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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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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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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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[A contrast medium uptake of the vessel wall is not specific for cerebral vasculitis]. DER NERVENARZT 2022; 93:1271-1273. [PMID: 35608618 DOI: 10.1007/s00115-022-01304-3] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Accepted: 04/28/2022] [Indexed: 10/18/2022]
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5
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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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Strunk D, Veltkamp R, Meuth SG, Chapot R, Kraemer M. Intra-arterial application of nimodipine in reversible cerebral vasoconstriction syndrome: a neuroradiological method to help differentiate from primary central nervous system vasculitis. Neurol Res Pract 2022; 4:8. [PMID: 35227319 PMCID: PMC8883624 DOI: 10.1186/s42466-022-00173-0] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/10/2022] [Accepted: 02/09/2022] [Indexed: 11/28/2022] Open
Abstract
Background Reversible cerebral vasoconstriction syndrome (RCVS) is characterized by a prolonged, but self-limiting segmental cerebral vasoconstriction. Neurological outcomes vary, but can be severe. The clinical hallmark of RCVS is thunderclap headache, which might come along with further neurological symptoms. Distinguishing RCVS from other entities, such as primary angiitis of the central nervous system (PACNS), is of utmost importance for appropriate therapy. The angiographic response to intra-arterial nimodipine application has been suggested as an additional diagnostic criterion for RCVS but confirmatory studies are limited. We aimed to evaluate the angiographic nimodipine test. Methods We reviewed retrospectively the clinical and imaging data of 13 RCVS patients, who were admitted to a single German neurological department between January 2013 and December 2020. Results Out of 13 patients diagnosed with RCVS, 4 patients underwent an angiographic nimodipine test. In all 4 patients cerebral vasoconstriction completely resolved during nimodipine application. Among the four patients with a positive test, there was one individual, in whom a response was detected after a delay of 60 min. In all patients, we found a complete resolution of cerebral vasoconstriction within 12 weeks. Conclusion Our findings support the usefulness of the application of nimodipine in diagnosing RCVS. Prolonged angiographic observation of the vascular response after nimodipine injection is important.
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Reversible Cerebral Vasoconstriction Syndromes. Stroke 2022. [DOI: 10.1016/b978-0-323-69424-7.00037-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
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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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Definitive Diagnostic Evaluation of the Child With Arterial Ischemic Stroke and Approaches to Secondary Stroke Prevention. Top Magn Reson Imaging 2021; 30:225-230. [PMID: 34613945 DOI: 10.1097/rmr.0000000000000272] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
ABSTRACT In children with arterial ischemic stroke (AIS), the definitive diagnosis of stroke subtype and confirmation of stroke etiology is necessary to mitigate stroke morbidity and prevent recurrent stroke. The common causes of AIS in children are sharply differentiated from the common causes of adult AIS. A comprehensive, structured diagnostic approach will identify the etiology of stroke in most children. Adequate diagnostic evaluation relies on advanced brain imaging and vascular imaging studies. A variety of medical and surgical secondary stroke prevention strategies directed at the underlying cause of stroke are available. This review aims to outline strategies for definitive diagnosis and secondary stroke prevention in children with AIS, emphasizing the critical role of neuroimaging.
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Kraemer M, Berlit P. Primary central nervous system vasculitis - An update on diagnosis, differential diagnosis and treatment. J Neurol Sci 2021; 424:117422. [PMID: 33832773 DOI: 10.1016/j.jns.2021.117422] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/20/2020] [Revised: 11/24/2020] [Accepted: 03/24/2021] [Indexed: 02/07/2023]
Abstract
IMPORTANCE Primary angiitis of the central nervous system (PACNS) is a rare condition which is often misdiagnosed. In order to avoid mistakes in the management, a step by step approach is necessary. OBSERVATIONS The most common presenting symptoms of PACNS are encephalopathy-related cognitive and affective abnormalities, headaches and multifocal symptoms associated with recurrent episodes of ischemia or hemorrhage. Seizures and spinal cord lesions may also occur. Diagnostic work up includes MRI, CSF examination, angiography and brain biopsy. Since all reported signs and findings lack specificity, the exclusion of differential diagnoses is essential before immunosuppressive therapy is started. Important differential diagnoses include reversible cerebral vasoconstriction syndrome, cerebral involvement of systemic vasculitides or rheumatic diseases, moyamoya angiopathy and infectious vasculopathies Effective treatment has been reported with glucocorticoids in combination with cyclophosphamide or rituximab; however, randomized clinical trials of PACNS treatment do not exist. CONCLUSIONS AND RELEVANCE PACNS is an important but rare differential diagnosis in daily neurological practice. The strict adherence to diagnostic criteria and the avoidance of inappropriate therapies in non-inflammatory vasculopathies and infectious diseases are essential.
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Affiliation(s)
- Markus Kraemer
- Department of Neurology, Alfried Krupp Hospital, Alfried-Krupp-Strasse 21, 45130 Essen, Germany; Department of Neurology, Medical Faculty, Heinrich Heine University, Moorenstrasse 5, 40225 Düsseldorf, Germany.
| | - Peter Berlit
- Department of Neurology, Alfried Krupp Hospital, Alfried-Krupp-Strasse 21, 45130 Essen, Germany; German Society of Neurology, Reinhardtstrasse 27 C, 10117 Berlin, Germany
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Alapatt PJ, Panwar A, Kuruttukulam GV, Sundar K. Lessons Learned from a Fulminant Case of Reversible Cerebral Vasoconstriction Syndrome: Past Medical History Misleads the Diagnosis and Intra-Arterial Milrinone Offers Diagnostic Utility. Neurointervention 2021; 16:78-82. [PMID: 33460536 PMCID: PMC7946561 DOI: 10.5469/neuroint.2020.00416] [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: 11/18/2020] [Accepted: 12/14/2020] [Indexed: 11/24/2022] Open
Abstract
A 34-year-old post-partum female having dermatomyositis developed headache and became comatose after a seizure episode. Magnetic resonance imaging of brain showed a massive left ganglio-capsular bleed for which decompressive surgery was done. Computed tomographic angiography showed multiple foci of narrowing and irregularities in distal cerebral vessels. In view of dermatomyositis, the diagnosis of vasculitis was considered and pulse therapy of intravenous methylprednisolone was started. The patient, however, showed no improvement and developed new brain infarcts. She was subsequently taken up for a diagnostic cerebral angiography which showed multifocal severe narrowing in bilateral major cerebral arteries. These angiographic abnormalities showed excellent reversibility to intra-arterial milrinone and hence, reversible cerebral vasoconstriction syndrome (RCVS) was diagnosed. Normal angiographic findings in the first week do not rule out the disease and a repeat angiography should be considered if the clinical suspicion of the RCVS is high. Intra-arterial milrinone has a high diagnostic utility.
