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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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Kaufmann J, Buecke P, Meinel T, Beyeler M, Scutelnic A, Kaesmacher J, Mujanović A, Dobrocky T, Arsany H, Peters N, Z'Graggen W, Jung S, Seiffge D. Frequency of ischaemic stroke and intracranial haemorrhage in patients with reversible cerebral vasoconstriction syndrome (RCVS) and posterior reversible encephalopathy syndrome (PRES) - A systematic review. Eur J Neurol 2024; 31:e16246. [PMID: 38470001 DOI: 10.1111/ene.16246] [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: 07/09/2023] [Revised: 01/29/2024] [Accepted: 01/30/2024] [Indexed: 03/13/2024]
Abstract
BACKGROUND Posterior reversible encephalopathy syndrome (PRES) and reversible cerebral vasoconstriction syndrome (RCVS) may cause ischaemic stroke and intracranial haemorrhage. The aim of our study was to assess the frequency of the afore-mentioned outcomes. METHODS We performed a PROSPERO-registered (CRD42022355704) systematic review and meta-analysis accessing PubMed until 7 November 2022. The inclusion criteria were: (1) original publication, (2) adult patients (≥18 years), (3) enrolling patients with PRES and/or RCVS, (4) English language and (5) outcome information. Outcomes were frequency of (1) ischaemic stroke and (2) intracranial haemorrhage, divided into subarachnoid haemorrhage (SAH) and intraparenchymal haemorrhage (IPH). The Cochrane Risk of Bias tool was used. RESULTS We identified 848 studies and included 48 relevant studies after reviewing titles, abstracts and full text. We found 11 studies on RCVS (unselected patients), reporting on 2746 patients. Among the patients analysed, 15.9% (95% CI 9.6%-23.4%) had ischaemic stroke and 22.1% (95% CI 10%-39.6%) had intracranial haemorrhage. A further 20.3% (95% CI 11.2%-31.2%) had SAH and 6.7% (95% CI 3.6%-10.7%) had IPH. Furthermore, we found 28 studies on PRES (unselected patients), reporting on 1385 patients. Among the patients analysed, 11.2% (95% CI 7.9%-15%) had ischaemic stroke and 16.1% (95% CI 12.3%-20.3%) had intracranial haemorrhage. Further, 7% (95% CI 4.7%-9.9%) had SAH and 9.7% (95% CI 5.4%-15%) had IPH. CONCLUSIONS Intracranial haemorrhage and ischaemic stroke are common outcomes in PRES and RCVS. The frequency reported in the individual studies varied considerably.
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Affiliation(s)
- Jana Kaufmann
- Department of Neurology, Inselspital University Hospital and University of Bern, Bern, Switzerland
| | - Philipp Buecke
- Department of Neurology, Inselspital University Hospital and University of Bern, Bern, Switzerland
| | - Thomas Meinel
- Department of Neurology, Inselspital University Hospital and University of Bern, Bern, Switzerland
| | - Morin Beyeler
- Department of Neurology, Inselspital University Hospital and University of Bern, Bern, Switzerland
| | - Adrian Scutelnic
- Department of Neurology, Inselspital University Hospital and University of Bern, Bern, Switzerland
| | - Johannes Kaesmacher
- Institute of Diagnostic and Interventional Neuroradiology, Inselspital University Hospital and University of Bern, Bern, Switzerland
| | - Adnan Mujanović
- Institute of Diagnostic and Interventional Neuroradiology, Inselspital University Hospital and University of Bern, Bern, Switzerland
| | - Thomas Dobrocky
- Institute of Diagnostic and Interventional Neuroradiology, Inselspital University Hospital and University of Bern, Bern, Switzerland
| | - Hakim Arsany
- Institute of Diagnostic and Interventional Neuroradiology, Inselspital University Hospital and University of Bern, Bern, Switzerland
| | - Nils Peters
- Neurology and Neurorehabilitation, University Department of Geriatric Medicine Felix Platter, University of Basel, Basel, Switzerland
- Stroke Center, Hirslanden Clinic, Zurich, Switzerland
| | - Werner Z'Graggen
- Department of Neurology, Inselspital University Hospital and University of Bern, Bern, Switzerland
- Department of Neurosurgery, Inselspital University Hospital and University of Bern, Bern, Switzerland
| | - Simon Jung
- Department of Neurology, Inselspital University Hospital and University of Bern, Bern, Switzerland
| | - David Seiffge
- Department of Neurology, Inselspital University Hospital and University of Bern, Bern, Switzerland
