Reversible cerebral vasoconstriction syndrome shows different clinical pictures at different times during the perinatal period: Two case reports

OBJECTIVE

With the development of diagnostic imaging, a new clinical entity called reversible cerebral vasoconstriction syndrome (RCVS), which is considered to be a cause of secondary headache, has emerged. We herein present two cases of RCVS with different patterns of clinical progression.

CASE REPORT

Case 1 occurred during labor, whereas case 2 occurred after delivery. Neither case presnted thunderclap headache at the onset of symptoms. Hypertensive disorders of pregnancy did not occur during the pregnancy or the puerperium in either case. Neurological symptoms following mild headache (Case 1: coma; Case 2: paralysis of the right extremities) were observed.

CONCLUSION

Even when a patient has no risk factors for RCVS and had no severe headache, it is important not to miss any of the neurological symptoms. Magnetic resonance imaging (MRI) strongly supports the diagnosis, even during pregnancy. In addition, the diagnosis should always be reviewed while excluding eclampsia.

Reversible cerebral Vasoconstriction syndrome intERnational CollaborativE (REVERCE) network: Study protocol and rationale of a multicentre research collaboration

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.

Reversible cerebral vasoconstriction syndrome in the postpartum period: A case report and review of the literature

Reversible cerebral vasoconstriction syndrome (RCVS) is a rare phenomenon that can present in the postpartum period. We show the experience of a 35-year-old patient who presented with headache after an uncomplicated pregnancy and vaginal delivery. She was initially diagnosed with pre-eclampsia, and subsequently with RCVS following discovery of multifocal vascular narrowing on magnetic resonance arteriography (MRA). Verapamil was initiated, and at 1 month there was improvement intracranially, but cervical vertebral arterial narrowing, likely dissection, was discovered. Verapamil was continued and aspirin was initiated. Follow-up imaging 5 months postpartum demonstrated near-complete resolution of previously noted abnormalities, which remained stable at reimaging at 10 months postpartum. In conclusion, the symptoms of RCVS can mimic or coexist with pre-eclampsia. Early intracranial imaging such as MRA can permit timely diagnosis and facilitate appropriate management and follow-up.

Posterior reversible encephalopathy syndrome and reversible cerebral vasoconstriction syndrome in patients with COVID-19 infection: is there a link? A systematic review and case report analysis

During the SARS-CoV2 pandemic, several cases of Posterior Reversible Encephalopathy Syndrome (PRES) and of Reversible Cerebral Vasoconstriction Syndrome (RCVS) in COVID-19 patients have been reported, but the link between these syndromes and COVID-19 is unclear. We performed a systematic review, according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) statement to evaluate whether SARS-CoV2 infection or the drugs used to treat it could be deemed potential risk factors for PRES or RCVS. We performed a literature search. We found 70 articles (60 on PRES and 10 on RCVS) concerning n = 105 patients (n = 85 with PRES, n = 20 with RCVS). We analyzed the clinical characteristics of the two populations separately, then performed an inferential analysis to search for other independent risk factors. We found fewer than usual PRES-related (43.9%) and RCVS-related (45%) risk factors in patients with COVID-19. Such a low incidence of risk factors for PRES and RCVS might suggest the involvement of COVID-19 as an additional risk factor for both diseases due to its capability to cause endothelial dysfunction. We discuss the putative mechanisms of endothelial damage by SARS-CoV2 and antiviral drugs which may underlie the development of PRES and RCVS.

Reversible cerebral vasoconstriction syndrome after levonorgestrel-releasing intrauterine device placement-Case report

BACKGROUND

Reversible cerebral vasoconstriction syndrome (RCVS) is a disease characterized by reversible multifocal narrowing of the cerebral arteries with clinical manifestations that typically include thunderclap headache and occasionally brain edema, stroke, or seizure. The exact pathophysiology of RCVS is not well known.

CASE

A 46-year-old female with history of episodic migraine presented with 1-month duration of worsening headaches that had become more severe over the past 2 weeks. The headaches were episodic and thunderclap in onset and aggravated by physical exertion or emotional situations. A neurological examination was unremarkable including initial head computed tomography (CT). A CT angiogram of the head showed multifocal stenosis in the right anterior cerebral artery, bilateral middle cerebral arteries, and right posterior cerebral artery. Cerebral angiogram confirmed the CT angiogram findings. A repeated CT angiogram a few days later showed improvement in the multifocal cerebral arterial stenosis. Lumbar puncture and autoimmune workup were not suggestive of neuroinflammatory etiology. She had one generalized tonic-clonic seizure during her second day of hospitalization. The patient's thunderclap onset headaches resolved in 1 week after she was managed with blood pressure control and pain medication. She denied any illicit drug use or any new medications other than the placement of a levonorgestrel-releasing intrauterine device (IUD) about 6 weeks prior to her presentation.