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Affiliation(s)
- Paul J Alapatt
- Department of Neurology, Rajagiri Hospital, Kochi, India
| | - Ajay Panwar
- Department of Neurology, Rajagiri Hospital, Kochi, India
| | | | - Kaushik Sundar
- Department of Neurology, Rabindranath International Institute of Cardiac Sciences, Kolkata, India
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12
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Sequeiros JM, Roa JA, Sabotin RP, Dandapat S, Ortega-Gutierrez S, Leira EC, Derdeyn CP, Bathla G, Hasan DM, Samaniego EA. Quantifying Intra-Arterial Verapamil Response as a Diagnostic Tool for Reversible Cerebral Vasoconstriction Syndrome. AJNR Am J Neuroradiol 2020; 41:1869-1875. [PMID: 32943423 DOI: 10.3174/ajnr.a6772] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/29/2020] [Accepted: 07/04/2020] [Indexed: 11/07/2022]
Abstract
BACKGROUND AND PURPOSE There is mounting evidence supporting the benefit of intra-arterial administration of vasodilators in diagnosing reversible cerebral vasoconstriction syndrome. We prospectively quantified the degree of luminal diameter dilation after intra-arterial administration of verapamil and its accuracy in diagnosing reversible cerebral vasoconstriction syndrome. MATERIALS AND METHODS Patients suspected of having intracranial arteriopathy on noninvasive imaging and referred for digital subtraction angiography were enrolled in a prospective registry. Intra-arterial verapamil was administered in vascular territories with segmental irregularities. The caliber difference (Caliberpost - Caliberpre) and the proportion of caliber change ([(Caliberpost - Caliberpre)/Caliberpre] × 100%) were used to determine the response to verapamil. The diagnosis of reversible cerebral vasoconstriction syndrome was made on the basis of clinical and imaging features at a follow-up appointment, independent of the reversibility of verapamil. Receiver operating characteristic curve analysis was performed to determine the best threshold. RESULTS Twenty-six patients were included, and 9 (34.6%) were diagnosed with reversible cerebral vasoconstriction syndrome. A total of 213 vascular segments were assessed on diagnostic angiography. Every patient with a final diagnosis of reversible cerebral vasoconstriction syndrome responded to intra-arterial verapamil. The maximal proportion of change (P < .001), mean proportion of change (P = .002), maximal caliber difference (P = .004), and mean caliber difference (P = .001) were statistically different between patients with reversible cerebral vasoconstriction syndrome and other vasculopathies. A maximal proportion of change ≥32% showed a sensitivity of 100% and a specificity of 88.2% to detect reversible cerebral vasoconstriction syndrome (area under the curve = 0.951). The Reversible Cerebral Vasoconstriction Syndrome-2 score of ≥5 points achieved a lower area under the curve (0.908), with a sensitivity of 77.8% and a specificity of 94.1%. CONCLUSIONS Objective measurement of the change in the arterial calibers after intra-arterial verapamil is accurate in distinguishing reversible cerebral vasoconstriction syndrome from other vasculopathies. A proportion of change ≥32% has the best diagnostic performance.
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Affiliation(s)
- J M Sequeiros
- From the Department of Neurology (J.M.S., J.A.R., R.P.S., S.D., S.O.-G., E.C.L., E.A.S.), University of Iowa Hospitals and Clinics, Iowa City, Iowa
| | - J A Roa
- From the Department of Neurology (J.M.S., J.A.R., R.P.S., S.D., S.O.-G., E.C.L., E.A.S.), University of Iowa Hospitals and Clinics, Iowa City, Iowa.,Department of Neurosurgery (J.A.R., S.O.-G., D.M.H., E.A.S.), University of Iowa Hospitals and Clinics, Iowa City, Iowa
| | - R P Sabotin
- From the Department of Neurology (J.M.S., J.A.R., R.P.S., S.D., S.O.-G., E.C.L., E.A.S.), University of Iowa Hospitals and Clinics, Iowa City, Iowa
| | - S Dandapat
- From the Department of Neurology (J.M.S., J.A.R., R.P.S., S.D., S.O.-G., E.C.L., E.A.S.), University of Iowa Hospitals and Clinics, Iowa City, Iowa
| | - S Ortega-Gutierrez
- From the Department of Neurology (J.M.S., J.A.R., R.P.S., S.D., S.O.-G., E.C.L., E.A.S.), University of Iowa Hospitals and Clinics, Iowa City, Iowa.,Department of Neurosurgery (J.A.R., S.O.-G., D.M.H., E.A.S.), University of Iowa Hospitals and Clinics, Iowa City, Iowa.,Department of Radiology (S.O.-G., C.P.D., G.B., E.A.S.), University of Iowa Hospitals and Clinics, Iowa City, Iowa
| | - E C Leira
- From the Department of Neurology (J.M.S., J.A.R., R.P.S., S.D., S.O.-G., E.C.L., E.A.S.), University of Iowa Hospitals and Clinics, Iowa City, Iowa
| | - C P Derdeyn
- Department of Radiology (S.O.-G., C.P.D., G.B., E.A.S.), University of Iowa Hospitals and Clinics, Iowa City, Iowa
| | - G Bathla
- Department of Radiology (S.O.-G., C.P.D., G.B., E.A.S.), University of Iowa Hospitals and Clinics, Iowa City, Iowa
| | - D M Hasan
- Department of Neurosurgery (J.A.R., S.O.-G., D.M.H., E.A.S.), University of Iowa Hospitals and Clinics, Iowa City, Iowa
| | - E A Samaniego
- From the Department of Neurology (J.M.S., J.A.R., R.P.S., S.D., S.O.-G., E.C.L., E.A.S.), University of Iowa Hospitals and Clinics, Iowa City, Iowa .,Department of Neurosurgery (J.A.R., S.O.-G., D.M.H., E.A.S.), University of Iowa Hospitals and Clinics, Iowa City, Iowa.,Department of Radiology (S.O.-G., C.P.D., G.B., E.A.S.), University of Iowa Hospitals and Clinics, Iowa City, Iowa
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Bersano A, Kraemer M, Burlina A, Mancuso M, Finsterer J, Sacco S, Salvarani C, Caputi L, Chabriat H, Oberstein SL, Federico A, Lasserve ET, Hunt D, Dichgans M, Arnold M, Debette S, Markus HS. Heritable and non-heritable uncommon causes of stroke. J Neurol 2020; 268:2780-2807. [PMID: 32318851 DOI: 10.1007/s00415-020-09836-x] [Citation(s) in RCA: 25] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/27/2019] [Revised: 04/09/2020] [Accepted: 04/10/2020] [Indexed: 12/15/2022]
Abstract
Despite intensive investigations, about 30% of stroke cases remains of undetermined origin. After exclusion of common causes of stroke, there is a number of rare heritable and non-heritable conditions, which often remain misdiagnosed, that should be additionally considered in the diagnosis of cryptogenic stroke. The identification of these diseases requires a complex work up including detailed clinical evaluation for the detection of systemic symptoms and signs, an adequate neuroimaging assessment and a careful family history collection. The task becomes more complicated by phenotype heterogeneity since stroke could be the primary or unique manifestation of a syndrome or represent just a manifestation (sometimes minor) of a multisystem disorder. The aim of this review paper is to provide clinicians with an update on clinical and neuroradiological features and a set of practical suggestions for the diagnostic work up and management of these uncommon causes of stroke. The identification of these stroke causes is important to avoid inappropriate and expensive diagnostic tests, to establish appropriate management measures, including presymptomatic testing, genetic counseling, and, if available, therapy. Therefore, physicians should become familiar with these diseases to provide future risk assessment and family counseling.