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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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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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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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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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Merli N, Padroni M, Azzini C, Bernardoni A, Marcialis C, Tugnoli V, Inchingolo V, Pugliatti M. Reversible cerebral vasoconstriction syndrome: strategies to early diagnosis and the role of transcranial color-coded doppler ultrasonography (TCCD). Neurol Sci 2023; 44:2541-2545. [PMID: 37014565 PMCID: PMC10257625 DOI: 10.1007/s10072-023-06755-3] [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: 02/15/2023] [Accepted: 03/08/2023] [Indexed: 04/05/2023]
Abstract
BACKGROUND Reversible cerebral vasoconstriction syndrome (RCVS) is a cerebrovascular transitory condition characterized by severe headache, possible concomitant acute neurological symptoms, evidence of diffuse multifocal segmental constriction of cerebral arteries, and usually spontaneously resolving within 3 months. Putative causes and/or precipitating factors are vasoactive drugs-e.g., antidepressants, α-sympathomimetics, triptans-post-partum, and immunosuppressants. CASE PRESENTATION We report the case of a middle-aged woman referred to the emergency room (ER) with a 7-day long intense headache and vomit. Cerebral non-contrast computed tomography (CT) was negative for acute ischemic lesions or intracranial bleedings. She was again referred to ER 7 days later with additional fluctuating episodes of weakness in left arm and both lower limbs. A new brain CT was negative. Due to worsening headache, a transcranial color-coded Doppler (TCCD) was performed, which showed diffuse multifocal blood flow acceleration in all principal intracranial vessels, and particularly on the right hemisphere. These findings were subsequently confirmed at MR angiogram and digital subtraction angiography. CONCLUSION TCCD imaging is a non-invasive and relatively inexpensive tool which provides real-time information on cerebrovascular function, blood flow velocities, and hemodynamic changes. TCCD may be a powerful tool in the early detection of acute infrequent cerebrovascular conditions, as well as in monitoring their course and the therapeutic response.
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Affiliation(s)
- Nicola Merli
- Department of Neuroscience and Rehabilitation, University of Ferrara, Ferrara, Italy
| | - Marina Padroni
- Department of Neuroscience and Rehabilitation, S. Anna University Hospital, Ferrara, Italy
| | - Cristiano Azzini
- Department of Neuroscience and Rehabilitation, S. Anna University Hospital, Ferrara, Italy
| | - Andrea Bernardoni
- Department of Radiology, S. Anna University Hospital, Ferrara, Italy
| | - Carla Marcialis
- Department of Neuroscience and Rehabilitation, University of Ferrara, Ferrara, Italy
| | - Valeria Tugnoli
- Department of Neuroscience and Rehabilitation, S. Anna University Hospital, Ferrara, Italy
- Interdepartmental Research Center for Multiple Sclerosis and Other Inflammatory and Degenerative Disorders of the Nervous System, University of Ferrara, Ferrara, Italy
| | - Vincenzo Inchingolo
- Neurology Unit, Fondazione IRCCS Casa Sollievo Della Sofferenza, San Giovanni Rotondo, Italy
| | - Maura Pugliatti
- Department of Neuroscience and Rehabilitation, University of Ferrara, Ferrara, Italy
- Interdepartmental Research Center for Multiple Sclerosis and Other Inflammatory and Degenerative Disorders of the Nervous System, University of Ferrara, Ferrara, Italy
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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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Kalashnikova LA, Konovalov RN, Dobrynina LA. [Reversible cerebral vasoconstriction syndrome and ischemic stroke]. Zh Nevrol Psikhiatr Im S S Korsakova 2023; 123:17-23. [PMID: 38148693 DOI: 10.17116/jnevro202312312217] [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: 12/28/2023]
Abstract
The article describes a 45-year-old female patient with recurrent transient ischemic attacks and ischemic stroke due to spontaneous spasm of the middle cerebral artery, the anterior cerebral artery and distal part of the internal cerebral artery on the left, verified by MR angiography and CT angiography. It is assumed that the spasm caused damage to the vascular wall, an increase in its permeability, the development of edema, inflammation and subsequent fibrosis, therefore a complete restoration of the arterial lumen did not occur.