CONCLUSIONS

Our case suggests a possible link between RCVS and levonorgestrel-releasing IUDs.

Postpartum reversible cerebral vasoconstriction with cortical subarachnoid hemorrhage and posterior reversible encephalopathy syndrome concomitant with vertebral artery dissection diagnosed by MRI MSDE method: A case report and review of literature

Headache is one of the most common symptoms encountered during the postpartum period. The cause may be unknown, or the following illnesses are possible: cervical artery dissection (CAD), reversible posterior cerebral encephalopathy syndrome (PRES), and reversible cerebral vasoconstrictor syndrome (RCVS). It is suggested that they are interrelated and share a similar mechanism such as small vessel endothelial dysfunction, deficiencies in self-regulation, and decreased sympathetic innervation of the posterior circulation. However, there are few reports of neuroradiological findings. We experienced a rare case of multiple postpartum vascular disease occurring at the same time. A 38-year-old woman suddenly developed thunderclap headache after giving birth. She was clear and had no neuropathy. Computed tomography revealed subarachnoid hemorrhage, including the cortical surface of the frontal lobe. Magnetic resonance image fluid-attenuated inversion recovery revealed high-intensity area in the bilateral basal ganglia and right occipital cortex. Angiography showed "string sausage" and extracranial left vertebral artery stenosis, but no aneurysm. Based on the clinical course and neuroradiological findings, we diagnosed her as postpartum vascular disease including CAD, PRES, RCVS, and cortical subarachnoid hemorrhage (SAH). Three-dimensional black blood T1-weighted images using a motion-sensitized driven equilibrium three-dimensional turbo spin echo (MSDE) sequencing method revealed an intramural hematoma consistent with the extracranial vertebral artery. After 3 months, MSDE lost its abnormal signal. Our case was rare in that multiple phenomena of postpartum vascular disease occurred at the same time. In particular, we could reveal that this speculation was reversible in the MRI MSDE sequencing.

Postpartum Reversible Cerebral Vasoconstriction Syndrome Presenting with Radiological Plethora

Reversible cerebral vasoconstriction syndrome (RCVS) is a clinicoradiological syndrome characterized by segmental vasoconstriction of cerebral arteries with resolution in most patients within 1 to 3 months. It has been known to be a benign uniphasic reversible illness but cases of fulminant RCVS with mortality have also been reported. The symptoms can be varied with presentations like transient ischemic attack (TIA), ischemic stroke (IS), intracerebral hemorrhage (ICH), subarachnoid hemorrhage (SAH), and posterior reversible encephalopathy syndrome (PRES). We report a postpartum female with RCVS with radiological features of ICH, SAH, atypical PRES, and atypical clinical presentation as well. RCVS can be frequently missed unless there is a high index of suspicion. Hence clinicians should be aware of the typical and the atypical presentation of RCVS along with the radiological findings with the potential complications. Early suspicion and detection in the emergency help in recovery and reducing morbidity.

Reversible Cerebral Vasoconstriction Syndrome: Symptoms, Incidence, and Resource Utilization in a Population-Based US Cohort

OBJECTIVE

To estimate the incidence of hospitalization for reversible cerebral vasoconstriction syndrome (RCVS), we identified RCVS-related hospital admissions across 11 US states in 2016.

METHODS

We tested the validity of ICD-10 code I67.841 in 79 patients with hospital admissions for RCVS or other cerebrovascular diseases at 1 academic and 1 community hospital. After determining that this code had a sensitivity of 100% (95% confidence interval [CI], 82%-100%) and a specificity of 90% (95% CI, 79%-96%), we applied it to administrative data from the Healthcare Cost and Utilization Project on all hospital admissions across 11 states. Age- and sex-standardized RCVS incidence was calculated using census data. Descriptive statistics were used to analyze associated diagnoses.

RESULTS

Across 5,067,250 hospital admissions in our administrative data, we identified 222 patients with a discharge diagnosis of RCVS in 2016. The estimated annual age- and sex-standardized incidence of RCVS hospitalization was 2.7 (95% CI, 2.4-3.1) cases per million adults. Many patients had concomitant neurologic diagnoses, including subarachnoid hemorrhage (37%), ischemic stroke (16%), and intracerebral hemorrhage (10%). In the 90 days before the index admission, 97 patients had an emergency department (ED) visit and 34 patients a hospital admission, most commonly for neurologic, psychiatric, and pregnancy-related diagnoses. Following discharge from the RCVS hospital admission, 58 patients had an ED visit and 31 had a hospital admission, most commonly for neurologic diagnoses.

