized by diffuse, multifocal segmental narrowing of cerebral arteries and can result in ischaemic stroke. Causal factors, identified in 60% of cases, include immunosuppressant pharmacotherapy. The few reports following heart transplantation are almost all in Asian recipients. We report on a Caucasian Australian patient with immunotherapy induced RCVS post heart transplantation to highlight the state of knowledge of the condition and the treatment dilemma it poses. CASE PRESENTATION A 51-year-old female underwent orthotopic heart transplantation at our institution. Induction immunotherapy comprised basiliximab, mycophenolate mofetil and methylprednisolone. On day 6 post-transplantation the patient was transitioned to oral prednisolone and tacrolimus. On day 7 the patient began to experience bilateral, severe, transient occipital and temporal headaches. On day 9 tacrolimus dose was up-titrated. A non-contrast computed tomography brain (CTB) was normal. Endomyocardial biopsy on day 12 demonstrated moderate Acute Cellular Rejection (ACR), which was treated with intravenous methylprednisolone. That evening the patient experienced a 15-minute episode of expressive dysphasia. The following morning she became confused, aphasic, and demonstrated right sided neglect and right hemianopia. A CT cerebral perfusion scan demonstrated hypoperfusion in the left middle cerebral artery (MCA) territory and cerebral angiography revealed widespread, focal multi-segmental narrowing of the anterior and posterior circulations. A diagnosis of RCVS was made, and nimodipine was commenced. As both steroids and tacrolimus are potential triggers of RCVS, cyclosporin replaced tacrolimus and methylprednisolone dose was reduced. A further CTB demonstrated a large left MCA territory infarct with left M2 MCA occlusion. The patient made steady neurological improvement. She was discharged 34 days post-transplantation with mild residual right lower limb weakness and persistent visual field defect on verapamil, cyclosporine, everolimus, mycophenolate mofetil and prednisolone. CONCLUSION Reversible cerebral vasoconstriction syndrome is rare after orthotopic heart transplantation. Until now, RCVS has been almost exclusively described in Asian recipients, and is typically caused by immunotherapy. The condition may lead to permanent neurological deficits, and in the absence of definitive treatments, early recognition and imaging based diagnosis is essential to provide the opportunity to remove the causal agent(s). Co-existent ACR, can pose unique treatment difficulties.
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Affiliation(s)
| | - Iain Irvine
- Department of Radiology, The Alfred, Melbourne, VIC, Australia
| | - Victoria Warner
- Department of Cardiology, The Alfred, Melbourne, VIC, Australia
- Department of Pharmacy, The Alfred, Melbourne, VIC, Australia
| | - James Hare
- Department of Cardiology, The Alfred, Melbourne, VIC, Australia
| | - David Kaye
- Department of Cardiology, The Alfred, Melbourne, VIC, Australia
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Favrelière S, Mahé J, Veyrac G, Neau JP, Lafay-Chebassier C, Pérault-Pochat MC. Drugs associated with reversible cerebral vasoconstriction syndrome: A pharmacovigilance study in vigiBase ®. Cephalalgia 2024; 44:3331024241267316. [PMID: 39127462 DOI: 10.1177/03331024241267316] [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] [Indexed: 08/12/2024]
Abstract
BACKGROUND Data on drug-induced reversible cerebral vasoconstriction syndrome (RCVS) are scarce. We aimed to describe RCVS characteristics with drugs previously identified as associated with RCVS and investigate potential signals related to other drugs. METHODS VigiBase® was queried for all reports of RCVS until 31 May 2023. A descriptive study was performed on reports concerning drug classes known to precipitate RCVS. To identify new drugs, a disproportionality analysis was conducted. RESULTS In total, 560 reports were included. RCVS occurred in patients aged between 45-64 years (40%) and 18-44 years (35%), mainly in females (72.5%). Drugs were antidepressants (38.4%), triptans (6.4%), nasal decongestants (3.7%) and immunosupressants (8.7%). In 50 cases, antidepressants were in association with drugs known to precipitate RCVS. The median time to onset was 195 days for antidepressants and much shorter (1-10 days) for triptans, nasal decongestants and immunosuppressants. The outcome was favorable in 87% of cases, and fatal in 4.4%. We found a disproportionality signal with 14 drugs: glucocorticoids, bupropion, varenicline, mycophenolic acid, aripiprazole, trazodone, monoclonal antibodies (erenumab, ustekinumab and tocilizumab), leuprorelin and anastrozole. CONCLUSIONS The present study confirms the role of vasoconstrictors in the onset of RCVS, particularly when used in combination and found potential signals, which may help clinicians envisage an iatrogenic etiology of RCVS.
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Affiliation(s)
- Sylvie Favrelière
- Service de Pharmacologie Clinique - Centre Régional de Pharmacovigilance de Poitiers, CHU Poitiers, Poitiers, France
| | - Julien Mahé
- Centre Régional de Pharmacovigilance de Nantes, CHU Nantes, Nantes, France
| | - Gwenaelle Veyrac
- Centre Régional de Pharmacovigilance de Nantes, CHU Nantes, Nantes, France
| | | | - Claire Lafay-Chebassier
- Service de Pharmacologie Clinique - Centre Régional de Pharmacovigilance de Poitiers, CHU Poitiers, Poitiers, France
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3
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de Sousa ÍA, Azevedo ADF, Veras ADO, de Barros-Araújo ML, Dos Santos EP, Marques MADN, Foss MP, Silva-Néto RP, Ricarte IF, Pontes-Neto OM. Neuropsychological aspects of reversible cerebral vasoconstriction syndrome. Dement Neuropsychol 2024; 18:e20230117. [PMID: 39015553 PMCID: PMC11251691 DOI: 10.1590/1980-5764-dn-2023-0117] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/09/2023] [Revised: 02/04/2024] [Accepted: 02/29/2024] [Indexed: 07/18/2024] Open
Abstract
Despite the increasing knowledge in the past years, only minimal attention has been directed to the neuropsychological aspects and the prevalence of cognitive impairment associated with reversible cerebral vasoconstriction syndrome (RCVS). Objective To describe the frequency and expand the understanding of cognitive dysfunction in RCVS. Methods The neuropsychological evaluation was performed using a battery consisting of specific neuropsychological instruments that were administered to patients diagnosed with RCVS. A triage was conducted to exclude other potential causes of cognitive impairment. Performance on the tests was treated as a categorical variable, and a cutoff of -1.5 Z-score was adopted to indicate impaired performance. Results Seven patients diagnosed with RCVS were evaluated, all of whom had a bachelor's degree and normal score in the Mini-Mental State Examination. The average time between diagnosis and neuropsychological evaluation was 1.8 years. Among the patients, 85.6% (n=6) exhibited performance below that of the normal population in at least two of the administered tests. Specifically, 71.4% (n=5) showed alterations in tests from the Psychological Battery for Attention Assessment, with impairment observed in concentrated (n=1), divided (n=3), or alternating (n=4) attention. Furthermore, 28.6% (n=2) demonstrated impairments in the Phonological Verbal Fluency Task, another 28.6% (n=2) exhibited difficulties copying elements of the Rey Complex Figure, and 14.3% (n=1) displayed lower performance in the Five-Digit test, all indicating executive dysfunction. Conclusion This study provides evidence that cognitive impairment associated with RCVS is more prevalent than previously believed and has not received sufficient attention. Specifically, attention and executive functions are the cognitive domains most significantly impacted by RCVS.
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Affiliation(s)
- Ícaro Araújo de Sousa
- Universidade de São Paulo, Faculdade de Medicina de Ribeirão Preto, Departamento de Neurociências e Ciências do Comportamento, Ribeirão Preto SP, Brazil
| | - Analina de Freitas Azevedo
- Universidade Federal do Piauí, Hospital Universitário, Departamento de Medicina Especializada, Teresina PI, Brazil
| | - Arthur de Oliveira Veras
- Universidade de São Paulo, Faculdade de Medicina de Ribeirão Preto, Departamento de Neurociências e Ciências do Comportamento, Ribeirão Preto SP, Brazil
| | - Marx Lima de Barros-Araújo
- Universidade Federal do Piauí, Hospital Universitário, Departamento de Medicina Especializada, Teresina PI, Brazil
| | | | | | - Maria Paula Foss
- Universidade de São Paulo, Faculdade de Filosofia, Ciências e Letras de Ribeirão Preto, Departamento de Psicologia, Ribeirão Preto SP, Brazil
| | | | - Irapuá Ferreira Ricarte
- Universidade Federal de São Paulo Escola Paulista de Medicina, Departamento de Neurologia e Neurocirurgia, São Paulo SP, Brazil
| | - Octávio Marques Pontes-Neto
- Universidade de São Paulo, Faculdade de Medicina de Ribeirão Preto, Departamento de Neurociências e Ciências do Comportamento, Ribeirão Preto SP, Brazil
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Yang JC, Chen SP, Wang YF, Chang CH, Chang KH, Fuh JL, Chow LH, Han CL, Chen YJ, Wang SJ. Cerebrospinal Fluid Proteome Map Reveals Molecular Signatures of Reversible Cerebral Vasoconstriction Syndrome. Mol Cell Proteomics 2024; 23:100794. [PMID: 38839039 PMCID: PMC11263949 DOI: 10.1016/j.mcpro.2024.100794] [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] [Received: 10/06/2023] [Revised: 04/08/2024] [Accepted: 05/07/2024] [Indexed: 06/07/2024] Open
Abstract
Reversible cerebral vasoconstriction syndrome (RCVS) is a complex neurovascular disorder characterized by repetitive thunderclap headaches and reversible cerebral vasoconstriction. The pathophysiological mechanism of this mysterious syndrome remains underexplored and there is no clinically available molecular biomarker. To provide insight into the pathogenesis of RCVS, this study reported the first landscape of dysregulated proteome of cerebrospinal fluid (CSF) in patients with RCVS (n = 21) compared to the age- and sex-matched controls (n = 20) using data-independent acquisition mass spectrometry. Protein-protein interaction and functional enrichment analysis were employed to construct functional protein networks using the RCVS proteome. An RCVS-CSF proteome library resource of 1054 proteins was established, which illuminated large groups of upregulated proteins enriched in the brain and blood-brain barrier (BBB). Personalized RCVS-CSF proteomic profiles from 17 RCVS patients and 20 controls reveal proteomic changes involving the complement system, adhesion molecules, and extracellular matrix, which may contribute to the disruption of BBB and dysregulation of neurovascular units. Moreover, an additional validation cohort validated a panel of biomarker candidates and a two-protein signature predicted by machine learning model to discriminate RCVS patients from controls with an area under the curve of 0.997. This study reveals the first RCVS proteome and a potential pathogenetic mechanism of BBB and neurovascular unit dysfunction. It also nominates potential biomarker candidates that are mechanistically plausible for RCVS, which may offer potential diagnostic and therapeutic opportunities beyond the clinical manifestations.
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Affiliation(s)
- Jhih-Ci Yang
- Institute of Chemistry, Academia Sinica, Taipei, Taiwan; Sustainable Chemical Science and Technology, Taiwan International Graduate Program, Academia Sinica, National Yang Ming Chiao Tung University, Taipei, Taiwan; Department of Applied Chemistry, National Yang Ming Chiao Tung University, Hsinchu, Taiwan
| | - Shih-Pin Chen
- Department of Neurology, Neurological Institute, Taipei Veterans General Hospital, Taipei, Taiwan; Brain Research Center, National Yang Ming Chiao Tung University, Taipei, Taiwan; Division of Translational Research, Department of Medical Research, Taipei Veterans General Hospital, Taipei, Taiwan; Institute of Clinical Medicine, College of Medicine, National Yang Ming Chiao Tung University, Taipei, Taiwan; College of Medicine, National Yang Ming Chiao Tung University, Taipei, Taiwan.
| | - Yen-Feng Wang
- Department of Neurology, Neurological Institute, Taipei Veterans General Hospital, Taipei, Taiwan; Brain Research Center, National Yang Ming Chiao Tung University, Taipei, Taiwan; College of Medicine, National Yang Ming Chiao Tung University, Taipei, Taiwan
| | - Chan-Hua Chang
- Institute of Chemistry, Academia Sinica, Taipei, Taiwan; Department of Chemistry, National Central University, Taoyuan, Taiwan
| | - Kun-Hao Chang
- Institute of Chemistry, Academia Sinica, Taipei, Taiwan; Molecular Science and Technology Program, Taiwan International Graduate Program, Academia Sinica, Taipei, Taiwan; Department of Chemistry, Institute of Chemistry, Academia Sinica, Naitonal Tsing Hua University, Hsinchu, Taiwan
| | - Jong-Ling Fuh
- Department of Neurology, Neurological Institute, Taipei Veterans General Hospital, Taipei, Taiwan; Brain Research Center, National Yang Ming Chiao Tung University, Taipei, Taiwan; College of Medicine, National Yang Ming Chiao Tung University, Taipei, Taiwan
| | - Lok-Hi Chow
- College of Medicine, National Yang Ming Chiao Tung University, Taipei, Taiwan; Department of Anesthesiology, Taipei Veterans General Hospital, Taipei, Taiwan
| | - Chia-Li Han
- Master Program in Clinical Genomics and Proteomics, College of Pharmacy, Taipei Medical University, Taipei, Taiwan.
| | - Yu-Ju Chen
- Institute of Chemistry, Academia Sinica, Taipei, Taiwan; Sustainable Chemical Science and Technology, Taiwan International Graduate Program, Academia Sinica, National Yang Ming Chiao Tung University, Taipei, Taiwan; Department of Chemistry, National Taiwan University, Taipei, Taiwan.
| | - Shuu-Jiun Wang
- Department of Neurology, Neurological Institute, Taipei Veterans General Hospital, Taipei, Taiwan; Brain Research Center, National Yang Ming Chiao Tung University, Taipei, Taiwan; College of Medicine, National Yang Ming Chiao Tung University, Taipei, Taiwan.