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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: 23] [Impact Index Per Article: 11.5] [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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Zou Z, Liu K, Li Y, Yi S, Wang X, Yu C, Zhu H. The Application of the GP Model to Manage Controllable Risk Factors in Stroke Patients with Diabetes Can Effectively Improve the Prognosis and Reduce the Recurrence Rate. EVIDENCE-BASED COMPLEMENTARY AND ALTERNATIVE MEDICINE : ECAM 2022; 2022:5413985. [PMID: 35966752 PMCID: PMC9374552 DOI: 10.1155/2022/5413985] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 03/09/2022] [Accepted: 06/18/2022] [Indexed: 11/17/2022]
Abstract
Objective The aim of this study is to examine the impacts of general practice model (GP) on prognosis and recurrence of stroke patients with diabetes. Methods Ninety patients with stroke combined with diabetes mellitus admitted to our hospital from June 2019 to June 2020 were selected for the study and were randomly and equally divided into 45 cases each in the control and experimental groups for the prospective trial. The patients in the control group received routine treatment while those in the experimental group were treated with GP model. Comparison in treatment effects, patients satisfaction, psychological status, quality of life, glycosylated hemoglobin level, and stroke recurrence was carried out between the two groups. Results The experimental group showed markedly better treatment effects (P < 0.05), higher satisfaction degree (P < 0.05), higher HAD (P < 0.05), GQOLI-74 score (P < 0.05), and BI index (P < 0.05), lower level of glycosylated hemoglobin (P < 0.05), and much lower recurrence rate (P < 0.05), as compared to the control group. Conclusion The application of the GP model to manage controllable risk factors in stroke patients with diabetes can effectively improve the prognosis and reduce the recurrence rate, which is worthy of clinical application and promotion.
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Affiliation(s)
- Zhehua Zou
- Department of General Practice, The First Hospital of Qinhuangdao, Hebei 066000, China
| | - Kai Liu
- Department of Neurology, Qinhuangdao Haigang Hospital, Hebei 066000, China
| | - Yunjing Li
- Department of General Practice, The First Hospital of Qinhuangdao, Hebei 066000, China
| | - Shuangyan Yi
- Department of General Practice, The First Hospital of Qinhuangdao, Hebei 066000, China
| | - Xiaotang Wang
- Department of Otorhinolaryngology Head and Neck Surgery, The First Hospital of Qinhuangdao, Hebei 066000, China
| | - Changying Yu
- Department of General Practice, The First Hospital of Qinhuangdao, Hebei 066000, China
| | - Haiying Zhu
- Department of General Practice, The First Hospital of Qinhuangdao, Hebei 066000, China
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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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Mazzacane F, Mazzoleni V, Scola E, Mancini S, Lombardo I, Busto G, Rognone E, Pichiecchio A, Padovani A, Morotti A, Fainardi E. Vessel Wall Magnetic Resonance Imaging in Cerebrovascular Diseases. Diagnostics (Basel) 2022; 12:diagnostics12020258. [PMID: 35204348 PMCID: PMC8871392 DOI: 10.3390/diagnostics12020258] [Citation(s) in RCA: 13] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/29/2021] [Revised: 01/08/2022] [Accepted: 01/14/2022] [Indexed: 01/27/2023] Open
Abstract
Cerebrovascular diseases are a leading cause of disability and death worldwide. The definition of stroke etiology is mandatory to predict outcome and guide therapeutic decisions. The diagnosis of pathological processes involving intracranial arteries is especially challenging, and the visualization of intracranial arteries’ vessel walls is not possible with routine imaging techniques. Vessel wall magnetic resonance imaging (VW-MRI) uses high-resolution, multiparametric MRI sequences to directly visualize intracranial arteries walls and their pathological alterations, allowing a better characterization of their pathology. VW-MRI demonstrated a wide range of clinical applications in acute cerebrovascular disease. Above all, it can be of great utility in the differential diagnosis of atherosclerotic and non-atherosclerotic intracranial vasculopathies. Additionally, it can be useful in the risk stratification of intracranial atherosclerotic lesions and to assess the risk of rupture of intracranial aneurysms. Recent advances in MRI technology made it more available, but larger studies are still needed to maximize its use in daily clinical practice.