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Affiliation(s)
- A Bersano
- Cerebrovascular Unit, Fondazione IRCCS Istituto Neurologico Carlo Besta, Milan, Italy.
| | - M Kraemer
- Department of Neurology Alfried, Krupp-Hospital, Essen, Germany.,Department of Neurology, Medical Faculty, Heinrich-Heine-University, Düsseldorf, Germany
| | - A Burlina
- Neurological Unit, St. Bassano Hospital, Bassano del Grappa, Italy
| | - M Mancuso
- Department of Clinical and Experimental Medicine, Neurological Institute, University of Pisa, Pisa, Italy
| | - J Finsterer
- Krankenanstalt Rudolfstiftung, Messerli Institute, Vienna, Austria
| | - S Sacco
- Department of Neurology, Avezzano Hospital, University of L'Aquila, L'Aquila, Italy
| | - C Salvarani
- University of Modena and Reggio Emilia, and Azienda USL-IRCCS, Reggio Emilia, Italy
| | - L Caputi
- Cerebrovascular Unit, Fondazione IRCCS Istituto Neurologico Carlo Besta, Milan, Italy
| | - H Chabriat
- Department of Neurology and CERVCO, DHU Neurovasc, INSERM U1141, University of Paris, Paris, France
| | - S Lesnik Oberstein
- Department of Clinical Genetics, Leiden University Medical Center, Leiden, The Netherlands
| | - A Federico
- Department of Medicine, Surgery and Neurosciences, University of Siena, Siena, Italy
| | - E Tournier Lasserve
- Department of Genetics, Lariboisière Hospital and INSERM U1141, Paris-Diderot University, Paris, France
| | - D Hunt
- MRC Human Genetics Unit, Institute of Genetics and Molecular Medicine, University of Edinburgh, Edinburgh, EH4 2XU, UK
| | - M Dichgans
- Institute for Stroke and Dementia Research, Klinikum Der Universität München, Munich, Germany
| | - M Arnold
- Inserm Centre Bordeaux Population Health (U1219), University of Bordeaux, Bordeaux, France
| | - S Debette
- Department of Neurology, INSELSPITAL, University Hospital Bern, Bern, Switzerland
| | - H S Markus
- Stroke Research Group, Department of Clinical Neurosciences, University of Cambridge, Cambridge, UK
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Hawkes MA, Hlavnicka AA, Wainsztein NA. Reversible Cerebral Vasoconstriction Syndrome Responsive to Intravenous Milrinone. Neurocrit Care 2020; 32:348-352. [PMID: 31571175 DOI: 10.1007/s12028-019-00850-0] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Affiliation(s)
- Maximiliano A Hawkes
- Department of Internal Medicine, FLENI, Montañeses 2325, Buenos Aires, Argentina.
- Department of Neurology, FLENI, Montañeses 2325, Buenos Aires, Argentina.
| | | | - Nestor A Wainsztein
- Department of Internal Medicine, FLENI, Montañeses 2325, Buenos Aires, Argentina
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Reversible Cerebral Vasoconstriction Syndrome: an Update of Recent Research. CURRENT TREATMENT OPTIONS IN RHEUMATOLOGY 2020. [DOI: 10.1007/s40674-020-00137-y] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
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16
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Ospel JM, Wright CH, Jung R, Vidal LLM, Manjila S, Singh G, Heck DV, Ray A, Blackham KA. Intra-Arterial Verapamil Treatment in Oral Therapy-Refractory Reversible Cerebral Vasoconstriction Syndrome. AJNR Am J Neuroradiol 2019; 41:293-299. [PMID: 31879333 DOI: 10.3174/ajnr.a6378] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/31/2018] [Accepted: 11/16/2019] [Indexed: 12/31/2022]
Abstract
Reversible vasoconstriction syndrome is a complex of clinical symptoms and angiographic findings, which, while having a mostly benign clinical course, has clinical and imaging overlap with more serious disorders such as vasculitis and aneurysmal SAH and itself includes a minority of patients with fulminant vasoconstriction resulting in severe intracranial complications. Endovascular options for patients with refractory reversible cerebral vasoconstriction syndrome include intra-arterial vasodilator infusion similar to therapy for patients with vasospasm after SAH. To date, only case reports and 1 small series have discussed the utility of intra-arterial vasodilators for the treatment of reversible cerebral vasoconstriction syndrome. We report an additional series of 11 medically refractory cases of presumed or proved reversible cerebral vasoconstriction syndrome successfully treated with intra-arterial verapamil infusion. Furthermore, we propose that the reversal of vasoconstriction, as seen on angiography, could fulfill a diagnostic criterion.
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Affiliation(s)
- J M Ospel
- From the Department of Radiology (J.M.O., K.A.B.), Section of Neuroradiology and Interventional Neuroradiology, Basel University Hospital, University of Basel, Basel, Switzerland
| | - C H Wright
- Departments of Neurological Surgery (C.H.W.)
| | - R Jung
- Department of Neurology (R.J.), The Sandra and Malcolm Berman Brain & Spine Institute, Sinai Hospital of Baltimore, LIfebridge Health, Baltimore, Maryland
| | - L L M Vidal
- Department of Diagnostic Radiology and Nuclear Medicine (L.L.M.V.), University of Maryland Medical Center, Baltimore, Maryland
| | - S Manjila
- Department of Neurosurgery and Neurosciences (S.M.), McLaren Bay Region Hospital, Bay City, Michigan
| | - G Singh
- Department of Radiology (G.S.), Section of Neuroradiology, Newark Beth Israel Medical Center, Newark, New Jersey
| | - D V Heck
- Forsyth Radiological Associates (D.V.H.), Winston-Salem, North Carolina
| | - A Ray
- Neurosurgery (A.R.), University Hospitals of Cleveland Case Medical Center, Cleveland, Ohio
| | - K A Blackham
- From the Department of Radiology (J.M.O., K.A.B.), Section of Neuroradiology and Interventional Neuroradiology, Basel University Hospital, University of Basel, Basel, Switzerland
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Posterior Reversible Encephalopathy Syndrome and Reversible Cerebral Vasoconstriction Syndrome: Distinct Clinical Entities with Overlapping Pathophysiology. Radiol Clin North Am 2019; 57:1133-1146. [PMID: 31582040 DOI: 10.1016/j.rcl.2019.07.001] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
Abstract
The clinical and radiologic manifestations of posterior reversible encephalopathy syndrome and reversible cerebral vasoconstriction syndrome are reviewed. The relationship between these entities is discussed. A hypothesis of a common underlying pathophysiology is proposed and substantiated based on the current medical literature.