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5
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Binaghi E, Eube N, Wegener S, Schmick A. [Reversible cerebral vasoconstriction syndrome : A rare cause of stroke]. DER NERVENARZT 2024; 95:564-572. [PMID: 38842549 PMCID: PMC11178600 DOI: 10.1007/s00115-024-01674-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Accepted: 04/19/2024] [Indexed: 06/07/2024]
Abstract
Reversible cerebral vasoconstriction syndrome (RCVS) is a complex and etiologically diverse neurovascular disorder that typically presents with severe thunderclap headaches (TCH) as the primary symptom, accompanied by reversible vasoconstriction of the cerebral arteries. The clinical course may include focal neurological deficits or epileptic seizures. There are two types: idiopathic RCVS and secondary RCVS, the latter triggered by various substances, medical interventions, or diseases. In clinical practice, various medical specialists may initially encounter this condition, underscoring the importance of accurate recognition and diagnosis of RCVS. The clinical course often appears monophasic and self-limiting, with recurrences reported in only 1.7% of cases annually. Complications such as cerebral hemorrhages and cerebral ischemia can lead to death in 5-10% of cases. This article utilizes a case study to explore RCVS, its complications, and the diagnostic procedures involved.
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Affiliation(s)
- Enrico Binaghi
- Klinik für Neurologie, Universitätsspital Zürich, Rämistrasse 100, 8091, Zürich, Schweiz
| | - Nadine Eube
- Klinik für Innere Medizin, Spital Lachen, Lachen, Schweiz
| | - Susanne Wegener
- Klinik für Neurologie, Universitätsspital Zürich, Rämistrasse 100, 8091, Zürich, Schweiz
| | - Anton Schmick
- Klinik für Neurologie, Universitätsspital Zürich, Rämistrasse 100, 8091, Zürich, Schweiz.
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6
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Kawashima Y, Ariji S, Aoyagi R, Noda M, Oba K, Ogasawara M. Pediatric Reversible Cerebral Vasoconstriction Syndrome/Posterior Encephalopathy Syndrome/Poststreptococcal Glomerulonephritis. Pediatr Neurol 2024; 155:33-35. [PMID: 38579434 DOI: 10.1016/j.pediatrneurol.2024.03.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/21/2023] [Revised: 02/16/2024] [Accepted: 03/12/2024] [Indexed: 04/07/2024]
Affiliation(s)
- Yuki Kawashima
- Department of Pediatrics, Showa General Hospital, Kodaira, Tokyo, Japan
| | - Shohei Ariji
- Department of Pediatrics, Showa General Hospital, Kodaira, Tokyo, Japan
| | - Rui Aoyagi
- Department of Pediatrics, Showa General Hospital, Kodaira, Tokyo, Japan
| | - Masahiro Noda
- Department of Pediatrics, Showa General Hospital, Kodaira, Tokyo, Japan
| | - Kunihiro Oba
- Department of Pediatrics, Showa General Hospital, Kodaira, Tokyo, Japan
| | - Masashi Ogasawara
- Department of Pediatrics, Showa General Hospital, Kodaira, Tokyo, Japan; Department of Neuromuscular Research, National Institute of Neuroscience, National Center of Neurology and Psychiatry (NCNP), Tokyo, Japan.
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7
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Osteraas ND. Sex-based difference in selected stroke etiologies: cerebral dural sinus venous thrombosis, reversible cerebral vasoconstriction syndrome, dissection, migraine, pregnancy/puerperium/OC use. J Stroke Cerebrovasc Dis 2024; 33:107753. [PMID: 38703878 DOI: 10.1016/j.jstrokecerebrovasdis.2024.107753] [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: 01/03/2024] [Revised: 04/26/2024] [Accepted: 05/01/2024] [Indexed: 05/06/2024] Open
Abstract
Females are at higher risk than males for a multitude of cerebrovascular conditions, both common and rare; partially resulting from a complex interplay between differing process involving genetics, hormonal influences, common cerebrovascular risk factors among others. Specific topics including cervical artery dissection, cerebral dural sinus venous thrombosis, reversible cerebral vasoconstriction syndrome, migraine, along with these disorders in the setting of pregnancy, puerperium and oral contraceptive utilization. Epidemiology, pathophysiology, presentation, basics of management and outcomes are presented, with sex differences throughout.
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Affiliation(s)
- Nicholas Dykman Osteraas
- Department of Neuroscience at Saint Lukes Hospital, Advocate Aurora Health. 2900 W Oklahoma Ave, Milwaukee, WI 53215, United States.
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8
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Tartarin H, Morotti A, Van Etten ES, Hausman-Kedem M, Charidimou A, Jouvent E, Susen S, Cordonnier C, Pasi M, Boulouis G. Uncommon Causes of Nontraumatic Intracerebral Hemorrhage. Stroke 2024; 55:1416-1427. [PMID: 38572651 DOI: 10.1161/strokeaha.123.043917] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/05/2024]
Abstract
Nontraumatic intracerebral hemorrhage is an important health issue. Although common causes such as hypertension and cerebral amyloid angiopathy predominantly affect the elderly, there exists a spectrum of uncommon etiologies that contribute to the overall incidence of intracerebral hemorrhage. The identification of these rare causes is essential for targeted clinical management, informed prognostication, and strategic secondary prevention where relevant. This topical review explores the uncommon intracerebral hemorrhage causes and provides practical clues for their clinical and imaging identification. By expanding the clinician's differential diagnosis, this review aims to bridge the gap between standard intracerebral hemorrhage classification systems and the nuanced reality of clinical practice.
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Affiliation(s)
- Hugo Tartarin
- Diagnostic and Interventional Neuroradiology, University Hospital, Tours, France (H.T., G.B.)
| | - Andrea Morotti
- Neurology Unit, Department of Clinical and Experimental Sciences, University of Brescia, Italy (A.M.)
| | - Ellis S Van Etten
- Department of Neurology, Leiden University Medical Center, the Netherlands (E.S.V.E.)
| | - Moran Hausman-Kedem
- Pediatric Neurology Institute, Dana-Dewk Children's Hospital, Tel Aviv Sourasky Medical Center, Faculty of Medicine, Tel Aviv Unisversity, Israel (M.H.-K.)
| | | | - Eric Jouvent
- Neurology Department, Lariboisière Hosp, APHP and Université Paris Cité, France (E.J.)
| | - Sophie Susen
- Hematology and Transfusion Department, Centre Hospitalier Universitaire de Lille, France (S.S.)
| | - Charlotte Cordonnier
- Univ. Lille, Inserm, CHU Lille, U1172 - LilNCog - Lille Neuroscience and Cognition, France (C.C.)
| | - Marco Pasi
- Stroke unit, CHU Tours, Centre Val de Loire, France (M.P.)
| | - Grégoire Boulouis
- Diagnostic and Interventional Neuroradiology, University Hospital, Tours, France (H.T., G.B.)
- INSERM 1253 iBrain, Tours, Centre Val de Loire, France (G.B.)
- CIC-IT 14.15, Tours, Centre Val de Loire, France (G.B.)
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9
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Lei CL, Gui XL, Wang LY, Guo YJ, Li Y. Analysis of drug-induced posterior reversible encephalopathy syndrome using the food and drug administration adverse drug events reporting system database. Expert Opin Drug Saf 2024; 23:607-616. [PMID: 38478961 DOI: 10.1080/14740338.2024.2327510] [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] [Received: 06/26/2023] [Accepted: 01/03/2024] [Indexed: 05/12/2024]
Abstract
OBJECTIVE In this retrospective pharmacovigilance study, we gathered data on drug-induced posterior reversible encephalopathy syndrome (PRES). Our goal was to identify the primary suspect drugs in PRES by analyzing the Food and Drug Administration Adverse Events Reporting System (FAERS) database. METHODS We identified and analyzed reports of PRES listed in the FAERS database between 2004 and 2021. Using the reporting odds ratio and 95% confidence interval, we evaluated the safety signals for each of the drugs associated with PRES. RESULTS We reviewed 11,077 reports of adverse events corresponding to PRES. The primary suspect drug categories were antineoplastics, immunosuppressants, and glucocorticoids. PRES was 24.77% more likely to occur in females than in males. Drug-induced PRES usually occurs in individuals with cancer, those who have undergone an organ/stem cell transplant, and those with autoimmune conditions. CONCLUSION Our results show that the drugs most commonly suspected to cause PRES were antineoplastics, immunosuppressants, and glucocorticoids. Future studies are needed to illuminate the pathophysiological alterations that underlie PRES. In the meantime, prescribers and patients should be made aware of the potential risks of PRES associated with pharmaceutical therapy, and the summaries of product characteristics for individual drugs should be updated to include this information.
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Affiliation(s)
- Cai-Lu Lei
- Department of Pharmacy, Guangxi Medical University Cancer Hospital, Nanning, China
- School of Pharmaceutical Science, Guangxi Medical University, Nanning, China
| | - Xiao-Long Gui
- Department of Gastrointestinal & Gland Surgery, The First Affiliated Hospital of Guangxi Medical University, Nanning, China
| | - Lin-Yu Wang
- Department of Pharmacy, Guangxi Medical University Cancer Hospital, Nanning, China
| | - You-Jia Guo
- Department of Pharmacy, Guangxi Medical University Cancer Hospital, Nanning, China
| | - Yan Li
- Department of Pharmacy, Guangxi Medical University Cancer Hospital, Nanning, China
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10
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Gotesman RD, Niznick N, Dewar B, Fergusson DA, Mallick R, Shorr R, Shamy M, Dowlatshahi D. The prevalence of non-contrast CT imaging abnormalities in reversible cerebral vasoconstriction syndrome: A systematic review and meta-analysis. PLoS One 2024; 19:e0295558. [PMID: 38466700 PMCID: PMC10927111 DOI: 10.1371/journal.pone.0295558] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/03/2023] [Accepted: 11/24/2023] [Indexed: 03/13/2024] Open
Abstract
BACKGROUND Reversible cerebral vasoconstriction syndrome (RCVS) is a syndrome of recurrent thunderclap headaches and reversible vasoconstriction of the cerebral arteries on neuroimaging within 3 months of onset. Initial non-contrast computed tomography (CT) can reveal abnormalities such as ischemic stroke, intracerebral hemorrhage, and subarachnoid hemorrhage (SAH) can be present in patients with RCVS and may delay diagnosis. AIMS We conducted a systematic review and meta-analysis in accordance with the PRISMA guidelines. We aimed to estimate the prevalence of imaging abnormalities on initial non-contrast CT head in adult patients with RCVS. DATA SOURCES & ELIGIBILITY CRITERIA We searched electronic databases including MEDLINE, EMBASE, and the Cochrane Register of Clinical Trials from inception to August 2, 2022. Eligible studies included articles reporting the prevalence of non-contrast CT abnormalities on initial neuroimaging in patients with RCVS, aged 18 and older. Case series, observational studies and clinical trials were included. Data was extracted directly from included papers using a standardized data charting form. RESULTS The search yielded 722 titles with duplicates removed. Twenty studies that included 379 patients with RCVS met inclusion criteria. We classified non-contrast CT abnormalities as either ischemic stroke, ICH, or SAH. We pooled prevalence data using a random effects model with the inverse-variance weighted method. The most common imaging finding was SAH with a pooled prevalence of 24% (95% CI:17%-33%), followed by ICH at 14% (95% CI:8%-22%), and ischemic stroke at 10% (95% CI:7%-14%). The pooled prevalence of any of these imaging abnormalities on initial non-contrast CT was 31% (95% CI:23%-40%). Risk of bias was moderate to very-high-risk for case-series and low-risk for observational studies. CONCLUSION Our review demonstrates that one-third of patients with RCVS will have an abnormality on initial non-contrast CT head, including either an ischemic stroke, ICH, or SAH. These findings highlight the diagnostic challenges of RCVS imaging and contribute to our understanding of this disease.
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Affiliation(s)
| | - Naomi Niznick
- Department of Medicine (Critical Care), The Ottawa Hospital, Ottawa, Canada
| | - Brian Dewar
- Ottawa Hospital Research Institute, Ottawa, Canada
| | - Dean A. Fergusson
- Ottawa Hospital Research Institute, Ottawa, Canada
- Department of Medicine, University of Ottawa, Ottawa, Canada
| | - Ranjeeta Mallick
- Ottawa Hospital Research Institute, Ottawa, Canada
- Department of Medicine, University of Ottawa, Ottawa, Canada
| | - Risa Shorr
- Faculty of Medicine, University of Ottawa, Ottawa, Canada
- The Ottawa Hospital, Ottawa, Canada
| | - Michel Shamy
- Ottawa Hospital Research Institute, Ottawa, Canada
- Department of Medicine, University of Ottawa, Ottawa, Canada
| | - Dar Dowlatshahi
- Ottawa Hospital Research Institute, Ottawa, Canada
- Department of Medicine, University of Ottawa, Ottawa, Canada
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11
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Zedde M, Napoli M, Moratti C, Pezzella FR, Seiffge DJ, Tsivgoulis G, Caputi L, Salvarani C, Toni D, Valzania F, Pascarella R. The Hemorrhagic Side of Primary Angiitis of the Central Nervous System (PACNS). Biomedicines 2024; 12:459. [PMID: 38398061 PMCID: PMC10886751 DOI: 10.3390/biomedicines12020459] [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: 01/01/2024] [Revised: 01/29/2024] [Accepted: 02/17/2024] [Indexed: 02/25/2024] Open
Abstract
Primary Angiitis of the Central Nervous System (PACNS) is a rare cerebrovascular disease involving the arteries of the leptomeninges, brain and spinal cord. Its diagnosis can be challenging, and the current diagnostic criteria show several limitations. Among the clinical and neuroimaging manifestations of PACNS, intracranial bleeding, particularly intracerebral hemorrhage (ICH), is poorly described in the available literature, and it is considered infrequent. This review aims to summarize the available data addressing this issue with a dedicated focus on the clinical, neuroradiological and neuropathological perspectives. Moreover, the limitations of the actual data and the unanswered questions about hemorrhagic PACNS are addressed from a double point of view (PACNS subtyping and ICH etiology). Fewer than 20% of patients diagnosed as PACNS had an ICH during the course of the disease, and in cases where ICH was reported, it usually did not occur at presentation. As trigger factors, both sympathomimetic drugs and illicit drugs have been proposed, under the hypothesis of an inflammatory response due to vasoconstriction in the distal cerebral arteries. Most neuroradiological descriptions documented a lobar location, and both the large-vessel PACNS (LV-PACNS) and small-vessel PACNS (SV-PACNS) subtypes might be the underlying associated phenotypes. Surprisingly, amyloid beta deposition was not associated with ICH when histopathology was available. Moreover, PACNS is not explicitly included in the etiological classification of spontaneous ICH. This issue has received little attention in the past, and it could be addressed in future prospective studies.