CONCLUSIONS

Using population-wide data, we estimated the age- and sex-standardized incidence of hospitalization for RCVS in US adults as approximately 3 per million per year.

Neurological Emergencies During Pregnancy

This article serves as a comprehensive review of neurologic emergencies in pregnancy. Common initial presentations of neuroemergencies are reviewed with a clinical algorithm. Neurovascular disorders in pregnancy are reviewed, including acute ischemic strokes with data on tPA and thrombectomy; cerebral venous sinus thrombosis diagnosis and management; posterior reversible encephalopathy syndrome management; reversible cerebral vasoconstriction syndrome; and intracerebral hemorrhage. Attention is paid to management of cerebral edema and safety of osmotic therapies. A review of seizures in pregnancy is provided, including new-onset causes and decreased seizure thresholds. For status epilepticus, a low teratogenicity risk medication protocol in pregnancy is provided.

Postpartum headaches after epidural or spinal anesthesia

PURPOSE OF REVIEW

Postpartum headache is a common occurrence with various obstetric, neurologic, and anesthetic etiologies. Post dural puncture headache (PDPH) after neuraxial anesthesia is a culprit that may be less familiar to obstetricians. In this review, authors will discuss the differential diagnosis and management of postpartum headache, review PDPH, and explore evidence suggesting that PDPH may have greater implications than previously considered.

RECENT FINDINGS

Emerging evidence suggests that PDPH, previously believed to be benign and self-limited, is associated with significant acute and chronic sequelae. A recent large database study links PDPH to subdural hematoma and cerebral venous sinus thrombosis. The authors also identified associations between PDPH and bacterial meningitis, depression, and back pain. A growing body of literature also links PDPH or unintentional dural puncture with an epidural needle (UDP) with development of chronic headaches.

SUMMARY

Patients who experience UDP or PDPH should be counseled to return for evaluation for new or worsening headache. In the immediate postpartum setting, clinicians assessing these patients should have a low threshold to obtain brain imaging. In addition, obstetricians should be alerted that patients who suffer UDP may be prone to develop chronic headache disorders and consider referral to pain specialists.

Ophthalmological symptoms in a patient with reversible cerebral vasoconstriction syndrome: a case report

Background

Reversible cerebral vasoconstriction syndrome is characterized by severe headache with reversible segmental constriction of the cerebral arteries. We present details on a patient with reversible cerebral vasoconstriction syndrome who initially visited an ophthalmologist because of visual symptoms.

Case presentation

A 34-year-old Japanese woman complained of sustained headache and insomnia starting 2 days after her first childbirth. In addition to the severe headache, a visual field defect was also observed 10 days later. Best corrected visual acuity at the initial visit was 20/20 and 20/25 for the right and left eye, respectively. Exudative retinal detachment was noted surrounding both optic heads. Visual field testing revealed left homonymous hemianopsia, while magnetic resonance imaging demonstrated the presence of edema and infarction of the bilateral basal nuclei and right occipital lobe. The homonymous hemianopsia and exudative retinal detachment recovered immediately after treatment with a free-radical scavenger and anticoagulant. There has been no recurrence of symptoms during the 4 years of follow-up.

Conclusions

We report a case of reversible cerebral vasoconstriction syndrome with ophthalmological symptoms that were reversible, including serous retinal detachment and homonymous hemianopsia.

Synchronous reversible cerebral vasoconstriction syndrome following thyrotoxicosis in a postpartum woman

Background

Reversible cerebral vasoconstriction syndrome (RCVS) typically manifests with acute‐onset, recursive, severe headache that continues for a month; it rarely manifests as seizures. Development of RCVS following thyrotoxicosis has not been previously reported in detail.

Case Presentation

A 30‐year‐old postpartum woman with thyrotoxicosis developed a generalized seizure refractory to anticonvulsants. Magnetic resonance angiography demonstrated cerebral artery stenosis in the right anterior cerebral artery and the right middle cerebral artery. These findings were compatible with RCVS. Reversible cerebral vasoconstriction syndrome was treated successfully with i.v. nicardipine and conventional management was undertaken for thyrotoxicosis.

Conclusion

This is the first well‐documented case of a postpartum woman with synchronous RCVS following thyrotoxicosis. Reversible cerebral vasoconstriction syndrome and thyrotoxicosis can coincidentally occur in postpartum women and manifest with postpartum seizures.