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18
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Al-Mufti F, Dodson V, Wajswol E, El-Ghanem M, Alchaki A, Nuoman R, Thabet A, Sutherland A, Roychowdhury S, Hidalgo A, Gupta G. Chemical angioplasty for medically refractory reversible cerebral vasoconstriction syndrome. Br J Neurosurg 2018; 32:431-435. [DOI: 10.1080/02688697.2018.1479512] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Affiliation(s)
- Fawaz Al-Mufti
- Rutgers University – Robert Wood Johnson Medical School, Department of Neurology, New Brunswick NJ, USA
- Rutgers University – New Jersey Medical School, Department of Neurosurgery, Newark, NJ, USA
| | - Vincent Dodson
- Rutgers University – New Jersey Medical School, Department of Neurosurgery, Newark, NJ, USA
| | - Ethan Wajswol
- Rutgers University – New Jersey Medical School, Department of Neurosurgery, Newark, NJ, USA
| | - Mohammad El-Ghanem
- Rutgers University – New Jersey Medical School, Department of Neurosurgery, Newark, NJ, USA
| | - Abdulrahman Alchaki
- Rutgers University – New Jersey Medical School, Department of Neurology, Newark, NJ, USA
| | - Rolla Nuoman
- Rutgers University – New Jersey Medical School, Department of Neurology, Newark, NJ, USA
| | - Ahmad Thabet
- Rutgers University – New Jersey Medical School, Department of Neurosurgery, Newark, NJ, USA
| | - Anne Sutherland
- Rutgers University – New Jersey Medical School, Department of Medicine, Newark, NJ, USA
| | - Sudipta Roychowdhury
- Rutgers University – Robert Wood Johnson Medical School, Department of Radiology, New Brunswick NJ, USA
| | - Andrea Hidalgo
- Rutgers University – New Jersey Medical School, Department of Neurology, Newark, NJ, USA
| | - Gaurav Gupta
- Rutgers University – Robert Wood Johnson Medical School, Department of Neurosurgery, New Brunswick NJ, USA
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Fatal reversible cerebral vasoconstriction syndrome. J Neurol Sci 2017; 385:146-150. [PMID: 29406896 DOI: 10.1016/j.jns.2017.12.009] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/03/2017] [Revised: 12/07/2017] [Accepted: 12/07/2017] [Indexed: 11/21/2022]
Abstract
We report four fatal cases of fulminant reversible cerebral vasoconstriction syndrome, all initially diagnosed as primary central nervous system vasculitis and treated with corticosteroids. Although reversible cerebral vasoconstriction syndrome is usually self-limiting without permanent neurologic deficits, rarely it can be fatal and worse outcomes have been associated with corticosteroid treatment.
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Fortini A, Cincotta M, Faraone A, Baruffi C, Carrieri G, Limbucci N, Boccadori C, Nenci G. Headache and visual impairment after twin birth: a challenging diagnosis. Intern Emerg Med 2017; 12:975-980. [PMID: 28710712 DOI: 10.1007/s11739-017-1712-y] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/25/2017] [Accepted: 07/08/2017] [Indexed: 11/26/2022]
Affiliation(s)
- Alberto Fortini
- Department of Internal Medicine, San Giovanni di Dio Hospital, Florence, Italy.
| | - Massimo Cincotta
- Department of Neurology, San Giovanni di Dio Hospital, Florence, Italy
| | - Antonio Faraone
- Department of Internal Medicine, San Giovanni di Dio Hospital, Florence, Italy
| | - Cristina Baruffi
- Department of Internal Medicine, San Giovanni di Dio Hospital, Florence, Italy
| | - Giovanni Carrieri
- Department of Radiology, San Giovanni di Dio Hospital, Florence, Italy
| | - Nicola Limbucci
- Department of Neuro-vascular Radiology, AOU Careggi, Florence, Italy
| | - Costanza Boccadori
- Department of Internal Medicine, San Giovanni di Dio Hospital, Florence, Italy
| | - Gabriele Nenci
- Department of Internal Medicine, San Giovanni di Dio Hospital, Florence, Italy
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Cappelen-Smith C, Calic Z, Cordato D. Reversible Cerebral Vasoconstriction Syndrome: Recognition and Treatment. Curr Treat Options Neurol 2017; 19:21. [DOI: 10.1007/s11940-017-0460-7] [Citation(s) in RCA: 48] [Impact Index Per Article: 6.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
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Abstract
Cerebral vasculitis can have a variety of origins. Furthermore, there are no vasculitis-specific symptoms or imaging signs and vasculitis of the CNS can mimic many other neurological diseases, which require different treatment approaches. Thus, the clinical and radiological diagnosis of cerebral vasculitis is challenging. Magnetic resonance imaging (MRI) and MR angiography (MRA) should be the radiological imaging methods of choice to assess the degree of parenchymal damage and to detect vessel wall changes. If the results are unclear digital subtraction angiography (DSA) should be pursued in order to also detect changes in medium sized vessels. Vasculitis of small vessels cannot be detected by vascular imaging and requires brain or leptomeningeal biopsy. In this review we present the current diagnostic approach and a variety of imaging findings in cerebral vasculitis and discuss the main radiological differential diagnoses.
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Singhal AB, Topcuoglu MA. Glucocorticoid-associated worsening in reversible cerebral vasoconstriction syndrome. Neurology 2016; 88:228-236. [PMID: 27940651 DOI: 10.1212/wnl.0000000000003510] [Citation(s) in RCA: 87] [Impact Index Per Article: 10.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/05/2016] [Accepted: 08/23/2016] [Indexed: 11/15/2022] Open
Abstract
OBJECTIVE Factors predicting poor outcome in patients with the reversible cerebral vasoconstriction syndrome (RCVS) have not been identified. METHODS In this single-center retrospective study, we analyzed the clinical, brain imaging, and angiography data in 162 patients with RCVS. Univariable and multivariable regression analysis were performed to identify predictors of persistent (nontransient) clinical worsening, radiologic worsening, early angiographic progression, and poor discharge outcome (modified Rankin Scale score 4-6). RESULTS The mean age was 44 ± 13 years; 78% of patients were women. Persistent clinical worsening occurred in 14% at 6.6 ± 4.1 days after symptom onset, radiologic worsening in 27% (mainly new infarcts), and angiographic progression in 15%. Clinical worsening correlated with angiographic progression and new nonhemorrhagic lesions. Age and sex did not independently predict any type of worsening. Infarction on baseline imaging predicted poor outcome. Prior serotonergic antidepressant use predicted clinical and angiographic worsening but not poor outcome. Intra-arterial vasodilator therapy independently predicted clinical worsening and poor discharge outcome but was offered to more severe cases. Glucocorticoid treatment proved to be an independent predictor of clinical, imaging, and angiographic worsening and poor outcome. Of the 23 patients with clinical worsening, 17 received glucocorticoids (15 within the preceding 2 days). There were no significant differences in baseline brain lesions and angiographic abnormalities between glucocorticoid-treated and untreated patients. CONCLUSION Patients with RCVS at risk for worsening can be identified on basis of baseline features. Iatrogenic factors such as glucocorticoid exposure may contribute to worsening.