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Affiliation(s)
- Marialuisa Zedde
- Neurology Unit, Stroke Unit, Azienda Unità Sanitaria Locale-IRCCS di Reggio Emilia, Viale Risorgimento 80, 42123 Reggio Emilia, Italy
| | - Manuela Napoli
- Neuroradiology Unit, Azienda Unità Sanitaria Locale-IRCCS di Reggio Emilia, Viale Risorgimento 80, 42123 Reggio Emilia, Italy; (M.N.); (R.P.)
| | - Claudio Moratti
- Neuroradiology Unit, Azienda Unità Sanitaria Locale-IRCCS di Reggio Emilia, Viale Risorgimento 80, 42123 Reggio Emilia, Italy; (M.N.); (R.P.)
| | | | - David Julian Seiffge
- Department of Neurology, Inselspital, Bern University Hospital, University of Bern, 3010 Bern, Switzerland
| | - Georgios Tsivgoulis
- Second Department of Neurology, School of Medicine, Attikon University Hospital, National and Kapodistrian University of Athens, 157 72 Athens, Greece
| | - Luigi Caputi
- Neurology Unit, Department of Cardio-Cerebrovascular Diseases, Maggiore Hospital ASST-Crema, 26013 Crema, Italy;
| | - Carlo Salvarani
- Rheumatology Unit, Azienda Unità Sanitaria Locale-IRCCS di Reggio Emilia, Viale Risorgimento 80, 42123 Reggio Emilia, Italy
| | - Danilo Toni
- Emergency Department Stroke Unit, Policlinico Umberto I, University La Sapienza, 00189 Rome, Italy;
| | - Franco Valzania
- Neurology Unit, Stroke Unit, Azienda Unità Sanitaria Locale-IRCCS di Reggio Emilia, Viale Risorgimento 80, 42123 Reggio Emilia, Italy
| | - Rosario Pascarella
- Neuroradiology Unit, Azienda Unità Sanitaria Locale-IRCCS di Reggio Emilia, Viale Risorgimento 80, 42123 Reggio Emilia, Italy; (M.N.); (R.P.)
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12
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Battal B, Castillo M. Imaging of Reversible Cerebral Vasoconstriction Syndrome and Posterior Reversible Encephalopathy Syndrome. Neuroimaging Clin N Am 2024; 34:129-147. [PMID: 37951698 DOI: 10.1016/j.nic.2023.07.004] [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] [Indexed: 11/14/2023]
Abstract
PRES and RCVS are increasingly recognized due to the wider use of brain MRI and increasing clinical awareness. Imaging plays a crucial role in confirming the diagnosis and guiding clinical management for PRES and RCVS. Imaging also has a pivotal role in determining the temporal progression of these entities, detecting complications, and predicting prognosis. In this review, we aim to describe PRES and RCVS, discuss their possible pathophysiological mechanisms, and discuss imaging methods that are useful in the diagnosis, management, and follow-up of patients.
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Affiliation(s)
- Bilal Battal
- Division of Neuroradiology, Department of Radiology, University of North Carolina School of Medicine, Chapel Hill, NC 27599, USA.
| | - Mauricio Castillo
- Division of Neuroradiology, Department of Radiology, University of North Carolina School of Medicine, Chapel Hill, NC 27599, USA
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13
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Singhal AB. Reversible cerebral vasoconstriction syndrome: A review of pathogenesis, clinical presentation, and treatment. Int J Stroke 2023; 18:1151-1160. [PMID: 37246916 DOI: 10.1177/17474930231181250] [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] [Indexed: 05/30/2023]
Abstract
Reversible segmental narrowing of the intracranial arteries has been described since several decades in numerous clinical settings, using variable nosology. Twenty-one years ago, we tentatively proposed the unifying concept that these entities, based on similar clinical-imaging features, represented a single cerebrovascular syndrome. This "reversible cerebral vasoconstriction syndrome" or RCVS has now come of age. A new International Classification of Diseases code, (ICD-10, I67.841) has been established, enabling larger-scale studies. The RCVS2 scoring system provides high accuracy in confirming RCVS diagnosis and excluding mimics such as primary angiitis of the central nervous system. Several groups have characterized its clinical-imaging features. RCVS predominantly affects women. Recurrent worst-ever (thunderclap) headaches are typical at onset. While initial brain imaging is often normal, approximately one-third to half develop complications such as convexity subarachnoid hemorrhages, lobar hemorrhages, ischemic strokes located in arterial "watershed" territories and reversible edema, alone or in combination. Vasoconstriction evolves over hours to days, first affecting distal and then the more proximal arteries. An overlap between RCVS and primary thunderclap headache, posterior reversible encephalopathy syndrome, Takotsubo cardiomyopathy, transient global amnesia, and other conditions has been recognized. The pathophysiology remains largely unknown. Management is mostly symptomatic: headache relief with analgesics and oral calcium-channel blockers, removal of vasoconstrictive factors, and avoidance of glucocorticoids that can significantly worsen outcome. Intra-arterial vasodilator infusions provide variable success. Overall, 90-95% of admitted patients achieve complete or major resolution of symptoms and clinical deficits within days to weeks. Recurrence is exceptional, although 5% can later develop isolated thunderclap headaches with or without mild cerebral vasoconstriction.
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Affiliation(s)
- Aneesh B Singhal
- Neurology Department, Massachusetts General Hospital, Boston, MA, USA
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14
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Lange KS, Choi SY, Ling YH, Chen SP, Mawet J, Duflos C, Lee MJ, Ducros A, Wang SJ, Pezzini A. Reversible cerebral Vasoconstriction syndrome intERnational CollaborativE (REVERCE) network: Study protocol and rationale of a multicentre research collaboration. Eur Stroke J 2023; 8:1107-1113. [PMID: 37329287 PMCID: PMC10683719 DOI: 10.1177/23969873231182207] [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] [Received: 04/11/2023] [Accepted: 05/30/2023] [Indexed: 06/19/2023] Open
Abstract
INTRODUCTION Reversible cerebral vasoconstriction syndrome (RCVS) is a rare, but increasingly recognised cerebrovascular condition with an estimated annual age-standardised incidence of approximately three cases per million. Knowledge about risk factors and triggering conditions and information about prognosis and optimal treatment in these patients are limited. METHODS The REversible cerebral Vasoconstriction syndrome intERnational CollaborativE (REVERCE) project aims to elucidate the epidemiological and clinical characteristics of RCVS by collecting individual patient data from four countries (France, Italy, Taiwan and South Korea) in the setting of a multicentric study. All patients with a diagnosis of definite RCVS will be included. Data on the distribution of risk factors and triggering conditions, imaging data, neurological complications, functional outcome, risk of recurrent vascular events and death and finally the use of specific treatments will be collected. Subgroup analyses will be made based on age, gender, aetiology, ethnicity and geographical region of residence. ETHICS AND DISSEMINATION Ethical approval for the REVERCE study will be obtained from national or local institutional review boards in the participating centres. When needed, a standardised data transfer agreement will be provided for participating centres. We plan dissemination of our results in peer-reviewed international scientific journals and through conference presentations. We expect that the results of this unique study will lead to better understanding of clinical and epidemiological characteristics of RCVS patients.
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Affiliation(s)
- Kristin Sophie Lange
- Department of Neurology, Charité – Universitätsmedizin Berlin, Berlin, Germany
- Center for Stroke Research Berlin (CSB), Charité – Universitätsmedizin, Berlin, Germany
- Department of Neurology, CHU Montpellier, Gui de Chauliac Hospital, Montpellier, France
| | - So Youn Choi
- Department of Neurology, Seoul National University Hospital, Seoul National University College of Medicine, Seoul, Korea
| | - Yu-Hsiang Ling
- Department of Neurology, Neurological Institute, Taipei Veterans General Hospital, Taipei, Taiwan
- School of Medicine, College of Medicine, National Yang Ming Chiao Tung University, Taipei, Taiwan
| | - Shih-Pin Chen
- Department of Neurology, Neurological Institute, Taipei Veterans General Hospital, Taipei, Taiwan
- School of Medicine, College of Medicine, National Yang Ming Chiao Tung University, Taipei, Taiwan
- Brain Research Center, National Yang Ming Chiao Tung University, Taipei, Taiwan
- Division of Translational Research, Department of Medical Research, Taipei Veterans General Hospital, Taipei, Taiwan
- Institute of Clinical Medicine, College of Medicine, National Yang Ming Chiao Tung University, Taipei, Taiwan
| | - Jérôme Mawet
- Emergency Headache Center, Department of Neurology, Lariboisière Hospital, Assistance Publique des Hôpitaux de Paris, Paris, France
| | - Claire Duflos
- Clinical Research and Epidemiology Unit, Department of Public Health, CHU Montpellier, Montpellier University, Montpellier, France
| | - Mi Ji Lee
- Department of Neurology, Seoul National University Hospital, Seoul National University College of Medicine, Seoul, Korea
| | - Anne Ducros
- Department of Neurology, CHU Montpellier, Gui de Chauliac Hospital, Montpellier, France
- Charles Coulomb Laboratory, CNRS UMR5221, Montpellier University, Montpellier, France
| | - Shuu-Jiun Wang
- Department of Neurology, Neurological Institute, Taipei Veterans General Hospital, Taipei, Taiwan
- School of Medicine, College of Medicine, National Yang Ming Chiao Tung University, Taipei, Taiwan
- Brain Research Center, National Yang Ming Chiao Tung University, Taipei, Taiwan
| | - Alessandro Pezzini
- Department of Clinical and Experimental Sciences, Neurology Clinic, University of Brescia, Brescia, Italy
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Toyama G, Tsuboguchi S, Igarashi K, Saji E, Konno T, Onodera O. A case report of reversible cerebral vasoconstriction syndrome with thunderclap headache significantly exacerbated in the supine position and alleviated in the standing position. BMC Neurol 2023; 23:348. [PMID: 37789263 PMCID: PMC10546625 DOI: 10.1186/s12883-023-03381-6] [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] [Received: 03/12/2023] [Accepted: 09/11/2023] [Indexed: 10/05/2023] Open
Abstract
BACKGROUND Reversible cerebral vasoconstriction syndrome (RCVS) is characterized by sudden onset thunderclap headache and multiple segmental reversible cerebral vasoconstrictions that improve within 3 months. The postpartum period is a well-known precipitating factor for the onset of RCVS. Cerebral venous thrombosis (CVT) causes thunderclap headaches in the postpartum period. While headache in CVT is sometimes exacerbated in the supine position, the severity of the headache in RCVS is usually independent of body position. In this study, we report a case of RCVS with thunderclap headache exacerbated in the supine position, and headache attacks that resolved quickly in the standing position during the postpartum period. CASE PRESENTATION A 33-year-old woman presented with a sudden increase in blood pressure and thunderclap headache on the fifth postpartum day (day 1: the first sick day). The headache was severe and pulsatile, with onset in the supine position in bed, and peaked at approximately 10 s. It was accompanied by nausea and chills but there were no scintillating scotomas or ophthalmic symptoms. The headache resolved in the standing or sitting position but was exacerbated and became unbearable within a few seconds when the patient was in the supine position. Therefore, she was unable to lie supine at night. Computed tomography angiography (CTA) of the head on day 2 and magnetic resonance imaging (MRI) and magnetic resonance angiography (MRA) on day 3 showed no abnormalities. However, considering the possibility of RCVS, verapamil was initiated on day 3. The headache resolved the following day. MRA of the head on day 10 revealed diffuse and segmental stenoses in the bilateral middle and posterior cerebral arteries and basilar artery. Therefore, the patient was diagnosed with RCVS. The headache gradually resolved and disappeared completely on day 42. Cerebral vasoconstriction was also improved on MRA on day 43. CONCLUSIONS This postpartum RCVS case was notable for the exacerbation of headaches in the supine position. For the diagnosis of thunderclap headache in the postpartum period, RCVS should be considered in addition to CVT when the patient presents with a headache that is exacerbated in the supine position.
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Affiliation(s)
- Genri Toyama
- Department of Neurology, Niigata University, 1-757 Asahimachidori, Chuo-ku, Niigata city, 951-8585, Niigata, Japan
| | - Shintaro Tsuboguchi
- Department of Neurology, Niigata University, 1-757 Asahimachidori, Chuo-ku, Niigata city, 951-8585, Niigata, Japan.
| | - Kazuya Igarashi
- Department of Neurology, Niigata University, 1-757 Asahimachidori, Chuo-ku, Niigata city, 951-8585, Niigata, Japan
| | - Etsuji Saji
- Department of Neurology, Niigata University, 1-757 Asahimachidori, Chuo-ku, Niigata city, 951-8585, Niigata, Japan
| | - Takuya Konno
- Department of Neurology, Niigata University, 1-757 Asahimachidori, Chuo-ku, Niigata city, 951-8585, Niigata, Japan
| | - Osamu Onodera
- Department of Neurology, Niigata University, 1-757 Asahimachidori, Chuo-ku, Niigata city, 951-8585, Niigata, Japan
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Jha S, Tiwari M, Ghosh S, Chatterjee D, Datta A, Shobhana A. Unilateral Basal Ganglia Hemorrhage and Lateral Rectus Palsy: An Unusual Association in Marijuana-Induced Reversible Cerebral Vasoconstriction Syndrome. Ann Indian Acad Neurol 2023; 26:810-812. [PMID: 38022463 PMCID: PMC10666895 DOI: 10.4103/aian.aian_458_23] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/24/2023] [Revised: 07/24/2023] [Accepted: 07/25/2023] [Indexed: 12/01/2023] Open
Affiliation(s)
- Shreyashi Jha
- Consultant Neurologist, Institute of Neurosciences, Kolkata, West Bengal, India
| | - Mona Tiwari
- Consultant Radiologist, Institute of Neurosciences, Kolkata, West Bengal, India
| | - Sagnik Ghosh
- Resident Medical Officer, Institute of Neurosciences, Kolkata, West Bengal, India
| | - Debarshi Chatterjee
- Consultant Neurosurgeon, Institute of Neurosciences, Kolkata, West Bengal, India
| | - Ashis Datta
- Consultant Neurologist, Institute of Neurosciences, Kolkata, West Bengal, India
| | - A Shobhana
- Consultant in Critical Care and Stroke Medicine, Institute of Neurosciences, Kolkata, West Bengal, India
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17
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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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18
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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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Sun RL, Chhabra A, Patel A, Shaltoni H. Reversible cerebral vasoconstriction syndrome after levonorgestrel-releasing intrauterine device placement-Case report. Headache 2023; 63:700-704. [PMID: 37140063 DOI: 10.1111/head.14515] [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: 02/03/2023] [Revised: 03/08/2023] [Accepted: 03/08/2023] [Indexed: 05/05/2023]
Abstract
BACKGROUND Reversible cerebral vasoconstriction syndrome (RCVS) is a disease characterized by reversible multifocal narrowing of the cerebral arteries with clinical manifestations that typically include thunderclap headache and occasionally brain edema, stroke, or seizure. The exact pathophysiology of RCVS is not well known. CASE A 46-year-old female with history of episodic migraine presented with 1-month duration of worsening headaches that had become more severe over the past 2 weeks. The headaches were episodic and thunderclap in onset and aggravated by physical exertion or emotional situations. A neurological examination was unremarkable including initial head computed tomography (CT). A CT angiogram of the head showed multifocal stenosis in the right anterior cerebral artery, bilateral middle cerebral arteries, and right posterior cerebral artery. Cerebral angiogram confirmed the CT angiogram findings. A repeated CT angiogram a few days later showed improvement in the multifocal cerebral arterial stenosis. Lumbar puncture and autoimmune workup were not suggestive of neuroinflammatory etiology. She had one generalized tonic-clonic seizure during her second day of hospitalization. The patient's thunderclap onset headaches resolved in 1 week after she was managed with blood pressure control and pain medication. She denied any illicit drug use or any new medications other than the placement of a levonorgestrel-releasing intrauterine device (IUD) about 6 weeks prior to her presentation. CONCLUSIONS Our case suggests a possible link between RCVS and levonorgestrel-releasing IUDs.