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Affiliation(s)
- Federico Mazzacane
- Department of Emergency Neurology and Stroke Unit, IRCCS Mondino Foundation, 27100 Pavia, Italy;
- Department of Brain and Behavioral Sciences, University of Pavia, 27100 Pavia, Italy;
| | - Valentina Mazzoleni
- Neurology Unit, Department of Clinical and Experimental Sciences, University of Brescia, 25121 Brescia, Italy; (V.M.); (A.P.)
- Neurology Unit, Department of Neurological Sciences and Vision, ASST-Spedali Civili, 25123 Brescia, Italy;
| | - Elisa Scola
- Neuroradiology Unit, Department of Radiology, Careggi University Hospital, 50134 Florence, Italy; (E.S.); (S.M.); (I.L.); (G.B.)
| | - Sara Mancini
- Neuroradiology Unit, Department of Radiology, Careggi University Hospital, 50134 Florence, Italy; (E.S.); (S.M.); (I.L.); (G.B.)
| | - Ivano Lombardo
- Neuroradiology Unit, Department of Radiology, Careggi University Hospital, 50134 Florence, Italy; (E.S.); (S.M.); (I.L.); (G.B.)
| | - Giorgio Busto
- Neuroradiology Unit, Department of Radiology, Careggi University Hospital, 50134 Florence, Italy; (E.S.); (S.M.); (I.L.); (G.B.)
| | - Elisa Rognone
- Department of Neuroradiology, IRCCS Mondino Foundation, 27100 Pavia, Italy;
| | - Anna Pichiecchio
- Department of Brain and Behavioral Sciences, University of Pavia, 27100 Pavia, Italy;
- Department of Neuroradiology, IRCCS Mondino Foundation, 27100 Pavia, Italy;
| | - Alessandro Padovani
- Neurology Unit, Department of Clinical and Experimental Sciences, University of Brescia, 25121 Brescia, Italy; (V.M.); (A.P.)