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Affiliation(s)
- Aneesh B Singhal
- From Massachusetts General Hospital and Harvard Medical School (A.B.S., M.A.T.), Boston; and Neurology Department (M.A.T.), Hacettepe University Hospitals, Ankara, Turkey.
| | - Mehmet A Topcuoglu
- From Massachusetts General Hospital and Harvard Medical School (A.B.S., M.A.T.), Boston; and Neurology Department (M.A.T.), Hacettepe University Hospitals, Ankara, Turkey
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Topcuoglu MA, Singhal AB. Hemorrhagic Reversible Cerebral Vasoconstriction Syndrome. Stroke 2016; 47:1742-7. [DOI: 10.1161/strokeaha.116.013136] [Citation(s) in RCA: 62] [Impact Index Per Article: 7.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/23/2016] [Accepted: 05/19/2016] [Indexed: 11/16/2022]
Affiliation(s)
- Mehmet A. Topcuoglu
- From the Massachusetts General Hospital, Harvard Medical School, Boston (M.A.T., A.B.S.); and Neurology Department, Hacettepe University Hospitals, Ankara, Turkey (M.A.T.)
| | - Aneesh B. Singhal
- From the Massachusetts General Hospital, Harvard Medical School, Boston (M.A.T., A.B.S.); and Neurology Department, Hacettepe University Hospitals, Ankara, Turkey (M.A.T.)
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Abstract
Background Altered cerebrovascular tone is implicated in reversible cerebral vasoconstriction syndrome (RCVS). We evaluated vasomotor reactivity using bedside transcranial Doppler in RCVS patients. Methods In this retrospective case-control study, middle cerebral artery (MCA) blood flow velocities were compared at rest and in response to breath-hold in RCVS ( n = 8), Migraineurs ( n = 10), and non-headache Controls ( n = 10). Hyperventilation response was measured in RCVS. Results In RCVS, Breath Holding Index (BHI) was severely reduced in seven of eight patients and 14/16 MCAs; seven of 16 MCAs showed exhausted (BHI < 0.1) or inverted (BHI < 0) vasomotor reactivity. Mean BHI in RCVS (0.23 ± 0.5) was significantly lower than Migraine (1.52 ± 0.57) and Controls (1.51 ± 0.32), p < 0.001. Triphasic velocity responses were seen in all groups. The maximum Vmean decline during the middle negative phase was −15.5 ± 9.2% in RCVS, −15.4 ± 7% in Migraine, and −10.3 ± 5% in Controls ( p = 0.04). In the late positive phase, average Vmean increase was 6.2 ± 14% in RCVS, which was significantly lower ( p < 0.001) than Migraine (30.5 ± 11%) and Controls (30.2 ± 6%). With hyperventilation, RCVS patients showed 23% decrease in Vmean. Conclusion Cerebral arterial tone is abnormal in RCVS, with proximal vasoconstriction and abnormally reduced capacity for vasodilation. Further studies are needed to determine the utility of BHI to diagnose RCVS before angiographic reversibility is established, and to estimate prognosis.
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Santos L, Azevedo E. Reversible cerebral vasoconstriction syndrome - A narrative revision of the literature. Porto Biomed J 2016; 1:65-71. [PMID: 32258552 DOI: 10.1016/j.pbj.2016.04.002] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/10/2015] [Accepted: 07/18/2015] [Indexed: 12/18/2022] Open
Abstract
Reversible Cerebral Vasoconstriction Syndrome (RCVS) is a not very well known clinical-imaging entity; it is characterized by thunderclap headache, which mimics an aneurysmal subarachnoid haemorrhage, and a diffuse and segmental constriction of cerebral arteries, that resolves spontaneously within 3 months. The pathophysiology remains unknown. The female gender is the more affected and more than half of cases occur in the puerperium or after exposure to vasoactive substances. Typically, RCVS is self-limited and has a benign course, although it may have more serious complications with permanent neurologic sequelae and death. Treatment is predominantly supportive and directed to the symptoms.
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Affiliation(s)
- Laura Santos
- Department of Neurology and Neurosurgery, Faculty of Medicine of University of Porto, Porto, Portugal
| | - Elsa Azevedo
- Department of Neurology and Neurosurgery, Faculty of Medicine of University of Porto, Porto, Portugal
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Singhal AB, Topcuoglu MA, Fok JW, Kursun O, Nogueira RG, Frosch MP, Caviness VS. Reversible cerebral vasoconstriction syndromes and primary angiitis of the central nervous system: clinical, imaging, and angiographic comparison. Ann Neurol 2016; 79:882-94. [DOI: 10.1002/ana.24652] [Citation(s) in RCA: 121] [Impact Index Per Article: 15.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/15/2015] [Revised: 03/22/2016] [Accepted: 03/27/2016] [Indexed: 11/06/2022]
Affiliation(s)
- Aneesh B. Singhal
- Massachusetts General Hospital and Harvard Medical School; Boston MA
| | - Mehmet A. Topcuoglu
- Massachusetts General Hospital and Harvard Medical School; Boston MA
- Neurology Department; Hacettepe University Hospitals; Ankara Turkey
| | - Joshua W. Fok
- Department of Medicine; Yan Chai Hospital; Hong Kong China
| | - Oguzhan Kursun
- Neurology Clinic; Ankara Numune Education and Research Hospital; Ankara Turkey
| | - Raul G. Nogueira
- Grady Memorial Hospital and Emory University School of Medicine; Atlanta GA
| | - Matthew P. Frosch
- Massachusetts General Hospital and Harvard Medical School; Boston MA
| | - Verne S. Caviness
- Massachusetts General Hospital and Harvard Medical School; Boston MA
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Ducros A, Wolff V. The Typical Thunderclap Headache of Reversible Cerebral Vasoconstriction Syndrome and its Various Triggers. Headache 2016; 56:657-73. [DOI: 10.1111/head.12797] [Citation(s) in RCA: 93] [Impact Index Per Article: 11.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/03/2023]
Affiliation(s)
- Anne Ducros
- Department of Neurology; Montpellier University Hospital, and Montpellier University; Montpellier France (A. Ducros)
| | - Valérie Wolff
- Stroke Unit, Department of Neurology; Strasbourg University Hospital; Strasbourg France (V. Wolff)
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29
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Singhal AB. Reversible Cerebral Vasoconstriction Syndromes. Stroke 2016. [DOI: 10.1016/b978-0-323-29544-4.00037-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
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Bhogal P, Navaei E, Makalanda HLD, Brouwer PA, Sjöstrand C, Mandell DM, Lilja A. Intracranial vessel wall MRI. Clin Radiol 2015; 71:293-303. [PMID: 26711874 DOI: 10.1016/j.crad.2015.11.012] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/19/2015] [Revised: 10/02/2015] [Accepted: 11/16/2015] [Indexed: 10/22/2022]
Abstract
There are many different methods of imaging the intracranial arteries; however, the vast majority of currently used techniques are based on luminal imaging. Although this is useful, it does have limitations as many different pathological processes can produce the same appearance. Therefore, directly imaging the site of the pathology - the vessel wall itself - offers the hope of discriminating between different disease processes. In this review, we will discuss the current status of vessel wall magnetic resonance imaging alongside its potential usefulness in differentiating between various disease entities.