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Affiliation(s)
- Ruiqing L Sun
- Department of Neurology, University of Texas Medical Branch, Galveston, Texas, USA
| | - Arun Chhabra
- Department of Neurology, University of Texas Medical Branch, Galveston, Texas, USA
| | - Anand Patel
- Department of Neurology, University of Texas Medical Branch, Galveston, Texas, USA
| | - Hashem Shaltoni
- Department of Neurology, University of Texas Medical Branch, Galveston, Texas, USA
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Lange KS, Tuloup G, Duflos C, Gobron C, Burcin C, Corti L, Roos C, Ducros A, Mawet J. Complications of reversible cerebral vasoconstriction syndrome in relation to age. J Neurol 2023:10.1007/s00415-023-11708-z. [PMID: 37052670 DOI: 10.1007/s00415-023-11708-z] [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: 03/07/2023] [Revised: 04/03/2023] [Accepted: 04/05/2023] [Indexed: 04/14/2023]
Abstract
INTRODUCTION Reversible cerebral vasoconstriction syndrome (RCVS) has a heterogenous clinical and radiological presentation. We investigated whether RCVS complications vary according to age. PATIENTS AND METHODS In a pooled French cohort of 345 patients with RCVS, we assessed (1) rates of clinical and radiological complications, and (2) the functional outcome at 3 months according to age as a continuous variable, and in young patients aged ≤ 49 years versus those aged ≥ 50 years. The Commission Nationale Informatique et Liberté and the local ethics committee approved this study (registration number: 202100733). RESULTS The risk for any focal deficit and for any brain lesion were independently associated with increasing age (OR 1.4, 95% CI 1.1-1.8; p = 0.014, and OR 1.6, 95% CI 1.2-2.1; p < 0.001, respectively). Subtypes of brain lesions independently associated with increasing age were subarachnoid haemorrhage (OR 1.7, 95% CI 1.3-2.3; p < 0.001) and intracerebral haemorrhage (OR 1.5, 95% CI 1.1-2.2; p = 0.023). Frequency of cervical artery dissections peaked at age 30-39, and young age was independently associated with cervical artery dissections (OR 13.6, 95% CI 2.4-76.6; p = 0.003). Age had no impact on the functional outcome, with a modified Rankin scale score of 0-1 in > 96% of patients. CONCLUSION Age seems to influence rates and types of complications of RCVS, with young age being associated with cervical artery dissections, and increasing age with haemorrhagic complications. If confirmed in larger prospective studies, recognition of age-specific patterns might help to guide clinical management and to identify complications in cases of RCVS and vice versa.
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Affiliation(s)
- Kristin Sophie Lange
- Department of Neurology, CHU Montpellier, Gui de Chauliac Hospital, Montpellier, France.
- Center for Stroke Research Berlin (CSB), Charité-Universitätsmedizin, Berlin, Germany.
- Department of Neurology, Charité-Universitätsmedizin Berlin, Charitéplatz 1, 10117, Berlin, Germany.
| | - Gabrielle Tuloup
- Emergency Headache Center, Department of Neurology, Lariboisière Hospital, Assistance Publique des Hôpitaux de Paris, Paris, France
- Department of Neurology, CHU Caen-Normandie, Caen, France
| | - Claire Duflos
- Clinical Research and Epidemiology Unit, Department of Public Health, CHU Montpellier, Montpellier University, Montpellier, France
| | - Claire Gobron
- Department of Clinical Physiology, APHP, Lariboisière-St Louis Hospitals, DMU DREAM, 75010, Paris, France
| | - Cécilia Burcin
- Emergency Headache Center, Department of Neurology, Lariboisière Hospital, Assistance Publique des Hôpitaux de Paris, Paris, France
| | - Lucas Corti
- Department of Neurology, CHU Montpellier, Gui de Chauliac Hospital, Montpellier, France
| | - Caroline Roos
- Emergency Headache Center, Department of Neurology, Lariboisière Hospital, Assistance Publique des Hôpitaux de Paris, Paris, France
| | - Anne Ducros
- Department of Neurology, CHU Montpellier, Gui de Chauliac Hospital, Montpellier, France
- Charles Coulomb Laboratory, CNRS UMR5221, Montpellier University, Montpellier, France
| | - Jérôme Mawet
- Emergency Headache Center, Department of Neurology, Lariboisière Hospital, Assistance Publique des Hôpitaux de Paris, Paris, France
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21
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Bonura A, Iaccarino G, Rossi SS, Capone F, Motolese F, Calandrelli R, Di Lazzaro V, Pilato F. Posterior reversible encephalopathy syndrome and reversible cerebral vasoconstriction syndrome in patients with COVID-19 infection: is there a link? A systematic review and case report analysis. J Neurol 2023; 270:2826-2852. [PMID: 37014421 PMCID: PMC10071475 DOI: 10.1007/s00415-023-11684-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/15/2023] [Revised: 02/26/2023] [Accepted: 03/21/2023] [Indexed: 04/05/2023]
Abstract
During the SARS-CoV2 pandemic, several cases of Posterior Reversible Encephalopathy Syndrome (PRES) and of Reversible Cerebral Vasoconstriction Syndrome (RCVS) in COVID-19 patients have been reported, but the link between these syndromes and COVID-19 is unclear. We performed a systematic review, according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) statement to evaluate whether SARS-CoV2 infection or the drugs used to treat it could be deemed potential risk factors for PRES or RCVS. We performed a literature search. We found 70 articles (60 on PRES and 10 on RCVS) concerning n = 105 patients (n = 85 with PRES, n = 20 with RCVS). We analyzed the clinical characteristics of the two populations separately, then performed an inferential analysis to search for other independent risk factors. We found fewer than usual PRES-related (43.9%) and RCVS-related (45%) risk factors in patients with COVID-19. Such a low incidence of risk factors for PRES and RCVS might suggest the involvement of COVID-19 as an additional risk factor for both diseases due to its capability to cause endothelial dysfunction. We discuss the putative mechanisms of endothelial damage by SARS-CoV2 and antiviral drugs which may underlie the development of PRES and RCVS.
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Affiliation(s)
- Adriano Bonura
- Department of Medicine and Surgery, Unit of Neurology, Neurophysiology, Neurobiology and Psychiatry, Università Campus Bio-Medico di Roma, Via Alvaro del Portillo, 21, 00128, Rome, Italy
- Institute of Neurology, Fondazione Policlinico Universitario Campus Bio-Medico, Via Alvaro del Portillo, 200, 00128, Rome, Italy
| | - Gianmarco Iaccarino
- Department of Medicine and Surgery, Unit of Neurology, Neurophysiology, Neurobiology and Psychiatry, Università Campus Bio-Medico di Roma, Via Alvaro del Portillo, 21, 00128, Rome, Italy
- Institute of Neurology, Fondazione Policlinico Universitario Campus Bio-Medico, Via Alvaro del Portillo, 200, 00128, Rome, Italy
| | - Sergio Soeren Rossi
- Department of Medicine and Surgery, Unit of Neurology, Neurophysiology, Neurobiology and Psychiatry, Università Campus Bio-Medico di Roma, Via Alvaro del Portillo, 21, 00128, Rome, Italy
- Institute of Neurology, Fondazione Policlinico Universitario Campus Bio-Medico, Via Alvaro del Portillo, 200, 00128, Rome, Italy
| | - Fioravante Capone
- Department of Medicine and Surgery, Unit of Neurology, Neurophysiology, Neurobiology and Psychiatry, Università Campus Bio-Medico di Roma, Via Alvaro del Portillo, 21, 00128, Rome, Italy
- Institute of Neurology, Fondazione Policlinico Universitario Campus Bio-Medico, Via Alvaro del Portillo, 200, 00128, Rome, Italy
| | - Francesco Motolese
- Department of Medicine and Surgery, Unit of Neurology, Neurophysiology, Neurobiology and Psychiatry, Università Campus Bio-Medico di Roma, Via Alvaro del Portillo, 21, 00128, Rome, Italy
- Institute of Neurology, Fondazione Policlinico Universitario Campus Bio-Medico, Via Alvaro del Portillo, 200, 00128, Rome, Italy
| | - Rosalinda Calandrelli
- Institute of Radiology, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, Largo A. Gemelli, 1, 00168, Rome, Italy
| | - Vincenzo Di Lazzaro
- Department of Medicine and Surgery, Unit of Neurology, Neurophysiology, Neurobiology and Psychiatry, Università Campus Bio-Medico di Roma, Via Alvaro del Portillo, 21, 00128, Rome, Italy
- Institute of Neurology, Fondazione Policlinico Universitario Campus Bio-Medico, Via Alvaro del Portillo, 200, 00128, Rome, Italy
| | - Fabio Pilato
- Department of Medicine and Surgery, Unit of Neurology, Neurophysiology, Neurobiology and Psychiatry, Università Campus Bio-Medico di Roma, Via Alvaro del Portillo, 21, 00128, Rome, Italy.
- Institute of Neurology, Fondazione Policlinico Universitario Campus Bio-Medico, Via Alvaro del Portillo, 200, 00128, Rome, Italy.
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22
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Stroke in Pregnancy. CURRENT OBSTETRICS AND GYNECOLOGY REPORTS 2023. [DOI: 10.1007/s13669-023-00351-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/24/2023]
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23
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Imai M, Shimoda M, Oda S, Hoshikawa K, Osada T, Aoki R, Sunaga A. Reversible Cerebral Vasoconstriction Syndrome Patients with a History of Migraine: A Retrospective Case-control Study. Intern Med 2023; 62:355-364. [PMID: 35831115 PMCID: PMC9970822 DOI: 10.2169/internalmedicine.9776-22] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/04/2023] Open
Abstract
Objective We investigated the clinical characteristics of patients with reversible cerebral vasoconstrictor syndrome who had a history of migraine before the onset and considered the relationship between these two pathologies. Methods We investigated 98 patients who underwent magnetic resonance angiography within 14 days of the onset of reversible cerebral vasoconstriction syndrome at our hospital. Of these, 11 cases involved recurrences, so data from 87 patients were analyzed. Materials All consecutive patients diagnosed with reversible cerebral vasoconstrictor syndrome at our institution between October 2010 and July 2021. Results Fifty of the 87 patients (57%) had a history of migraine. A multivariate analysis revealed that the following clinical factors were significantly more frequent in patients with a history of migraine than in those without such a history: female sex; emotional situations as a trigger of the onset; presence of deep and subcortical white matter hyperintensity, absence of vasoconstriction in the M1 portion of the middle cerebral artery, and absence of other cerebral lesions on initial magnetic resonance imaging; absence of vasoconstriction of the basilar artery on follow-up magnetic resonance imaging; and progression of deep and subcortical white matter hyperintensity in the chronic stage. Conclusion Reversible cerebral vasoconstrictor syndrome patients with a history of migraine showed clinical features of migraine, including one aspect of cerebral small-vessel disease due to endothelial dysfunction, as a common causative condition.
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Affiliation(s)
- Masaaki Imai
- Department of Neurosurgery, Tokai University Hachioji Hospital, Japan
| | - Masami Shimoda
- Department of Neurosurgery, Tokai University Hachioji Hospital, Japan
| | - Shinri Oda
- Department of Neurosurgery, Tokai University Hachioji Hospital, Japan
| | - Kaori Hoshikawa
- Department of Neurosurgery, Tokai University Hachioji Hospital, Japan
| | - Takahiro Osada
- Department of Neurosurgery, Tokai University Hachioji Hospital, Japan
| | - Rie Aoki
- Department of Neurosurgery, Tokai University Hachioji Hospital, Japan
| | - Azusa Sunaga
- Department of Neurosurgery, Tokai University Hachioji Hospital, Japan
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Rizzati F, Marie G, Chanez V, Ferry T, Natterer J, Longchamp D, Saliou G, Perez MH. Intra-arterial vasodilators infusion for management of reversible cerebral vasoconstriction syndrome in a 12-year-old girl: A case report. Front Pediatr 2023; 11:1042509. [PMID: 36937972 PMCID: PMC10020348 DOI: 10.3389/fped.2023.1042509] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/12/2022] [Accepted: 01/30/2023] [Indexed: 03/06/2023] Open
Abstract
Reversible cerebral vasoconstriction syndrome (RCVS) is a vascular disease characterized by diffuse transient vasoconstriction and vasodilatation of the cerebral arteries. It is commonly associated with recurrent severe acute headaches with or without focal neurological deficits due to hemorrhages, infarcts, and even posterior reversible encephalopathy syndrome. The optimal management of acute neurologic deficits caused by RCVS is still uncertain. Calcium channel blockers (CCBs) such as nimodipine or verapamil have been reported to be effective in adult series. Intra-arterial injection of nimodipine, verapamil, and milrinone has recently been demonstrated to be safe and effective for treating severe segmental vasoconstriction in adults. CCBs are the most used treatment in the available pediatric literature. Intra-arterial vasodilators have been reported in some rare pediatric reports with more severe diseases, but their utility is still under investigation. We report a case of a 12-year-old girl who underwent a severe course of RCVS complicated by multiple cerebral infarcts, treated by several sessions of intra-arterial vasodilators infusion.