- Neurology Unit, Department of Neurological Sciences and Vision, ASST-Spedali Civili, 25123 Brescia, Italy;
| | - Andrea Morotti
- Neurology Unit, Department of Neurological Sciences and Vision, ASST-Spedali Civili, 25123 Brescia, Italy;
| | - Enrico Fainardi
- Neuroradiology Unit, Department of Experimental and Clinical Biomedical Sciences “Mario Serio”, University of Florence, 50121 Florence, Italy
- Correspondence:
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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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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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16
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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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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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Garg A, Starr M, Rocha M, Ortega-Gutierrez S. Early Risk of Readmission Following Hospitalization for Reversible Cerebral Vasoconstriction Syndrome. Neurology 2021; 96:e2912-e2919. [PMID: 33952654 PMCID: PMC8253564 DOI: 10.1212/wnl.0000000000012107] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/15/2020] [Accepted: 03/11/2021] [Indexed: 11/15/2022] Open
Abstract
OBJECTIVE For evaluation of 90-day readmissions after an inpatient admission for reversible cerebral vasoconstriction syndrome (RCVS), hospitalizations due to RCVS were identified from the Nationwide Readmissions Database from 2016 to 2017. METHODS The primary outcome of interest was nonelective readmission within 90 days of index hospitalization discharge. Survival analysis was performed, and multivariable Cox proportional hazards regression was used to determine the factors associated with readmission. RESULTS Among the 1,157 hospitalizations due to RCVS during the study period (mean ± SD age 48.6 ± 16.1 years, women 76.4%), 164 (14.2%) patients had nonelective readmission within 90 days of discharge. The most common reasons for readmissions included acute cerebrovascular events (18.9%), continued or recurrent symptoms of RCVS (13.4%), infections (11.6%), and headache (9.8%). Diabetes, history of tobacco use, opioid use, and longer length of index hospitalization were independent predictors of 90-day readmission. For readmissions, the mean (SD) length of stay was 5.2 (6.1) days, and the mean (SD) cost per hospitalization was $14,214 ($15,140). There was no in-hospital mortality; however, 37.2% of patients were not discharged to home. CONCLUSION Nearly 14% of patients with RCVS are readmitted within 90 days of discharge, and a significant proportion of these readmissions are due to the ongoing/recurrent symptoms or neurologic sequelae of RCVS. Given that these patients are at a risk of early recurrence/worsening of their symptoms, an early postdischarge follow-up plan may need to be integrated into their care.
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Affiliation(s)
- Aayushi Garg
- From the Department of Neurology (A.G.) and Department of Neurology, Neurosurgery, and Radiology (S.O.-G.), University of Iowa Hospitals and Clinics, Iowa City; and Department of Neurology (M.S., M.R.), University of Pittsburgh Medical Center, PA
| | - Matthew Starr
- From the Department of Neurology (A.G.) and Department of Neurology, Neurosurgery, and Radiology (S.O.-G.), University of Iowa Hospitals and Clinics, Iowa City; and Department of Neurology (M.S., M.R.), University of Pittsburgh Medical Center, PA
| | - Marcelo Rocha
- From the Department of Neurology (A.G.) and Department of Neurology, Neurosurgery, and Radiology (S.O.-G.), University of Iowa Hospitals and Clinics, Iowa City; and Department of Neurology (M.S., M.R.), University of Pittsburgh Medical Center, PA
| | - Santiago Ortega-Gutierrez
- From the Department of Neurology (A.G.) and Department of Neurology, Neurosurgery, and Radiology (S.O.-G.), University of Iowa Hospitals and Clinics, Iowa City; and Department of Neurology (M.S., M.R.), University of Pittsburgh Medical Center, PA.
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Maningding E, Kermani TA. Mimics of vasculitis. Rheumatology (Oxford) 2021; 60:34-47. [PMID: 33167039 DOI: 10.1093/rheumatology/keaa495] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/26/2020] [Revised: 06/07/2020] [Accepted: 07/06/2020] [Indexed: 11/14/2022] Open
Abstract
While prompt diagnosis of vasculitis is important, recognition of vasculitis mimics is equally essential. As in the case of vasculitis, an approach to mimics based on the anatomic size of vessels can be useful. Infections can mimic vasculitis of any vessel size, including the formation of aneurysms and induction of ANCAs. Genetic disorders and vasculopathies are important considerations in large and medium vessel vasculitis. Cholesterol emboli, thrombotic conditions and calciphylaxis typically affect the medium and small vessels and, like vasculitis, can cause cutaneous, renal and CNS manifestations. Reversible cerebral vasoconstriction syndrome is important to distinguish from primary angiitis of the CNS. As an incorrect diagnosis of vasculitis can result in harmful consequences, it is imperative that the evaluation of suspected vasculitis includes consideration of mimics. We discuss the above mimics and outline a systematic and practical approach for differentiating vasculitis from its mimics.