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Affiliation(s)
- P Bhogal
- Department of Neuroradiology, The Karolinska University Hospital, Stockholm 17176, Sweden.
| | - E Navaei
- Department of Neuroradiology, The Karolinska University Hospital, Stockholm 17176, Sweden
| | - H L D Makalanda
- Department of Interventional Neuroradiology, The Royal London Hospital, London E1 1BB, UK
| | - P A Brouwer
- Department of Neuroradiology, The Karolinska University Hospital, Stockholm 17176, Sweden
| | - C Sjöstrand
- Department of Neuroradiology, The Karolinska University Hospital, Stockholm 17176, Sweden
| | - D M Mandell
- Division of Neuroradiology, Department of Medical Imaging, University Health Network and the University of Toronto, Toronto, Canada
| | - A Lilja
- Department of Neuroradiology, The Karolinska University Hospital, Stockholm 17176, Sweden
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Pharmacokinetic Modeling of Intra-arterial Nimodipine Therapy for Subarachnoid Hemorrhage-Related Cerebral Vasospasm. Clin Neuroradiol 2015; 27:199-203. [PMID: 26350588 DOI: 10.1007/s00062-015-0464-1] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/19/2014] [Accepted: 08/27/2015] [Indexed: 10/23/2022]
Abstract
PURPOSE Intra-arterial (IA) administration of nimodipine has been shown to be an effective treatment for subarachnoid hemorrhage-related cerebral vasospasm. The concentrations achieved in cerebral arteries during this procedure, though, are unknown. Therefore, there are no clinical studies investigating dose-dependent effects of nimodipine. We aimed at providing a pharmacokinetic model for IA nimodipine therapy for this purpose. METHODS A two-compartment pharmacokinetic model for intravenous nimodipine therapy was modified and used to assess cerebral arterial nimodipine concentration during IA nimodipine infusion into the internal carotid artery (ICA). RESULTS According to our simulations, continuous IA nimodipine infusion at 2 mg/h and 1 mg/h resulted in steady-state cerebral arterial concentrations of about 200 ng/ml and 100 ng/ml assuming an ICA blood flow of 200 ml/min and a clearance of 70 l/h. About 85 % of the maximal concentration is achieved within the first minute of IA infusion independent on the infusion dose. Within the range of physiological and pharmacokinetic data available in the literature, ICA blood flow has more impact on cerebral arterial concentration than nimodipine clearance. CONCLUSION The presented pharmacokinetic model is suitable for estimations of cerebral arterial nimodipine concentration during IA infusion. It may, for instance, assist in dose-dependent analyses of angiographic results.
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Miller TR, Shivashankar R, Mossa-Basha M, Gandhi D. Reversible Cerebral Vasoconstriction Syndrome, Part 2: Diagnostic Work-Up, Imaging Evaluation, and Differential Diagnosis. AJNR Am J Neuroradiol 2015; 36:1580-8. [PMID: 25614476 DOI: 10.3174/ajnr.a4215] [Citation(s) in RCA: 109] [Impact Index Per Article: 12.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/20/2023]
Abstract
The diagnostic evaluation of a patient with reversible cerebral vasoconstriction syndrome integrates clinical, laboratory, and radiologic findings. Imaging plays an important role by confirming the presence of cerebral vasoconstriction; monitoring potential complications such as ischemic stroke; and suggesting alternative diagnoses, including CNS vasculitis and aneurysmal subarachnoid hemorrhage. Noninvasive vascular imaging, including transcranial Doppler sonography and MR angiography, has played an increasingly important role in this regard, though conventional angiography remains the criterion standard for the evaluation of cerebral artery vasoconstriction. Newer imaging techniques, including high-resolution vessel wall imaging, may help in the future to better discriminate reversible cerebral vasoconstriction syndrome from primary angiitis of the CNS, an important clinical distinction.
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Affiliation(s)
- T R Miller
- From the Department of Diagnostic Radiology (T.R.M., R.S., D.G.), Section of Neuroradiology, University of Maryland Medical Center, Baltimore, Maryland
| | - R Shivashankar
- From the Department of Diagnostic Radiology (T.R.M., R.S., D.G.), Section of Neuroradiology, University of Maryland Medical Center, Baltimore, Maryland
| | - M Mossa-Basha
- Department of Diagnostic Radiology (M.M.-B.), Section of Neuroradiology, University of Washington, Seattle, Washington
| | - D Gandhi
- From the Department of Diagnostic Radiology (T.R.M., R.S., D.G.), Section of Neuroradiology, University of Maryland Medical Center, Baltimore, Maryland
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Kass-Hout T, Kass-Hout O, Sun CHJ, Kass-Hout T, Ramakrishnan P, Nahab F, Nogueira R, Gupta R. A novel approach to diagnose reversible cerebral vasoconstriction syndrome: a case series. J Stroke Cerebrovasc Dis 2014; 24:e31-7. [PMID: 25440342 DOI: 10.1016/j.jstrokecerebrovasdis.2014.08.023] [Citation(s) in RCA: 30] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/18/2014] [Revised: 08/16/2014] [Accepted: 08/21/2014] [Indexed: 11/25/2022] Open
Abstract
BACKGROUND Reversible cerebral vasoconstriction syndrome (RCVS) is classically diagnosed based on the presence of severe thunderclap headache, focal neurologic symptoms, and the radiographic findings of reversible diffuse segmental cerebral vasoconstriction. We present a diagnostic test that may assist in the clinical diagnosis and facilitate treatment. METHODS From October 1, 2010, to August 1, 2013, we identified consecutive patients who presented with a presumptive diagnosis of RCVS and underwent cerebral diagnostic angiography with intra-arterial (IA) vasodilator therapy. Medical records including clinical presentation, radiographic, and angiographic images were all reviewed. RESULTS We identified a total of 7 patients (4 females; age range, 22-56; mean, 45 years) who met our inclusion criteria. Four patients received a combination of milrinone and nicardipine infusion either in the internal carotid arteries or in the left vertebral artery; the remaining patients received IA therapy solely with either nicardipine or milrinone. Five patients had a positive angiographic response, defined as significant improvement or resolution of the blood vessels irregularities. All 5 patients had a definite discharge diagnosis of RCVS. The remaining 2 patients had a negative angiographic response and based on their clinical and radiographic course had a final diagnosis of intracranial atherosclerotic disease. CONCLUSIONS Our small case series suggest that IA administration of vasodilators is safe and may aid in distinguishing vasodilator responsive syndromes such as RCVS from other causes. Further study is required with long-term clinical outcome to determine the utility of this diagnostic test.
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Affiliation(s)
- Tareq Kass-Hout
- Department of Neurology, Emory University School of Medicine, Atlanta, GA
| | - Omar Kass-Hout
- Department of Neurology, Emory University School of Medicine, Atlanta, GA
| | - Chung-Huan J Sun
- Department of Neurology, Emory University School of Medicine, Atlanta, GA
| | | | - Pankajavalli Ramakrishnan
- Department of Neurology, Emory University School of Medicine, Atlanta, GA; Department of Neurosurgery, Emory University School of Medicine, Atlanta, GA
| | - Fadi Nahab
- Department of Neurology, Emory University School of Medicine, Atlanta, GA
| | - Raul Nogueira
- Department of Neurology, Emory University School of Medicine, Atlanta, GA
| | - Rishi Gupta
- Department of Neurosurgery, Wellstar Neurosurgery, Kennestone Hospital, Marietta, GA.