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Affiliation(s)
- Frida Rizzati
- Paediatric Intensive Care Unit, Woman, Mother and Child Department, Lausanne University Hospital and Lausanne University, Lausanne, Switzerland
| | - Guillaume Marie
- Department of Radiology, Cantonal Hospital Lucerne, Lucerne, Switzerland
| | - Vivianne Chanez
- Paediatric Intensive Care Unit, Woman, Mother and Child Department, Lausanne University Hospital and Lausanne University, Lausanne, Switzerland
| | - Thomas Ferry
- Paediatric Intensive Care Unit, Woman, Mother and Child Department, Lausanne University Hospital and Lausanne University, Lausanne, Switzerland
| | - Julia Natterer
- Paediatric Intensive Care Unit, Woman, Mother and Child Department, Lausanne University Hospital and Lausanne University, Lausanne, Switzerland
| | - David Longchamp
- Paediatric Intensive Care Unit, Woman, Mother and Child Department, Lausanne University Hospital and Lausanne University, Lausanne, Switzerland
| | - Guillaume Saliou
- Department of Radiology, Lausanne University Hospital and University of Lausanne, Lausanne, Switzerland
| | - Maria-Helena Perez
- Paediatric Intensive Care Unit, Woman, Mother and Child Department, Lausanne University Hospital and Lausanne University, Lausanne, Switzerland
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25
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RCVS: by clinicians for clinicians-a narrative review. J Neurol 2023; 270:673-688. [PMID: 36305970 PMCID: PMC9615630 DOI: 10.1007/s00415-022-11425-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/20/2022] [Revised: 10/12/2022] [Accepted: 10/13/2022] [Indexed: 02/02/2023]
Abstract
BACKGROUND/OBJECTIVE Reversible cerebral vasoconstriction syndrome may be underdiagnosed. It can be accompanied by various complications, mainly intracerebral hemorrhage and ischemic stroke. The clinical presentation of this condition varies according to its localization. The aims of this review are to raise awareness of the disease, especially in the presence of corresponding risk factors; to connect its precipitating factors, pathophysiology, and complications; and to compare various differential diagnoses of vasoconstriction. METHODS A review of the literature in PubMed/MEDLINE and Google Scholar was conducted from May 1997 until May 2022. RESULTS Reversible cerebral vasoconstriction syndrome, which is a clinical-radiological syndrome, is mainly characterized by the occurrence of thunderclap headache and widespread vasoconstriction. The most common precipitating factors are the use of vasoactive substances and postpartum status. The pathophysiology is currently assumed to include two mechanisms: sympathetic overactivity and endothelial dysfunction. From these mechanisms, it is possible to derive potential complications as well as the most important differential diagnoses: posterior reversible encephalopathy syndrome, convexity subarachnoid hemorrhage, ischemic and hemorrhagic stroke, and primary angiitis of the central nervous system. CONCLUSION In general, the outcome of reversible cerebral vasoconstriction syndrome is very good. Vasospasm as well as thunderclap headache attacks can be fully reversible, and > 90% of patients are functionally independent at discharge.
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26
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Veras ADO, Noleto FM, Ribas MZ, Paticcié GF, Palomo Barreira R, Correa BM, Torres TZM, Rossette VM, Miranda NF, Miyahira CK, Claudino dos Santos JC. Reversible cerebral vasoconstriction syndrome associated with probable drug poisoning. Radiol Case Rep 2022; 18:844-849. [PMID: 36589490 PMCID: PMC9800248 DOI: 10.1016/j.radcr.2022.11.044] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/09/2022] [Revised: 11/14/2022] [Accepted: 11/16/2022] [Indexed: 12/24/2022] Open
Abstract
Reversible cerebral vasoconstriction syndrome (RCVS) is a clinical condition characterized by arterial involvement of the intracranial vessels, manifesting with vasospasm. The most common clinical manifestation related to the syndrome is the thunderclap headache, which consists of a severe headache that reaches the peak of pain within minutes. The imaging study assumes a leading role in the complementary investigation. Laboratory tests and cerebrospinal fluid analysis are often nonspecific and without significant diagnostic importance. Non-contrast studies of the brain parenchyma reveal variable results that can often be normal. Angiographic findings, which initially may not reveal any changes, allow the visualization of diffuse narrowing of the vessels, with the posterior cerebral circulation being preferentially affected. The present study reports the case of a 19-year-old woman with no relevant medical history, except that she was a regular user of marijuana and a drug based on chloroform and ether. The patient showed clinical and imaging signs compatible with RCVS, and the narcotics used by her were considered precipitating factors.
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Affiliation(s)
- Arthur de Oliveira Veras
- Hospital das Clínicas da Faculdade de Medicina de Ribeirão Preto - USP, Ribeirão Preto, SP, Brasil
| | - Felipe Micelli Noleto
- Faculdade de Medicina, Centro Universitário Christus, UNICHRISTUS, Fortaleza, CE, Brasil
| | - Michelle Zonkowski Ribas
- Universidade Federal do Paraná, UFPR, Rua XV de Novembro, 1299 – Centro, Curitiba, Paraná CEP 80060-000, Brasil
- Corresponding author.
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Yoon M, Kim T. Extracranial reversible cerebral vasoconstriction syndrome associated with vertebral artery dissection: A case report. Brain Circ 2022; 8:222-224. [PMID: 37181837 PMCID: PMC10167846 DOI: 10.4103/bc.bc_58_22] [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: 09/02/2022] [Revised: 10/12/2022] [Accepted: 10/17/2022] [Indexed: 12/14/2022] Open
Abstract
In the present vignette, we describe a lateral medullary infarction developed immediately after strenuous straining owing to constipation in a 42-year-old female. There was a dissection in left vertebral artery V4 segment. Computed tomography (CT) angiography revealed beaded appearance of cervical V2 and V3 segments of bilateral vertebral arteries. A follow-up CT angiogram performed about 3 months later showed resolution of vasoconstriction and normalization of vertebral arteries. Reversible cerebral vasoconstriction syndrome (RCVS) is usually known as an intracranial pathologic condition. Extracranial RCVS is very rare. Therefore, the diagnosis of RCVS could be challenging when its location is extracranial, particularly when comingling vertebral artery dissection (VAD) is present because of their similar vascular luminal morphology. Physician should be vigilant about the possibility of a concomitant presence of RCVS and VAD, even in extracranial vessels.
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Affiliation(s)
- Miyeon Yoon
- Department of Neurology, Incheon St. Mary's Hospital, The Catholic University of Korea, Incheon, Korea
| | - Taewon Kim
- Department of Neurology, Incheon St. Mary's Hospital, The Catholic University of Korea, Incheon, Korea
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28
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Ikuta G, Makino K, Takamatsu K, Takada A, Wada K, Hashimoto Y. [Subdural hematoma with reversible cerebral vasoconstriction syndrome: a case report]. Rinsho Shinkeigaku 2022; 62:732-735. [PMID: 36031380 DOI: 10.5692/clinicalneurol.cn-001766] [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] [Indexed: 06/15/2023]
Abstract
A 71-year-old man had persistent cervical pain secondary to thunderclap headache during sleep. MRI conducted the next morning revealed subdural hematoma and convexity subdural hemorrhage on the right occipital region, and the patient was hospitalized. MRA showed vascular narrowing in the bilateral PCA. Follow-up MRA on day 8 of admission showed aggravated vascular narrowing of PCA, indicative of reversible cerebral vasoconstriction syndrome (RCVS). The patient was treated with a calcium-channel antagonist. Post-discharge MRA showed improvement of PCA narrowing, and the diagnosis of RCVS was confirmed.
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Affiliation(s)
- Genki Ikuta
- Department of Neurosurgery, Kumamoto City Hospital
| | | | | | - Akira Takada
- Department of Neurosurgery, Kumamoto City Hospital
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29
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Chen SP, Wang SJ. Pathophysiology of reversible cerebral vasoconstriction syndrome. J Biomed Sci 2022; 29:72. [PMID: 36127720 PMCID: PMC9489486 DOI: 10.1186/s12929-022-00857-4] [Citation(s) in RCA: 26] [Impact Index Per Article: 13.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/28/2022] [Accepted: 09/14/2022] [Indexed: 11/29/2022] Open
Abstract
Reversible cerebral vasoconstriction syndrome (RCVS) is a complex neurovascular disorder being recognized during the past two decades. It is characterized by multiple abrupt severe headaches and widespread cerebral vasoconstrictions, with potential complications such as ischemic stroke, convexity subarachnoid hemorrhage, intracerebral hemorrhage and posterior reversible encephalopathy syndrome. The clinical features, imaging findings, and dynamic disease course have been delineated. However, the pathophysiology of RCVS remains elusive. Recent studies have had substantial progress in elucidating its pathogenesis. It is now believed that dysfunction of cerebral vascular tone and impairment of blood–brain barrier may play key roles in the pathophysiology of RCVS, which explains some of the clinical and radiological manifestations of RCVS. Some other potentially important elements include genetic predisposition, sympathetic overactivity, endothelial dysfunction, and oxidative stress, although the detailed molecular mechanisms are yet to be identified. In this review, we will summarize what have been revealed in the literature and elaborate how these factors could contribute to the pathophysiology of RCVS.
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Affiliation(s)
- Shih-Pin Chen
- Department of Neurology, Neurological Institute, Taipei Veterans General Hospital, Taipei, 11217, Taiwan. .,Institute of Clinical Medicine, National Yang Ming Chiao Tung University, Taipei, Taiwan. .,Division of Translational Research, Department of Medical Research, Taipei Veterans General Hospital, Taipei, Taiwan. .,Brain Research Center & School of Medicine, National Yang Ming Chiao Tung University, Taipei, Taiwan.
| | - Shuu-Jiun Wang
- Department of Neurology, Neurological Institute, Taipei Veterans General Hospital, Taipei, 11217, Taiwan. .,Brain Research Center & School of Medicine, National Yang Ming Chiao Tung University, Taipei, Taiwan.
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30
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Sano K, Kuge A, Kondo R, Yamaki T, Homma H, Saito S, Sonoda Y. Postpartum reversible cerebral vasoconstriction with cortical subarachnoid hemorrhage and posterior reversible encephalopathy syndrome concomitant with vertebral artery dissection diagnosed by MRI MSDE method: A case report and review of literature. Clin Case Rep 2022; 10:e6257. [PMID: 36110331 PMCID: PMC9465692 DOI: 10.1002/ccr3.6257] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/06/2021] [Revised: 05/11/2022] [Accepted: 08/01/2022] [Indexed: 11/05/2022] Open
Abstract
Headache is one of the most common symptoms encountered during the postpartum period. The cause may be unknown, or the following illnesses are possible: cervical artery dissection (CAD), reversible posterior cerebral encephalopathy syndrome (PRES), and reversible cerebral vasoconstrictor syndrome (RCVS). It is suggested that they are interrelated and share a similar mechanism such as small vessel endothelial dysfunction, deficiencies in self-regulation, and decreased sympathetic innervation of the posterior circulation. However, there are few reports of neuroradiological findings. We experienced a rare case of multiple postpartum vascular disease occurring at the same time. A 38-year-old woman suddenly developed thunderclap headache after giving birth. She was clear and had no neuropathy. Computed tomography revealed subarachnoid hemorrhage, including the cortical surface of the frontal lobe. Magnetic resonance image fluid-attenuated inversion recovery revealed high-intensity area in the bilateral basal ganglia and right occipital cortex. Angiography showed "string sausage" and extracranial left vertebral artery stenosis, but no aneurysm. Based on the clinical course and neuroradiological findings, we diagnosed her as postpartum vascular disease including CAD, PRES, RCVS, and cortical subarachnoid hemorrhage (SAH). Three-dimensional black blood T1-weighted images using a motion-sensitized driven equilibrium three-dimensional turbo spin echo (MSDE) sequencing method revealed an intramural hematoma consistent with the extracranial vertebral artery. After 3 months, MSDE lost its abnormal signal. Our case was rare in that multiple phenomena of postpartum vascular disease occurred at the same time. In particular, we could reveal that this speculation was reversible in the MRI MSDE sequencing.
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Affiliation(s)
- Kenshi Sano
- Department of NeurosurgeryYamagata City Hospital SaiseikanYamagataJapan
| | - Atsushi Kuge
- Department of NeurosurgeryYamagata City Hospital SaiseikanYamagataJapan
- Department of Emergency MedicineYamagata City Hospital SaiseikanYamagataJapan
| | - Rei Kondo
- Department of NeurosurgeryYamagata City Hospital SaiseikanYamagataJapan
| | - Tetsu Yamaki
- Department of NeurosurgeryYamagata City Hospital SaiseikanYamagataJapan
| | - Hiroshi Homma
- Department of NeurosurgeryYamagata City Hospital SaiseikanYamagataJapan
| | - Shinjiro Saito
- Department of NeurosurgeryYamagata City Hospital SaiseikanYamagataJapan
| | - Yukihiko Sonoda
- Department of NeurosurgeryYamagata University, School of MedicineYamagataJapan
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31
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Reversible cerebral vasoconstriction syndrome: review of neuroimaging findings. Radiol Med 2022; 127:981-990. [PMID: 35932443 PMCID: PMC9362037 DOI: 10.1007/s11547-022-01532-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/15/2022] [Accepted: 07/22/2022] [Indexed: 12/04/2022]
Abstract
Reversible cerebral vasoconstriction syndrome (RCVS) is a group of disorders characterized by segmental narrowing and dilatation of medium-to-large cerebral arteries, clinically presenting with recurrent episodes of sudden-onset thunderclap headaches, with or without focal neurological deficits. Cerebral vasoconstriction is typically reversible, with spontaneous resolution within 3 months. Although the syndrome has generally a benign course, patients with neurological deficits may experience worse outcome. The main imaging finding is segmental constriction of intracranial arteries, which can be associated with subarachnoid hemorrhage and/or ischemic foci. Other possible findings are intracranial hemorrhage, subdural bleeding and cerebral edema. The latter may have a pattern which can resemble that of posterior reversible encephalopathy syndrome, a condition that can overlap with RCVS. New imaging techniques, such as vessel wall imaging and arterial spin labeling, are proving useful in RCVS and are giving new insights into the pathophysiology of this condition. In this paper, we aim to review neuroimaging findings of RCVS.