Postpartum intracranial hypotension complicated by posterior reversible encephalopathy syndrome: a case report

Purpose: To present an unusual case of posterior encephalopathy syndrome (PRES) preceded by intracranial hypotension.Materials and Methods: We present a case of a 27-year-old parturient with an uneventful pregnancy that shortly after labor developed a persistent headache with characteristics compatible with intracranial hypotension. The patient had undergone epidural anesthesia for caesarian section. Results: The symptomatology of intracranial hypotension was attributed to inadvertent dural puncture during epidural anesthesia. The MRI revealed multiple white matter lesions located in frontal, temporal and parietal regions of both hemispheres. The type of lesions was suggestive of PRES. Pachymeningeal enhancement was also observed. The patient was managed conservatively. The symptoms improved gradually and the imaging findings resolved completely. Conclusions: This case demonstrates the need for clinical alertness for PRES in patients with prolonged and possibly atypical symptoms of intracranial hypotension. As probable causal relationship between these disorders we propose a sympathetic over-activation as a result of cerebrospinal fluid leakage leading to vasospasm and manifestation of PRES.

Migraine and other headache disorders in pregnancy

Migraine prevalence is three times higher in women than in men during fertile years, which is mainly due to sex hormone differences. The majority of women suffering from migraine without aura report improvement of their migraine attacks during pregnancy. Migraine attacks with aura can also improve during pregnancy, but more often remain the same or worsen. Anovulation caused by lactation is generally associated with a decrease in migraine attacks in breastfeeding women. This chapter describes the current knowledge on acute and prophylactic treatment options of migraine and other primary headache disorders during pregnancy and lactation. Further, clinical profiles of secondary headaches during pregnancy and the postpartum period are summarized.

Analysis of postpartum reversible cerebral vasoconstriction syndrome in China: A case report and literature review

Reversible cerebral vasoconstriction syndrome (RCVS) is a rare clinical syndrome accompanying with severe headache as its main symptom. Postpartum reversible cerebral vasoconstriction syndrome (PPRCVS) refers to RCVS occurring in the puerperium, in which it has a low incidence, and that is easily missed diagnosed and misdiagnosed in clinical practice.By searching in CNKI and Wanfang databases, 9 published articles reported PPRCVS were found, totally including 12 cases with PPRCVS. The clinical data of these 12 cases were accordingly analyzed and summarized. The characteristics of these cases were compared with those reported in other countries, and eventually the clinical characteristics of Chinese PPRCVS patients were summarized.The clinical characteristics of Chinese PPRCVS patients were basically as same as those found in other countries, while the onset age was earlier, PPRCVS often occurred earlier after delivery, with higher proportions of concomitant symptoms and abnormal laboratory and imaging examinations; moreover, and fewer patients were diagnosed by digital subtraction angiography (DSA).

Impact of Intraoperative Blood Pressure Control and Temporary Parent Artery Blocking on Prognosis in Cerebral Aneurysms Surgery

Objective In cerebral aneurysm clipping and embolization, blood pressure control and temporary parent artery blocking are common methods to prevent aneurysm rupture. Their influence on the prognosis is uncertain. In this study, we try to find out the association between methods above and prognostic indicators.Methods We held a retrospective analysis on patients' medical records of cerebral aneurysms surgical clipping and endovascular coiling , and recorded gender, age, diagnosis, Hunt-Hess grade, Glasgow coma scale score, treatment methods, a history of hypertension, preoperative systolic blood pressure, with or without controlled hypotension, systolic blood pressure difference before and after controlled hypotension, with or without temporary artery blocking, with or without hypertension after treated aneurysm, prognostic indicators including mortality after 1 month, intensive care unit (ICU) stay time of survivors, discharged Glasgow outcome scale (GOS) score. Prognostic indicators were regarded as dependent variable, all the factors were regarded as independent variable, and the strength analysis of influence factors on prognostic indicators was made by binary logistic regression.Results Total cases were 165, including 68 males and 97 females, with an average age of 56 (12-85) years. The mortality after 1 month was 10.9% (18 cases). The ICU stay time of survivors was 7.35 (0-67) days. GOS score at discharge was 1-3 in 40 (24.2%) patients and 4-5 in 125 (75.8%) patients. Systolic blood pressure difference before and after controlled hypotension was an independent factor influencing mortality (t=2.273, P=0.024), and the greater the difference was, the higher the mortality would be. Timely hypertension after aneurysm treated was an independent factor affecting ICU stay time of survivors and patients with hypertension had shorter ICU stay time (χ²=10.017, P=0.001). Blood pressure control (χ²=0.088, P=0.767) and temporary blocking (χ²=1.307, P=0.253) did not show significant influence on GOS score at discharge.Conclusions Timely controlled hypertension after aneurysm clipping and embolization can significantly shorten the stay time in ICU. The degree of controlled hypotension associates with postoperative mortality, the greater systolic blood pressure difference before and after antihypertensive treatment is, the higher the mortality will be.