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Mehdi A, Hajj-Ali RA. Reversible Cerebral Vasoconstriction Syndrome: a Comprehensive Update. Curr Pain Headache Rep 2014; 18:443. [DOI: 10.1007/s11916-014-0443-2] [Citation(s) in RCA: 27] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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Berlit P, Kraemer M. Cerebral vasculitis in adults: what are the steps in order to establish the diagnosis? Red flags and pitfalls. Clin Exp Immunol 2014; 175:419-24. [PMID: 24117125 DOI: 10.1111/cei.12221] [Citation(s) in RCA: 71] [Impact Index Per Article: 7.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/04/2013] [Indexed: 12/29/2022] Open
Abstract
Cerebral vasculitis is a rare cause of juvenile stroke. It may occur as primary angiitis of the central nervous system (PACNS) or as CNS manifestation in the setting of systemic vasculitis. Clinical hints for vasculitis are headache, stroke, seizures, encephalopathy and signs of a systemic inflammatory disorder. Diagnostic work-up includes anamnesis, whole body examination, laboratory and cerebral spinal fluid (CSF) studies, magnetic resonance imaging (MRI), angiography and brain biopsy. Due to the rarity of the disease, exclusion of more frequent differential diagnoses is a key element of diagnostic work -up. This review summarizes the steps that lead to the diagnosis of cerebral vasculitis and describes the red flags and pitfalls. Despite considering the dilemma of angiography-negative vasculitis and false-negative brain biopsy in some cases, it is important to protect patients from 'blind' immunosuppressive therapy in unrecognized non-inflammatory differential diagnosis.
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Affiliation(s)
- P Berlit
- Department of Neurology, Alfried Krupp Hospital, Essen, Germany
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Reversible cerebral vasoconstriction syndromes: what the cardiologist should know. CURRENT TREATMENT OPTIONS IN CARDIOVASCULAR MEDICINE 2014; 16:290. [PMID: 24500680 DOI: 10.1007/s11936-013-0290-1] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
Abstract
OPINION STATEMENT Over the past decade, the reversible cerebral vasoconstriction syndromes (RCVS) have emerged as a group of conditions with easily recognizable clinical-angiographic features and a usually benign prognosis. The RCVS affect young individuals, mostly women, and the majority present with recurrent, severe, 'thunderclap' headaches. Vascular imaging studies show dynamic and reversible narrowing and dilatation of multiple intracerebral arteries. Brain imaging usually shows no parenchymal lesions, however, approximately one-third of patients develop ischemic or hemorrhagic strokes or reversible brain edema. The etiopathogenesis of this syndrome remains unclear. It has been associated with diverse conditions such as pregnancy, vasoconstrictive drug use, and neurovascular procedures. Recent studies characterizing RCVS have made it relatively easy to exclude mimics such as aneurysmal subarachnoid hemorrhage and primary angiitis of the central nervous system. There is no proven treatment, although calcium channel blockers may help to reduce the intensity of headaches. Empiric glucocorticoid treatment should be avoided. Since most patients do well with simple observation alone, invasive strategies such as pharmacologically-induced hypertension, balloon angioplasty, and direct intra-arterial vasodilator infusion should be reserved for patients showing clear clinical progression.
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Yancy H, Lee-Iannotti JK, Schwedt TJ, Dodick DW. Reversible cerebral vasoconstriction syndrome. Headache 2013; 53:570-6. [PMID: 23489219 DOI: 10.1111/head.12040] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 12/05/2012] [Indexed: 11/29/2022]
Abstract
Reversible cerebral vasoconstriction syndrome (RCVS) is a cerebrovascular disorder with a clinical picture that continues to be refined. It has presented to multiple subspecialties over the past several decades, bringing with it many questions regarding risk factors, diagnosis, and management. Answers have been forthcoming but many questions remain. RCVS presents with recurrent, secondary thunderclap headaches and predominantly affects young women. The mechanism of vasoconstriction is unclear, but there has been speculation regarding a hyperadrenergic state. Diagnosis requires physician awareness, vascular imaging, and knowledge of the differential. The hallmark of its diagnosis is reversibility. Management is empiric, usually with calcium-channel blockers, as there are no controlled treatment trials for RCVS. Randomized controlled trials are needed.
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Affiliation(s)
- Holly Yancy
- Department of Neurology, Mayo Clinic, Phoenix, AZ, USA
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John S, Donnelly M, Uchino K. Catastrophic reversible cerebral vasoconstriction syndrome associated with serotonin syndrome. Headache 2013; 53:1482-7. [PMID: 24001215 DOI: 10.1111/head.12202] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/08/2013] [Indexed: 11/30/2022]
Abstract
OBJECTIVES To report fulminant cases of reversible cerebral vasoconstriction syndrome (RCVS) in the setting of serotonin syndrome. BACKGROUND RCVS is characterized by acute onset of severe headaches, with or without neurologic deficit, with evidence of reversible cerebral vasoconstriction. It is often benign, and prognosis is generally considered favorable. In the largest prospective study on RCVS, only 4% of patients were disabled from strokes and there were no fatalities. METHODS We report a case series. RESULTS We report 2 women with history of depression on selective serotonin re-uptake inhibitors who presented with thunderclap headache and dizziness, respectively. Through the course of hospitalization, both patients developed rigidity, diaphoresis, fever, tachycardia with labile blood pressures and clonus on examination. Since there was a recent addition/increase in a known serotonergic agent, they met criteria for serotonin syndrome. Cerebrovascular imaging in both patients revealed severe multi-focal vessel narrowing. The first patient developed large bi-hemispheric ischemic infarcts and increased intra-cranial pressure that was refractory to management, and she eventually expired. The second patient developed bilateral parieto-occipital strokes and decerebrate posturing. Her course slowly stabilized, and she was eventually discharged with residual left-sided hemiparesis. Repeat cerebrovascular imaging 1 month later showed normal vessels. In both patients, intra-arterial nicardipine infusion improved angiographic appearance of stenoses, consistent with RCVS. CONCLUSIONS Both cases satisfied the Sternbach criteria for serotonin syndrome. Fatality in case 1 prevents demonstration of reversal of cerebral vasoconstriction, but improvement of arterial diameters with intra-arterial calcium channel blockers in both cases suggests that both had RCVS. Serotonergic agents are known triggers of RCVS, but the concurrent presence of serotonin syndrome likely precipitated the malignant course in our patients. Severe clinical and angiographic manifestations should be considered as part of the spectrum of RCVS.
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Affiliation(s)
- Seby John
- Department of Neurology, Cleveland Clinic, Cleveland, OH, USA
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Abstract
Cranial or cervical vascular disease is commonly associated with headaches. The descriptions may range from a thunderclap onset of a subarachnoid hemorrhage to a phenotype similar to tension type headache. Occasionally, this may be the sole manifestation of a potentially serious underlying disorder like vasculitis. A high index of clinical suspicion is necessary to diagnose the disorder. Prompt recognition and treatment is usually needed for many conditions to avoid permanent sequelae that result in disability. Treatments for many conditions remain challenging and are frequently controversial due to paucity of well controlled studies. This is a review of the recent advances that have been made in the diagnosis or management of these secondary headaches.