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Abstract
Vessel wall MR imaging (VW-MRI) has been introduced into clinical practice and applied to a variety of diseases, and its usefulness has been reported. High-resolution VW-MRI is essential in the diagnostic workup and provides more information than other routine MR imaging protocols. VW-MRI is useful in assessing lesion location, morphology, and severity. Additional information, such as vessel wall enhancement, which is useful in the differential diagnosis of atherosclerotic disease and vasculitis could be assessed by this special imaging technique. This review describes the VW-MRI technique and its clinical applications in arterial disease, venous disease, vasculitis, and leptomeningeal disease.
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Ahmad SJ, Zampolin RL, Brook AL, Kobets AJ, Altschul DJ. A case of hydrocephalus confounded by suprasellar arachnoid cyst and concomitant reversible cerebral vasoconstriction syndrome. Surg Neurol Int 2022; 13:331. [PMID: 36128109 PMCID: PMC9479517 DOI: 10.25259/sni_313_2022] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/03/2022] [Accepted: 07/03/2022] [Indexed: 11/25/2022] Open
Abstract
Background: Obstructive hydrocephalus is a neurologic condition that has varied clinical and imaging presentations, as well as a multitude of congenital etiologies including aqueductal stenosis and less commonly arachnoid cysts. Aqueductal stenosis is a physical limitation to cerebrospinal fluid flow along the course of the aqueduct, which results in enlargement of the third and lateral ventricles. Arachnoid cysts are thin walled and fluid filled central nervous system lesions that can result in mass effect on adjacent structures. While arachnoid cysts are mostly asymptomatic, they may present with neurological symptoms that vary depending on the location of the lesion. Suprasellar cysts in particular may cause obstructive hydrocephalus as well as endocrine dysfunction. Reversible cerebral vasoconstriction syndrome (RCVS) is an unusual condition caused by cerebral arterial vasoconstriction that often presents initially with a thunderclap headache. Frequently, there is some environmental trigger associated with this condition. RCVS more commonly affects women and can induce stroke. Case Description: A 57-year-old female presented to the emergency department with progressive headache and visual changes. Initial workup suggested the patient’s symptoms where related to RCVS but subsequent surgical management of what was presumed to be long standing, compensated hydrocephalus resulted in resolution of the patient’s symptoms. Conclusion: We report, to the best of our knowledge, the first case of aquedutal stenosis and suprasellar arachnoid cyst with concomitant RCVS. The presence of multiple pathologies found on radiologic imaging illustrates the challenges presented by incidental findings and subsequent anchoring bias in medical diagnosis.
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Affiliation(s)
- Samuel Jack Ahmad
- Department of Neurosurgery, Albert Einstein College of Medicine, New York, United States
| | - Richard L. Zampolin
- Department of Radiology, Montefiore Medical Center, Bronx, New York, United States
| | - Allan L. Brook
- Department of Radiology, Montefiore Medical Center, Bronx, New York, United States
| | - Andrew J. Kobets
- Department of Neurosurgery, Montefiore Medical Center, Bronx, New York, United States
| | - David J. Altschul
- Department of Neurosurgery, Montefiore Medical Center, Bronx, New York, United States
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Shabo L, Ishaque M, Sarathy D, Kumar J, Xixis K, Park M. Pediatric Tacrolimus-Induced Reversible Cerebral Vasoconstriction Syndrome after Heart Transplantation. JOURNAL OF PEDIATRIC NEUROLOGY 2022. [DOI: 10.1055/s-0042-1745778] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/17/2022]
Abstract
AbstractReversible cerebral vasoconstriction syndrome (RCVS) is a rare post-organ transplantation complication. While uncommon, complications of post-transplant RCVS can be devastating, with sequelae including ischemic or hemorrhagic stroke and potential significant neurological morbidity. There is a paucity of literature on tacrolimus-mediated RCVS, particularly in the pediatric population. To date, only five case reports have been published, with the youngest patient being 15 years of age. We report the youngest case to date of post-heart transplant tacrolimus-induced RCVS in a 6-year-old male. The present case highlights the necessity of urgent imaging in suspected cases of RCVS, the potential diagnostic challenges surrounding the etiology of headache, the benefits of treating underlying cerebral vasospasm, and the importance of rapid discontinuation of the offending agent for the remission of symptoms and prevention of long-term sequelae.
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Affiliation(s)
- Leah Shabo
- University of Virginia School of Medicine, Charlottesville, Virginia, United States
| | - Mariam Ishaque
- Department of Neurosurgery, University of Virginia, Charlottesville, Virginia, United States
| | - Danyas Sarathy
- University of Virginia School of Medicine, Charlottesville, Virginia, United States
| | - Jeyan Kumar
- Department of Neurosurgery, University of Virginia, Charlottesville, Virginia, United States
| | - Kathryn Xixis
- Department of Neurology, University of Virginia, Charlottesville, Virginia, United States
| | - Min Park
- Department of Neurosurgery, University of Virginia, Charlottesville, Virginia, United States
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35
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PRES and RCVS: Two Distinct Entities or a Spectrum of the Same Disease? J Stroke Cerebrovasc Dis 2022; 31:106472. [DOI: 10.1016/j.jstrokecerebrovasdis.2022.106472] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/10/2021] [Revised: 03/14/2022] [Accepted: 03/20/2022] [Indexed: 12/24/2022] Open
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Pacheco K, Ortiz JF, Parwani J, Cruz C, Yépez M, Buj M, Khurana M, Ojeda D, Iturburu A, Aguirre AS, Yuen R, Datta S. Reversible Cerebral Vasoconstriction Syndrome in the Postpartum Period: A Systematic Review and Meta-Analysis. Neurol Int 2022; 14:488-496. [PMID: 35736621 PMCID: PMC9230388 DOI: 10.3390/neurolint14020040] [Citation(s) in RCA: 11] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/31/2022] [Revised: 05/01/2022] [Accepted: 05/13/2022] [Indexed: 12/10/2022] Open
Abstract
(1) Background: Reversible cerebral vasoconstriction syndrome (RCVS) encompasses a clinical and radiological diagnosis characterized by recurrent thunderclap headache, with or without focal deficits due to multifocal arterial vasoconstriction and dilation. RCVS can be correlated to pregnancy and exposure to certain drugs. Currently, the data on prevalence of RCVS in the postpartum period is lacking. We aim to investigate the prevalence of RCVS in the postpartum period and the rate of hemorrhagic complications of RCVS among the same group of patients; (2) Methods: We conducted the metanalysis by using the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA), and Meta-Analyses and Systematic Reviews of Observational Studies in Epidemiology (MOOSE) protocol. To analyze the Bias, we used the Ottawa Newcastle scale tool. We included only full-text observational studies conducted on humans and written in English. We excluded Literature Reviews, Systematic Reviews, and Metanalysis. Additionally, we excluded articles that did not document the prevalence of RCVS in the postpartum period (3). Results: According to our analysis, the Prevalence of RCVS in the postpartum period was 129/1083 (11.9%). Of these, 51/100 (52.7%) patients had hemorrhagic RCVS vs. 49/101 (49.5%) with non-hemorrhagic RCVS. The rates of Intracerebral Hemorrhage (ICH) and Subarachnoid Hemorrhage (SAH) were (51.6% and 10.7%, respectively. ICH seems to be more common than.; (4) Conclusions: Among patients with RCVS, the prevalence in PP patients is relativity high. Pregnant women with RCVS have a higher recurrence of hemorrhagic vs. non-hemorrhagic RCVS. Regarding the type of Hemorrhagic RCVS, ICH is more common than SAH among patients in the postpartum period. Female Sex, history of migraine, and older age group (above 45) seem to be risk factors for H-RCVS. Furthermore, recurrence of RCVS is associated with a higher age group (above 45). Recurrence of RCVS is more commonly idiopathic than being triggered by vasoactive drugs in the postpartum period.
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Affiliation(s)
- Kimberly Pacheco
- School of Medicine, Colegio de Ciencias de la Salud, Universidad San Francisco de Quito, Quito 170901, Ecuador; (C.C.); (D.O.); (A.S.A.)
- Correspondence: (K.P.); (J.F.O.)
| | - Juan Fernando Ortiz
- Department of Neurology, California Institute of Behavioral Neuroscience & Psychology, Fairfield, CA 94534, USA
- Correspondence: (K.P.); (J.F.O.)
| | - Jashank Parwani
- Neurology, Lokmanya Tilak Municipal Medical College, Mumbai 400022, India;
| | - Claudio Cruz
- School of Medicine, Colegio de Ciencias de la Salud, Universidad San Francisco de Quito, Quito 170901, Ecuador; (C.C.); (D.O.); (A.S.A.)
| | - Mario Yépez
- School of Medicine, Colegio de Ciencias de la Salud, Universidad Católica Santiago de Guayaquil, Guayaquil 090615, Ecuador;
| | - Maja Buj
- East Side Medical Practice, New York, NY 10075, USA;
| | - Mahika Khurana
- Department of Public Health, University of California, Berkeley, CA 94720, USA;
| | - Diego Ojeda
- School of Medicine, Colegio de Ciencias de la Salud, Universidad San Francisco de Quito, Quito 170901, Ecuador; (C.C.); (D.O.); (A.S.A.)
| | - Alisson Iturburu
- School of Medicine, Colegio de Ciencias de la Salud, Universidad de Guayaquil, Guayaquil 090510, Ecuador;
| | - Alex S. Aguirre
- School of Medicine, Colegio de Ciencias de la Salud, Universidad San Francisco de Quito, Quito 170901, Ecuador; (C.C.); (D.O.); (A.S.A.)
| | - Ray Yuen
- Neurology Department, Larkin Community Hospital, Miami, FL 33143, USA;
| | - Shae Datta
- Neurology Department, NYU Langone Health, New York, NY 10017, USA;
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Katsafanas C, Bushnell C. Pregnancy and stroke risk in women. Neurobiol Dis 2022; 169:105735. [PMID: 35477033 DOI: 10.1016/j.nbd.2022.105735] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/12/2021] [Revised: 04/05/2022] [Accepted: 04/13/2022] [Indexed: 10/18/2022] Open
Abstract
Stroke associated with pregnancy and post-partum occurs in about 30 per 100,000 deliveries, and includes subtypes of ischemic and hemorrhagic stroke as well as cerebral venous sinus thrombosis (CVST). There are a wide variety of underlying causes and risk factors, some that are common to both pregnant and non-pregnant women, and others that are unique to pregnancy. Although some of the strokes that occur may be a direct result of the pregnancy itself, such as hypertensive disorders of pregnancy, others could be anticipated or prevented by understanding the risk factors. These may include the presence of pre-pregnancy clotting disorders, aneurysms or arteriovenous malformations, hypertension, diabetes, or advanced maternal age. Treatment of stroke during pregnancy is based on the current recommendations for non-pregnant stroke patients, assuming the benefit of these treatments is likely higher than the risks. These decisions must be made with the appropriate specialists in stroke and endovascular treatment, as well as high-risk obstetrician/gynecologists, and most importantly, patient and family preferences.
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Affiliation(s)
- Constance Katsafanas
- University of Florida at Jacksonville, Department of Neurology, United States of America
| | - Cheryl Bushnell
- Wake Forest School of Medicine, Department of Neurology, United States of America.
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Lopez-Arevalo H, Romero Noboa ME, Joseph D, Edigin E, Arora S, Manadan A. Primary angiitis of the central nervous system and reversible cerebral vasoconstriction syndrome: analysis of the National Inpatient Sample. Clin Rheumatol 2022; 41:2467-2473. [PMID: 35411414 DOI: 10.1007/s10067-022-06172-5] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/03/2022] [Revised: 03/31/2022] [Accepted: 04/04/2022] [Indexed: 11/03/2022]
Abstract
INTRODUCTION Primary angiitis of the central nervous system (PACNS) and reversible cerebral vasoconstriction syndrome (RCVS) are two rare syndromes that affect the cerebral vasculature. Both conditions have been shown to cause severe neurologic complications. Distinguishing these two conditions in clinical practice is often challenging. Here, we compare the clinical features and outcomes of RCVS and PACNS hospitalizations against the general adult inpatient population. MATERIALS AND METHODS We conducted a retrospective review of hospitalizations with a diagnosis of PACNS or RCVS from 2016 to 2018 in the National Inpatient Sample (NIS) database. Multivariate analysis was performed to calculate adjusted odds ratios (ORadj) for hospital outcomes. RESULTS In the NIS, 3305 hospitalizations had a diagnosis of RCVS and 6035 hospitalizations had a diagnosis of PACNS. RCVS hospitalizations had a significantly greater association with cerebral aneurysms (ORadj 23.80), hemiplegia/hemiparesis following subarachnoid hemorrhage (SAH) (ORadj 324.09), ischemic stroke (ORadj 7.59), and nontraumatic SAH (ORadj 253.61). PACNS hospitalizations had a significantly greater association with hemiplegia/hemiparesis following cerebrovascular accident (CVA) (ORadj 6.16), ischemic stroke (ORadj 11.55), nontraumatic SAH (ORadj 7.29), seizure (ORadj 2.49), and in-hospital mortality (ORadj 2.85). CONCLUSIONS We performed an analysis of the NIS to better understand RCVS and PACNS hospitalizations. Severe neurologic events including CVA and SAH were elevated in both, but SAH and related hemiplegia/hemiparesis were extremely common among RCVS hospitalizations. In-hospital mortality was elevated in PACNS but not RCVS. This information can be used to help clinicians better understand, distinguish, and diagnose these conditions. Key Points • Despite clear description of RCVS and PACNS in the medical literature, there remains a scarcity of national population-based studies comparing these two entities against the general adult inpatient population. • This study aims to fill knowledge gaps in this area. • Here, we compare the clinical features and outcomes of RCVS and PACNS hospitalizations against the general adult inpatient population.