Cerebral haemodynamics in early puerperium: A prospective study

AIM

Prospective study on 900 consecutive puerperae to assess normal values and range of the blood flow velocity in the middle cerebral artery in both hemispheres.

MATERIAL AND METHOD

M1 and M2 segments of both middle cerebral arteries were assessed in all subjects within 96 hours of delivery. Mean flow velocity was recorded after adjusting for insonation angle. Lindegaard index (LI = middle cerebral artery-Internal Carotid Artery mean flow velocity ratio) was calculated whenever the mean flow velocity exceeded 100 cm/second. Asymmetry indexes were calculated inter hemispherically for M1 and M2 segments separately.

RESULTS

Mean flow velocities were 74 ± 17 and 72 ± 17 in right and 73 ± 17 and 72 ± 17 cm/second in the left M1 and M2, respectively. A total of 136 subjects (12.1%) exceeded the threshold of 100 cm/second, but LI was consistently <3 in all of them. Mean flow velocity was inversely and independently correlated to haemoglobin levels and to parity. Mean asymmetry indexes were 0.25 ± 23 in M1 and 0.45 ± 25 in M2.

CONCLUSION

Mean flow velocity in the middle cerebral artery of healthy subjects in early puerperium is higher than in age-matched non-puerperal women and may exceed the threshold of 100 cm/second with no evidence of intracranial spasm, because of blood loss during delivery. Mean flow velocity is independently correlated with parity. Right-to-left mean flow velocity asymmetry may reach 50% as a consequence of a transient imbalance in vascular tone regulation.

Reversible cerebral vasoconstriction syndrome in puerperium: A prospective study

BACKGROUND AND AIM OF THE STUDY

Reversible cerebral vasoconstriction syndrome (RCVS) is characterized by severe "thunderclap" headache, with or without associated neurological symptoms and neuroimaging findings of reversible vasoconstriction of cerebral arteries. Puerperium is a recognized precipitant, but the incidence of puerperal RCVS is unknown. We conducted a prospective study to assess incidence, risk factors and clinical features of RCVS.

MATERIAL AND METHOD

Nine-hundred consecutive puerperae were prospectively enrolled within three days of delivery. Past medical history, basal demographic, anthropometric and biological variables were recorded. Transcranial Colour Coded Sonography (TCCS) was performed to assess early signs of vasospasm in brain vessels. A structured telephone interview was planned in all subjects one month postdelivery.

RESULTS

Thunderclap headache was recorded in 8 subjects (0.9%) on the first visit. At the one month follow-up interview 27 more patients reported having had at least one episode of thunderclap headache. In these 33 (3.8%) patients the course was spontaneously benign. One patient presented to the Emergency ward with throbbing thunderclap headache three weeks after delivery. Diagnostic work-up ended up in the diagnosis of RCVS, the outcome was favourable CONCLUSION: In normally coursing pregnancies and after uncomplicated delivery the risk of puerperal RCVS is negligible (0.1%). On the other way thunderclap headache may occur in a measurable proportion of (3.4%), although in the vast majority of cases (33/34=97%) it is of benign course. Transcranial Doppler sonography may be helpful to pick up those cases in whom further neuroradiological investigation is warranted.

Headache in the Emergency Department: Avoiding Misdiagnosis of Dangerous Secondary Causes

There are a number of dangerous secondary causes of headaches that are life, limb, brain, or vision threatening that emergency physicians must consider in patients presenting with acute headache. Careful history and physical examination targeted at these important secondary causes of headache will help to avoid misdiagnosis in these patients. Patients with acute thunderclap headache have a differential diagnosis beyond subarachnoid hemorrhage. Considering the "context" of headache "PLUS" some other symptom or sign is one strategy to help focus the differential diagnosis.

Reversible Cerebral Vasoconstriction Syndrome with Transient Splenial Lesions after Delivery

Reversible cerebral vasoconstriction syndrome (RCVS) is characterized by segmental vasospasm and it is often accompanied by either posterior reversible encephalopathy syndrome or stroke. However, other MRI abnormalities have rarely been reported. A 28-year-old woman presented with a thunderclap headache immediately after delivery; MRI showed segmental vasoconstriction and an abnormal signal in the splenium of the corpus callosum. Neuroimaging abnormalities normalized 20 days after the first examination. Only two cases of RCVS with transient splenial lesions (TSL) have so far been reported. Both cases occurred postpartum like ours, indicating that delivery may be a trigger for the development of both TSLs and RCVS.