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Affiliation(s)
- Anne Ducros
- AP-HP, Lariboisière Hospital, Head and Neck Clinic, Emergency Headache Centre, 75010 Paris, France.
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Abstract
Recurrent thunderclap headaches, seizures, strokes, and non-aneurysmal subarachnoid haemorrhage can all reveal reversible cerebral vasoconstriction syndrome. This increasingly recognised syndrome is characterised by severe headaches, with or without other symptoms, and segmental constriction of cerebral arteries that resolves within 3 months. Reversible cerebral vasoconstriction syndrome is supposedly due to a transient disturbance in the control of cerebrovascular tone. More than half the cases occur post partum or after exposure to adrenergic or serotonergic drugs. Manifestations have a uniphasic course, and vary from pure cephalalgic forms to rare catastrophic forms associated with several haemorrhagic and ischaemic strokes, brain oedema, and death. Diagnosis can be hampered by the dynamic nature of clinicoradiological features. Stroke can occur a few days after initial normal imaging, and cerebral vasoconstriction is at a maximum on angiograms 2-3 weeks after clinical onset. The calcium channel blocker nimodipine seems to reduce thunderclap headaches within 48 h of administration, but has no proven effect on haemorrhagic and ischaemic complications.
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Affiliation(s)
- Anne Ducros
- Emergency Headache Centre, Head and Neck Clinic, Lariboisière Hospital, Paris, France.
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Purdy RA, Ward TN. Dangerous and Thunderclap Headaches. Headache 2012; 52 Suppl 2:56-9. [DOI: 10.1111/j.1526-4610.2012.02235.x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
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Reversible cerebral vasoconstriction syndrome: an important cause of acute severe headache. Emerg Med Int 2012; 2012:303152. [PMID: 22830030 PMCID: PMC3399374 DOI: 10.1155/2012/303152] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/08/2012] [Revised: 04/30/2012] [Accepted: 05/10/2012] [Indexed: 11/18/2022] Open
Abstract
Reversible cerebral vasoconstriction syndrome (RCVS) is an increasingly recognized and important cause of acute headache. The majority of these patients develop potentially serious neurological complications. Rigorous investigation is required to exclude other significant differential diagnoses. Differentiating RCVS from subarachnoid haemorrhage (SAH) and primary angiitis of the central nervous system (PACNS) may be difficult but has important therapeutic implications. This paper describes what is currently known about the epidemiology, pathophysiology, clinical, and diagnostic features of the syndrome, an approach to investigation, a summary of treatments, and what is known of prognosis.
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Néel A, Guillon B, Auffray-Calvier E, Hello M, Hamidou M. [Reversible cerebral vasoconstriction syndrome]. Rev Med Interne 2012; 33:586-92. [PMID: 22727502 DOI: 10.1016/j.revmed.2012.05.004] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/12/2011] [Revised: 03/27/2012] [Accepted: 05/08/2012] [Indexed: 10/28/2022]
Abstract
The reversible cerebral vasoconstriction syndrome (RCVS) is an under-estimated transient acute cerebrovascular disorder. It has long been mistaken as central nervous system vasculitis whereas it is now believed to result from an acute but prolonged vasospasm of cerebral arteries. This disorder can be precipitated by postpartum or vasoactive drug. However, it occurs spontaneously in a significant number of cases. The characteristic clinico-radiological presentation and disease course of the RCVS has been delineated only recently. Mean age at onset is 40-45 years, with a female predominance. A provocative factor can be identified in 12-60% out of the patients. Clinical presentation is predominantly marked by recurrent thunderclap headaches, but can be complicated with focal neurological deficit or seizures. Brain imaging is normal in most cases, but can reveal hemorrhagic or ischemic complications. Cortical subarachnoid hemorrhage is a suggestive finding. A posterior reversible encephalopathy syndrome (PRES) can be seen occasionally. Cerebral angiography reveals multifocal arterial narrowing with string and bead appearance. Cerebrospinal fluid reveals no or mild abnormalities. The disease resumes spontaneously within several days to weeks, whereas vasoconstriction reverses within 1 to 3 months. This clinico-radiological presentation should be promptly recognized in order to avoid unnecessary investigations and aggressive treatment, and lead to search for a triggering factor. Further studies are required in order to clarify the precipitating role of several drugs, and clinical trials are needed to reduce the occurrence of strokes.
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Affiliation(s)
- A Néel
- Service de Médecine Interne, CHU Hôtel-Dieu, 1, place Alexis-Ricordeau, 44093 Nantes cedex, France.
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Palma JA, Fontes-Villalba A, Irimia P, Garcia-Eulate R, Martinez-Vila E. Reversible cerebral vasoconstriction syndrome induced by adrenaline. Cephalalgia 2012; 32:500-4. [PMID: 22623754 DOI: 10.1177/0333102412444011] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
INTRODUCTION Reversible cerebral vasoconstriction syndrome (RCVS) is characterized by acute severe thunderclap headaches and evidence of multifocal, segmental, reversible vasoconstrictions of the cerebral arteries. Several precipitating factors have been identified and reported, including the use of recreational substances or sympathomimetic drugs and the postpartum state. CASE DESCRIPTION Here we present the case of a woman who developed RCVS after the administration of adrenaline (epinephrine) in the setting of an anaphylactic reaction during antibiotic allergy testing. DISCUSSION To our knowledge, this is the first reported case of RCVS following the administration of exogenous adrenaline. This case contributes to the understanding of the physiopathological mechanisms underlying reversible cerebral vasoconstriction.
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Chen SP, Fuh JL, Wang SJ. Reversible cerebral vasoconstriction syndrome: current and future perspectives. Expert Rev Neurother 2012; 11:1265-76. [PMID: 21864073 DOI: 10.1586/ern.11.112] [Citation(s) in RCA: 92] [Impact Index Per Article: 7.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
Reversible cerebral vasoconstriction syndromes (RCVS) are characterized by recurrent acute severe headaches, namely thunderclap headaches, and multifocal segmental vasoconstrictions. Interest has arisen in the definitions, clinical presentations, differential diagnoses, risk factors and complications of RCVS. This article will comprehensively review the milestone monographs and the latest research work addressing these issues. Studies that have focused on the relationship between RCVS and thunderclap headache will be detailed. We will also discuss research on the enigmatic pathophysiology and potential therapeutic approaches. Up-to-date information and challenges, undergoing studies and future research directions will be deeply probed.
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Affiliation(s)
- Shih-Pin Chen
- Department of Neurology, Neurological Institute, Taipei Veterans General Hospital, Taipei, Taiwan
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French KF, Hoesch RE, Allred J, Wilder M, Smith A, Digre KB, La Barge DV. Repetitive use of intra-arterial verapamil in the treatment of reversible cerebral vasoconstriction syndrome. J Clin Neurosci 2012; 19:174-6. [DOI: 10.1016/j.jocn.2011.06.016] [Citation(s) in RCA: 32] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/11/2011] [Revised: 06/11/2011] [Accepted: 06/13/2011] [Indexed: 11/17/2022]
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