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Affiliation(s)
- Hugo Lopez-Arevalo
- Department of Medicine, John H. Stroger Hospital of Cook County, 1950 W. Polk, Chicago, IL, 60612, USA.
| | - Maria Emilia Romero Noboa
- Department of Medicine, John H. Stroger Hospital of Cook County, 1950 W. Polk, Chicago, IL, 60612, USA
| | - Dijo Joseph
- Division of Rheumatology, Rush University Medical Center, 1611 W. Harrison St., Suite 510, Chicago, IL, 60612, USA
| | - Ehizogie Edigin
- Department of Rheumatology, Loma Linda University Health, Loma Linda, CA, USA
| | - Shilpa Arora
- John H. Stroger Hospital of Cook County, 1950 W. Polk, 5th floor, Chicago, IL, 60612, USA
| | - Augustine Manadan
- Division of Rheumatology, Rush University Medical Center, 1611 W. Harrison St., Suite 510, Chicago, IL, 60612, USA
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Gil Y, Lee MJ, Cho S, Chung C. Effect of caffeine and caffeine cessation on cerebrovascular reactivity in patients with migraine. Headache 2022; 62:169-175. [DOI: 10.1111/head.14263] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/24/2021] [Accepted: 11/23/2021] [Indexed: 11/29/2022]
Affiliation(s)
- Young‐Eun Gil
- Department of Neurology Ajou University School of Medicine, Ajou University Medical Center Suwon South Korea
| | - Mi Ji Lee
- Department of Neurology Neuroscience Center Samsung Medical Center Sungkyunkwan University School of Medicine Seoul Korea
| | - Soohyun Cho
- Department of Neurology Uijeongbu Eulji Medical Center Eulji University School of Medicine Uijeongbu Korea
| | - Chin‐Sang Chung
- Department of Neurology Neuroscience Center Samsung Medical Center Sungkyunkwan University School of Medicine Seoul Korea
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Miller EC. Maternal Stroke Associated With Pregnancy. Continuum (Minneap Minn) 2022; 28:93-121. [PMID: 35133313 PMCID: PMC10101187 DOI: 10.1212/con.0000000000001078] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
PURPOSE OF REVIEW This article summarizes current knowledge of the epidemiology, pathophysiology, prevention, and treatment of cerebrovascular disease in pregnant and postpartum women. RECENT FINDINGS Stroke is a leading cause of maternal morbidity and mortality, and most fatal strokes are preventable. Adaptive physiologic changes of pregnancy, including hemodynamic changes, venous stasis, hypercoagulability, and immunomodulation, contribute to increased maternal stroke risk. The highest-risk time period for maternal stroke is the immediate postpartum period. Migraine and hypertensive disorders of pregnancy, including gestational hypertension and preeclampsia, are major risk factors for maternal stroke. Adverse pregnancy outcomes, including gestational hypertension, preeclampsia, preterm delivery, and fetal growth restriction, are important risk factors for cerebrovascular disease later in life. SUMMARY Many catastrophic maternal strokes could be avoided with targeted prevention efforts, early recognition of warning signs, and rapid evaluation of neurologic symptoms. Neurologists play a central role in the care of pregnant patients with cerebrovascular disease, whether acute or chronic, and should be familiar with the unique and complex physiology of pregnancy and its complications, particularly hypertensive disorders of pregnancy.
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Triplett JD, Kutlubaev MA, Kermode AG, Hardy T. Posterior reversible encephalopathy syndrome (PRES): diagnosis and management. Pract Neurol 2022; 22:183-189. [PMID: 35046115 DOI: 10.1136/practneurol-2021-003194] [Citation(s) in RCA: 22] [Impact Index Per Article: 11.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/23/2021] [Indexed: 01/31/2023]
Abstract
Posterior reversible encephalopathy syndrome (PRES) may present with diverse clinical symptoms including visual disturbance, headache, seizures and impaired consciousness. MRI shows oedema, usually involving the posterior subcortical regions. Triggering factors include hypertension, pre-eclampsia/eclampsia, renal failure, cytotoxic agents and autoimmune conditions. The mechanism underlying PRES is not certain, but endothelial dysfunction is implicated. Treatment is supportive and involves correcting the underlying cause and managing associated complications, such as seizures. Although most patients recover, PRES is not always reversible and may be associated with considerable morbidity and even mortality.
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Affiliation(s)
- James D Triplett
- Neurology, Concord Hospital, Concord, New South Wales, Australia
| | | | - Allan G Kermode
- Perron Institute, University of Western Australia, Perth, Western Australia, Australia.,CMMIT, Murdoch University, Murdoch, Western Australia, Australia
| | - Todd Hardy
- Neurology, Concord Hospital, Concord, New South Wales, Australia.,Brain and Mind Centre, University of Sydney, Sydney, New South Wales, Australia
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Balu R, Fischer M. Posterior Reversible Encephalopathy Syndrome. Stroke 2022. [DOI: 10.1016/b978-0-323-69424-7.00038-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
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Spadaro A, Scott KR, Koyfman A, Long B. Reversible cerebral vasoconstriction syndrome: A narrative review for emergency clinicians. Am J Emerg Med 2021; 50:765-772. [PMID: 34879501 DOI: 10.1016/j.ajem.2021.09.072] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/23/2021] [Revised: 09/23/2021] [Accepted: 09/26/2021] [Indexed: 12/21/2022] Open
Abstract
INTRODUCTION Reversible Cerebral Vasoconstriction Syndrome (RCVS) is a rare cause of severe headache that can mimic other causes of sudden, severe headache and result in frequent emergency department (ED) visits. OBJECTIVE This narrative review provides an evidence-based update concerning the presentation, evaluation, and management of RCVS for the emergency clinician. DISCUSSION RCVS can present as recurrent, severe headaches that may be maximal in onset, known as a thunderclap headache. Distinguishing from other causes of thunderclap headache such as aneurysmal subarachnoid hemorrhage, cerebral venous thrombosis, and posterior reversible encephalopathy syndrome is challenging. Risk factors for RCVS include use of vasoactive substances, exertion, coughing, showering, sexual activity, and cervical artery dissection. Diagnosis relies on clinical features and imaging. Cerebral catheter digital subtraction angiography (DSA) is considered the gold standard imaging modality; however, computed tomography angiography or magnetic resonance angiography are reliable non-invasive diagnostic modalities. Treatment focuses on avoiding or removing the offending agent, administration of calcium channel blockers such as nimodipine, and reversing anticoagulation if bleeding is present. Although most cases have a benign course and resolve within 3 months, focal subarachnoid hemorrhage, intracerebral hemorrhage, permanent neurologic disability, or death can occur in a minority of cases. CONCLUSIONS Diagnosis and appropriate management of RCVS can be aided by understanding key aspects of the history and examination. The emergency clinician can then obtain indicated imaging, confirming the diagnosis and allowing for appropriate management.
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Affiliation(s)
- Anthony Spadaro
- Department of Emergency Medicine, University of Pennsylvania Health System, Philadelphia, PA, United States.
| | - Kevin R Scott
- Department of Emergency Medicine, University of Pennsylvania Health System, Philadelphia, PA, United States.
| | - Alex Koyfman
- The University of Texas Southwestern Medical Center, Department of Emergency Medicine, 5323 Harry Hines Boulevard, Dallas, TX 75390, United States
| | - Brit Long
- Department of Emergency Medicine, Brooke Army Medical Center, 3841 Roger Brooke Dr, Fort Sam Houston, TX 78234, United States.
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Cheng X, Li J, Lan Y, Liu J, Chen S, Lu G. Cerebrovascular Disease in the Setting of Posterior Reversible Encephalopathy Syndrome. Front Neurol 2021; 12:765333. [PMID: 34867751 PMCID: PMC8635685 DOI: 10.3389/fneur.2021.765333] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/26/2021] [Accepted: 10/25/2021] [Indexed: 12/03/2022] Open
Abstract
Overlap between the pathogenesis of posterior reversible encephalopathy syndrome and that of cerebrovascular disease can confound their clinical and radiological presentations, posing a diagnostic challenge. This article presents a literature review and discussion of the clinical manifestations, pathological mechanisms, and imaging manifestations of subarachnoid hemorrhage and vasculitis leading to posterior reversible encephalopathy syndrome, coexistence of posterior reversible encephalopathy syndrome with reversible cerebral vasoconstriction syndrome, and hemorrhage and infarction secondary to posterior reversible encephalopathy syndrome. The findings show that posterior reversible encephalopathy syndrome shares some overlapping pathophysiological mechanisms with cerebrovascular disease. Importantly, neuroimaging plays an important role in identifying this entity in a timely manner and differentiating it from other diseases.
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Affiliation(s)
- XiaoQing Cheng
- Department of Medical Imaging, Jinling Hospital, Nanjing University School of Medicine, Nanjing, China
| | - JianRui Li
- Department of Medical Imaging, Jinling Hospital, Nanjing University School of Medicine, Nanjing, China
| | - Ying Lan
- Special Medical Service, Lushan Rehabilitation and Recuperation Center of People's Liberation Army (PLA), Jiujiang, China
| | - Jia Liu
- Department of Medical Imaging, Jinling Hospital, Nanjing University School of Medicine, Nanjing, China
| | - Sui Chen
- Department of Medical Imaging, Jinling Hospital, Nanjing University School of Medicine, Nanjing, China
| | - GuangMing Lu
- Department of Medical Imaging, Jinling Hospital, Nanjing University School of Medicine, Nanjing, China
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Wu CH, Lirng JF, Wu HM, Ling YH, Wang YF, Fuh JL, Lin CJ, Ling K, Wang SJ, Chen SP. Blood-Brain Barrier Permeability in Patients With Reversible Cerebral Vasoconstriction Syndrome Assessed With Dynamic Contrast-Enhanced MRI. Neurology 2021; 97:e1847-e1859. [PMID: 34504032 DOI: 10.1212/wnl.0000000000012776] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/14/2021] [Accepted: 08/23/2021] [Indexed: 12/13/2022] Open
Abstract
BACKGROUND AND OBJECTIVES Blood-brain barrier (BBB) disruption has been proposed to be important in the pathogenesis of reversible cerebral vasoconstriction syndrome (RCVS), but not all patients present an identifiable macroscopic BBB disruption; that is, visible contrast leakage on contrast-enhanced T2 fluid-attenuated inversion recovery imaging. This study aimed to evaluate microscopic BBB permeability and its dynamic change in patients with RCVS. METHODS This prospective cohort implemented 3T dynamic contrast-enhanced MRI. We measured microscopic BBB permeability by determining the whole-brain and white matter hyperintensity (WMH) Ktrans values and evaluated the correlation of whole-brain Ktrans permeability with clinical and vascular measures in transcranial color-coded sonography. RESULTS In total, 176 patients (363 scans) were analyzed and separated into acute (≦30 days) and remission (≧90 days) groups based on the onset-to-examination time. Whole-brain Ktrans values were similar between patients with and without macroscopic BBB disruption in either acute or remission stage. The whole-brain Ktrans was significantly decreased (p < 0.001) from acute to remission stages. The WMH Ktrans was significantly higher than mirror references and decreased from acute to remission stages (p < 0.001). Whole-brain Ktrans correlated with mean pulsatility index (r s = 0.5, p = 0.029), mean resistance index (r s = 0.662, p = 0.002), and distal-to-proximal ratio of resistance index (r s = 0.801, p < 0.001) of M1 segment of middle cerebral arteries at around 10-15 days after onset. The time-trend curve of whole-brain Ktrans depicted dynamic changes during disease course, similar to temporal trends of vasoconstrictions and WMH. DISCUSSION Patients with RCVS presented increased microscopic brain permeability during acute stage, even without discernible macroscopic BBB disruption. The dynamic changes in BBB permeability may be related to impaired cerebral microvascular compliance and WMH formation.