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Affiliation(s)
- Ernest Maningding
- Division of Rheumatology, University of California, Los Angeles, Los Angeles, CA, USA
| | - Tanaz A Kermani
- Division of Rheumatology, University of California, Los Angeles, Los Angeles, CA, USA
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21
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Garg A, Ortega-Gutierrez S. Reply to the letter to the editor regarding "predictors and outcomes of hemorrhagic stroke in reversible cerebral vasoconstriction syndrome". J Neurol Sci 2021; 424:117429. [PMID: 33867163 DOI: 10.1016/j.jns.2021.117429] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/24/2021] [Accepted: 03/25/2021] [Indexed: 11/15/2022]
Affiliation(s)
- Aayushi Garg
- Department of Neurology, University of Iowa Hospitals and Clinics, Iowa City, IA, USA
| | - Santiago Ortega-Gutierrez
- Department of Neurology, Neurosurgery, and Radiology, University of Iowa Hospitals and Clinics, Iowa City, IA, USA.
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22
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Gotesman RD, Niznick N, Dewar B, Fergusson DA, Shorr R, Shamy M, Dowlatshahi D. Prevalence of non-contrast CT abnormalities in adults with reversible cerebral vasoconstriction syndrome: protocol for a systematic review and meta-analysis. BMJ Open 2020; 10:e041776. [PMID: 32958496 PMCID: PMC7507847 DOI: 10.1136/bmjopen-2020-041776] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
INTRODUCTION Reversible cerebral vasoconstriction syndrome (RCVS) is characterised by severe, recurrent thunderclap headaches (TCHs) and vasoconstriction of cerebral arteries that resolve within 3 months. Abnormalities on non-contrast CT (NCCT) such as ischaemic strokes, intracerebral haemorrhage and subarachnoid haemorrhages are frequently observed on brain imaging of patients with RCVS though their prevalence varies considerably between studies. The aim of this systematic review and meta-analysis is to estimate the prevalence of NCCT abnormalities seen on neuroimaging of adult patients with RCVS. METHODS AND ANALYSIS We will search the Medline, Embase and the Cochrane Library databases for studies on the prevalence of NCCT abnormalities on neuroimaging of patients with RCVS. Search results will be screened for eligibility by title and abstract. Suitable studies will be fully reviewed and relevant data extracted using a data abstraction form. The studies will be assessed for methodological quality, risk of bias and heterogeneity. Prevalence estimates across studies will be pooled using a random-effects model and subgroup analysis will be performed to assess the impact of age, sex, publication year and study design on prevalence of vascular lesions. Sensitivity analysis will be used to investigate the robustness of the findings. This protocol has been devised using the Preferred Reporting Items for Systematic Review and Meta-Analysis Protocols 2015 checklist. ETHICS AND DISSEMINATION Formal ethics is not required as primary data will not be collected. The findings of this study will be disseminated through a peer-reviewed publication and conference presentations. TRIAL REGISTRATION NUMBER CRD42020190637.
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Affiliation(s)
| | - Naomi Niznick
- Neurology, The Ottawa Hospital, Ottawa, Ontario, Canada
| | - Brian Dewar
- Ottawa Hospital Research Institute, Ottawa, Ontario, Canada
| | - Dean A Fergusson
- Faculty of Medicine, University of Ottawa, Ottawa, Ontario, Canada
- Ottawa Hospital Research Institute, Ottawa, Ontario, Canada
| | - Risa Shorr
- Learning Services, The Ottawa Hospital, Ottawa, Ontario, Canada
| | - Michel Shamy
- Neurology, The Ottawa Hospital, Ottawa, Ontario, Canada
- Ottawa Hospital Research Institute, Ottawa, Ontario, Canada
| | - Dar Dowlatshahi
- Neurology, The Ottawa Hospital, Ottawa, Ontario, Canada
- Ottawa Hospital Research Institute, Ottawa, Ontario, Canada
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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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24
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Rocha EA, Singhal AB. Current Treatment Options in Cardiovascular Medicine: Update on Reversible Cerebral Vasoconstriction Syndrome. CURRENT TREATMENT OPTIONS IN CARDIOVASCULAR MEDICINE 2020. [DOI: 10.1007/s11936-020-00819-9] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
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25
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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: 13] [Impact Index Per Article: 3.3] [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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