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Affiliation(s)
- Chia-Hung Wu
- From the Department of Radiology (C.-H.W., J.-F.L., H.-M.W., C.-J.L., K.L.), Department of Neurology, Neurological Institute (Y.-H.L., Y.-F.W., J.-L.F., S.-J.W., S.-P.C.), and Division of Translational Research, Department of Medical Research (S.-P.C.), Taipei Veterans General Hospital; and Institute of Clinical Medicine (C.-H.W., S.-P.C.), School of Medicine (C.-H.W., J.-F.L., H.-M.W., Y.-H.L., Y.-F.W., J.-L.F., C.-J.L., K.L., S.-J.W., S.-P.C.), and Brain Research Center (Y.-F.W., J.-L.F., S.-J.W., S.-P.C.), National Yang Ming Chiao Tung University, Taipei, Taiwan
| | - Jiing-Feng Lirng
- From the Department of Radiology (C.-H.W., J.-F.L., H.-M.W., C.-J.L., K.L.), Department of Neurology, Neurological Institute (Y.-H.L., Y.-F.W., J.-L.F., S.-J.W., S.-P.C.), and Division of Translational Research, Department of Medical Research (S.-P.C.), Taipei Veterans General Hospital; and Institute of Clinical Medicine (C.-H.W., S.-P.C.), School of Medicine (C.-H.W., J.-F.L., H.-M.W., Y.-H.L., Y.-F.W., J.-L.F., C.-J.L., K.L., S.-J.W., S.-P.C.), and Brain Research Center (Y.-F.W., J.-L.F., S.-J.W., S.-P.C.), National Yang Ming Chiao Tung University, Taipei, Taiwan
| | - Hsiu-Mei Wu
- From the Department of Radiology (C.-H.W., J.-F.L., H.-M.W., C.-J.L., K.L.), Department of Neurology, Neurological Institute (Y.-H.L., Y.-F.W., J.-L.F., S.-J.W., S.-P.C.), and Division of Translational Research, Department of Medical Research (S.-P.C.), Taipei Veterans General Hospital; and Institute of Clinical Medicine (C.-H.W., S.-P.C.), School of Medicine (C.-H.W., J.-F.L., H.-M.W., Y.-H.L., Y.-F.W., J.-L.F., C.-J.L., K.L., S.-J.W., S.-P.C.), and Brain Research Center (Y.-F.W., J.-L.F., S.-J.W., S.-P.C.), National Yang Ming Chiao Tung University, Taipei, Taiwan
| | - Yu-Hsiang Ling
- From the Department of Radiology (C.-H.W., J.-F.L., H.-M.W., C.-J.L., K.L.), Department of Neurology, Neurological Institute (Y.-H.L., Y.-F.W., J.-L.F., S.-J.W., S.-P.C.), and Division of Translational Research, Department of Medical Research (S.-P.C.), Taipei Veterans General Hospital; and Institute of Clinical Medicine (C.-H.W., S.-P.C.), School of Medicine (C.-H.W., J.-F.L., H.-M.W., Y.-H.L., Y.-F.W., J.-L.F., C.-J.L., K.L., S.-J.W., S.-P.C.), and Brain Research Center (Y.-F.W., J.-L.F., S.-J.W., S.-P.C.), National Yang Ming Chiao Tung University, Taipei, Taiwan
| | - Yen-Feng Wang
- From the Department of Radiology (C.-H.W., J.-F.L., H.-M.W., C.-J.L., K.L.), Department of Neurology, Neurological Institute (Y.-H.L., Y.-F.W., J.-L.F., S.-J.W., S.-P.C.), and Division of Translational Research, Department of Medical Research (S.-P.C.), Taipei Veterans General Hospital; and Institute of Clinical Medicine (C.-H.W., S.-P.C.), School of Medicine (C.-H.W., J.-F.L., H.-M.W., Y.-H.L., Y.-F.W., J.-L.F., C.-J.L., K.L., S.-J.W., S.-P.C.), and Brain Research Center (Y.-F.W., J.-L.F., S.-J.W., S.-P.C.), National Yang Ming Chiao Tung University, Taipei, Taiwan
| | - Jong-Ling Fuh
- From the Department of Radiology (C.-H.W., J.-F.L., H.-M.W., C.-J.L., K.L.), Department of Neurology, Neurological Institute (Y.-H.L., Y.-F.W., J.-L.F., S.-J.W., S.-P.C.), and Division of Translational Research, Department of Medical Research (S.-P.C.), Taipei Veterans General Hospital; and Institute of Clinical Medicine (C.-H.W., S.-P.C.), School of Medicine (C.-H.W., J.-F.L., H.-M.W., Y.-H.L., Y.-F.W., J.-L.F., C.-J.L., K.L., S.-J.W., S.-P.C.), and Brain Research Center (Y.-F.W., J.-L.F., S.-J.W., S.-P.C.), National Yang Ming Chiao Tung University, Taipei, Taiwan
| | - Chung-Jung Lin
- From the Department of Radiology (C.-H.W., J.-F.L., H.-M.W., C.-J.L., K.L.), Department of Neurology, Neurological Institute (Y.-H.L., Y.-F.W., J.-L.F., S.-J.W., S.-P.C.), and Division of Translational Research, Department of Medical Research (S.-P.C.), Taipei Veterans General Hospital; and Institute of Clinical Medicine (C.-H.W., S.-P.C.), School of Medicine (C.-H.W., J.-F.L., H.-M.W., Y.-H.L., Y.-F.W., J.-L.F., C.-J.L., K.L., S.-J.W., S.-P.C.), and Brain Research Center (Y.-F.W., J.-L.F., S.-J.W., S.-P.C.), National Yang Ming Chiao Tung University, Taipei, Taiwan
| | - Kan Ling
- From the Department of Radiology (C.-H.W., J.-F.L., H.-M.W., C.-J.L., K.L.), Department of Neurology, Neurological Institute (Y.-H.L., Y.-F.W., J.-L.F., S.-J.W., S.-P.C.), and Division of Translational Research, Department of Medical Research (S.-P.C.), Taipei Veterans General Hospital; and Institute of Clinical Medicine (C.-H.W., S.-P.C.), School of Medicine (C.-H.W., J.-F.L., H.-M.W., Y.-H.L., Y.-F.W., J.-L.F., C.-J.L., K.L., S.-J.W., S.-P.C.), and Brain Research Center (Y.-F.W., J.-L.F., S.-J.W., S.-P.C.), National Yang Ming Chiao Tung University, Taipei, Taiwan
| | - Shuu-Jiun Wang
- From the Department of Radiology (C.-H.W., J.-F.L., H.-M.W., C.-J.L., K.L.), Department of Neurology, Neurological Institute (Y.-H.L., Y.-F.W., J.-L.F., S.-J.W., S.-P.C.), and Division of Translational Research, Department of Medical Research (S.-P.C.), Taipei Veterans General Hospital; and Institute of Clinical Medicine (C.-H.W., S.-P.C.), School of Medicine (C.-H.W., J.-F.L., H.-M.W., Y.-H.L., Y.-F.W., J.-L.F., C.-J.L., K.L., S.-J.W., S.-P.C.), and Brain Research Center (Y.-F.W., J.-L.F., S.-J.W., S.-P.C.), National Yang Ming Chiao Tung University, Taipei, Taiwan
| | - Shih-Pin Chen
- From the Department of Radiology (C.-H.W., J.-F.L., H.-M.W., C.-J.L., K.L.), Department of Neurology, Neurological Institute (Y.-H.L., Y.-F.W., J.-L.F., S.-J.W., S.-P.C.), and Division of Translational Research, Department of Medical Research (S.-P.C.), Taipei Veterans General Hospital; and Institute of Clinical Medicine (C.-H.W., S.-P.C.), School of Medicine (C.-H.W., J.-F.L., H.-M.W., Y.-H.L., Y.-F.W., J.-L.F., C.-J.L., K.L., S.-J.W., S.-P.C.), and Brain Research Center (Y.-F.W., J.-L.F., S.-J.W., S.-P.C.), National Yang Ming Chiao Tung University, Taipei, Taiwan.
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Boitet R, de Gaalon S, Ducros A. Sindrome da vasocostrizione cerebrale reversibile. Neurologia 2021. [DOI: 10.1016/s1634-7072(21)45780-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022] Open
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Singhal AB. Posterior Reversible Encephalopathy Syndrome and Reversible Cerebral Vasoconstriction Syndrome as Syndromes of Cerebrovascular Dysregulation. Continuum (Minneap Minn) 2021; 27:1301-1320. [PMID: 34618761 DOI: 10.1212/con.0000000000001037] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
PURPOSE OF REVIEW This article describes the causes, clinical and imaging features, management, and prognosis of posterior reversible encephalopathy syndrome (PRES) and reversible cerebral vasoconstriction syndrome (RCVS), in which the underlying pathophysiology is related to reversible dysregulation of the cerebral vasculature. RECENT FINDINGS PRES and RCVS are descriptive terms, each bringing together conditions with similar clinical-imaging manifestations. Headache, visual symptoms, seizures, and confusion occur in both syndromes. RCVS is usually heralded by recurrent thunderclap headaches, whereas encephalopathy and seizures are typical in PRES. In PRES, brain imaging shows reversible vasogenic edema that is typically symmetric and located in subcortical regions (mostly posterior predominant). In RCVS, brain imaging is often normal; cerebral angiography shows segmental vasoconstriction-vasodilatation affecting the circle of Willis arteries and their branches. Aside from shared clinical features, significant imaging overlap exists. Both PRES and RCVS can be complicated by ischemic and hemorrhagic brain lesions; angiographic abnormalities frequently occur in PRES and vasogenic edematous lesions in RCVS. Common triggers (eg, eclampsia, vasoconstrictive and chemotherapeutic agents) have been identified. Abnormal cerebrovascular tone and endothelial dysfunction may explain both syndromes. Management of these syndromes includes the removal of identified triggers, symptomatic treatment of headache or seizures, and moderate blood pressure control. Both syndromes are self-limited, with clinical recovery occurring within days to weeks. Long-term deficits and mortality are uncommon. SUMMARY PRES and RCVS have been well characterized and acknowledged to have significant overlap. Advances in our understanding of pathophysiology and risk factors for poor outcome are expected to optimize the management of these not uncommon syndromes.
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Reversible cerebral vasoconstriction with quadrigeminal cistern subarachnoid hemorrhage. Can J Neurol Sci 2021; 49:793-794. [PMID: 34486964 DOI: 10.1017/cjn.2021.209] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
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Patel SD, Topiwala K, Otite Oliver F, Saber H, Panza G, Mui G, Liebeskind DS, Saver JL, Alberts M, Ducros A. Outcomes Among Patients With Reversible Cerebral Vasoconstriction Syndrome: A Nationwide United States Analysis. Stroke 2021; 52:3970-3977. [PMID: 34470494 DOI: 10.1161/strokeaha.121.034424] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Abstract
BACKGROUND AND PURPOSE Reversible cerebral vasoconstriction syndrome (RCVS) is a well-established cause of stroke, but its demographics and outcomes have not been well delineated. METHODS Analysis of the United States Nationwide Inpatient Sample database (2016-2017) to characterize the frequency of hospitalizations for RCVS, demographic features, inpatient mortality, and discharge outcomes. RESULTS During the 2-year study period, 2020 patients with RCVS were admitted to Nationwide Inpatient Sample hospitals, representing 0.02 cases per 100 000 national hospitalizations. The mean age at admission was 47.6 years, with 85% under 65 years of age, and 75.5% women. Concomitant neurological diagnoses during hospitalization included ischemic stroke (17.1%), intracerebral hemorrhage (11.0%), subarachnoid hemorrhage (32.7%), seizure disorders (6.7%), and reversible brain edema (13.6%). Overall, 70% of patients were discharged home, 29.7% discharged to a rehabilitation facility or nursing home and 0.3% died before discharge. Patient features independently associated with the poor outcome of discharge to another facility or death were advanced age (odds ratio [OR], 1.04 [95% CI, 1.03-1.04]), being a woman (OR, 2.45 [1.82-3.34]), intracerebral hemorrhage (OR, 2.91 [1.96-4.31]), ischemic stroke (OR, 5.72 [4.32-7.58]), seizure disorders (OR, 2.61 [1.70-4.00]), reversible brain edema (OR, 6.26 [4.41-8.89]), atrial fibrillation (OR, 2.97 [1.83-4.81]), and chronic kidney disease (OR, 3.43 [2.19-5.36]). CONCLUSIONS Projected to the entire US population, >1000 patients with RCVS are hospitalized each year, with the majority being middle-aged women, and about 300 required at least some rehabilitation or nursing home care after discharge. RCVS-related inpatient mortality is rare.
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Affiliation(s)
- Smit D Patel
- Neurology Department, University of Connecticut/Hartford Hospital (S.D.P., G.M., M.A.)
| | - Karan Topiwala
- Neurology Department, University of Minnesota, Minneapolis (K.T.)
| | - Fadar Otite Oliver
- Neurology Department, State University of New York (SUNY) Upstate Medical University, Syracuse, NY (F.O.O.)
| | - Hamidreza Saber
- Neurology Department, University of California of Los Angelos (H.S., D.S.L., J.L.S.)
| | - Gregory Panza
- Department of Research, Hartford Hospital, CT (G.P.)
| | - Gracia Mui
- Neurology Department, University of Connecticut/Hartford Hospital (S.D.P., G.M., M.A.)
| | - David S Liebeskind
- Neurology Department, University of California of Los Angelos (H.S., D.S.L., J.L.S.)
| | - Jeffrey L Saver
- Neurology Department, University of California of Los Angelos (H.S., D.S.L., J.L.S.)
| | - Mark Alberts
- Neurology Department, University of Connecticut/Hartford Hospital (S.D.P., G.M., M.A.)
| | - Anne Ducros
- Neurology Department, Montpellier University Hospital, France (A.D.).,Laboratory Charles Coulomb UMR 5221 CNRS-UM, Montpellier University, France (A.D.)
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Lange KS, Forster O, Mawet J, Tuloup G, Burcin C, Corti L, Duflos C, Roos C, Ducros A. Type of headache at onset and risk for complications in reversible cerebral vasoconstriction syndrome. Eur J Neurol 2021; 29:130-137. [PMID: 34390103 DOI: 10.1111/ene.15064] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/03/2021] [Accepted: 08/07/2021] [Indexed: 11/28/2022]
Abstract
BACKGROUND In a recent Italian study, 30% of patients with reversible cerebral vasoconstriction syndrome (RCVS) presented without thunderclap headache (TCH), and tended to present more severe forms of RCVS than patients with TCH. We aimed to analyze the risk for complications of RCVS in patients with and without TCH at onset. METHODS In a pooled cohort of 345 French patients with RCVS, we compared patients with and without TCH at onset regarding rates of neurological complications, and the functional outcome at 3 months. RESULTS As compared to the 281 patients with TCH at onset, the 64 patients without TCH had a higher risk for any neurological complication (61% vs. 24%, OR 4.9, 95% CI 2.8-8.7, p < 0.001). The association was strongest for cervical artery dissections (28% vs. 5%, OR 8.1, 95% CI 3.7-17.6, p < 0.001), followed by posterior reversible encephalopathy syndrome (17% vs. 3%, OR 7.1, 95% CI 2.7-18.4, p < 0.001), seizures (9% vs. 2.5%, OR 4.1, 95% CI 1.3-12.5, p = 0.019), and subarachnoid hemorrhage (41% vs. 16%, OR 3.5, 95% CI 1.9-6.3, p < 0.001). In multivariable analysis, the risk for any neurological complication remained significantly elevated in the absence of TCH (OR 3.5, 95% CI 1.8-6.8, p < 0.001). The functional outcome was equal in both groups, with a modified Rankin scale score of 0-1 in ≥90% of patients. CONCLUSIONS Absence of TCH at onset might predict a higher risk of complications in RCVS. Our results warrant further multicentric studies to prove this finding.
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Affiliation(s)
- Kristin Sophie Lange
- Department of Neurology, CHU Montpellier, Hospital Gui de Chauliac, Montpellier, France.,Center for Stroke Research Berlin (CSB), Charité - Universitätsmedizin, Berlin, Germany.,Department of Neurology I Charité, Universitätsmedizin Berlin, Berlin, Germany
| | - Ophélie Forster
- Department of Neurology, CHU Montpellier, Hospital Gui de Chauliac, Montpellier, France
| | - Jérôme Mawet
- Emergency Headache Center, Department of Neurology, Lariboisière Hospital, Assistance Publique des Hôpitaux de Paris, Paris, France
| | | | - Cécilia Burcin
- Emergency Headache Center, Department of Neurology, Lariboisière Hospital, Assistance Publique des Hôpitaux de Paris, Paris, France
| | - Lucas Corti
- Department of Neurology, CHU Montpellier, Hospital Gui de Chauliac, Montpellier, France
| | - Claire Duflos
- Clinical Research and Epidemiology Unit, Department of Medical Information, CHU Montpellier, Montpellier University, Montpellier, France
| | - Caroline Roos
- Emergency Headache Center, Department of Neurology, Lariboisière Hospital, Assistance Publique des Hôpitaux de Paris, Paris, France
| | - Anne Ducros
- Department of Neurology, CHU Montpellier, Hospital Gui de Chauliac, Montpellier, France.,Charles Coulomb Laboratory, CNRS UMR5221, Montpellier University, Montpellier, France
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