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Yang JC, Chen SP, Wang YF, Chang CH, Chang KH, Fuh JL, Chow LH, Han CL, Chen YJ, Wang SJ. Cerebrospinal Fluid Proteome Map Reveals Molecular Signatures of Reversible Cerebral Vasoconstriction Syndrome. Mol Cell Proteomics 2024; 23:100794. [PMID: 38839039 DOI: 10.1016/j.mcpro.2024.100794] [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: 10/06/2023] [Revised: 04/08/2024] [Accepted: 05/07/2024] [Indexed: 06/07/2024] Open
Abstract
Reversible cerebral vasoconstriction syndrome (RCVS) is a complex neurovascular disorder characterized by repetitive thunderclap headaches and reversible cerebral vasoconstriction. The pathophysiological mechanism of this mysterious syndrome remains underexplored and there is no clinically available molecular biomarker. To provide insight into the pathogenesis of RCVS, this study reported the first landscape of dysregulated proteome of cerebrospinal fluid (CSF) in patients with RCVS (n = 21) compared to the age- and sex-matched controls (n = 20) using data-independent acquisition mass spectrometry. Protein-protein interaction and functional enrichment analysis were employed to construct functional protein networks using the RCVS proteome. An RCVS-CSF proteome library resource of 1054 proteins was established, which illuminated large groups of upregulated proteins enriched in the brain and blood-brain barrier (BBB). Personalized RCVS-CSF proteomic profiles from 17 RCVS patients and 20 controls reveal proteomic changes involving the complement system, adhesion molecules, and extracellular matrix, which may contribute to the disruption of BBB and dysregulation of neurovascular units. Moreover, an additional validation cohort validated a panel of biomarker candidates and a two-protein signature predicted by machine learning model to discriminate RCVS patients from controls with an area under the curve of 0.997. This study reveals the first RCVS proteome and a potential pathogenetic mechanism of BBB and neurovascular unit dysfunction. It also nominates potential biomarker candidates that are mechanistically plausible for RCVS, which may offer potential diagnostic and therapeutic opportunities beyond the clinical manifestations.
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Affiliation(s)
- Jhih-Ci Yang
- Institute of Chemistry, Academia Sinica, Taipei, Taiwan; Sustainable Chemical Science and Technology, Taiwan International Graduate Program, Academia Sinica, National Yang Ming Chiao Tung University, Taipei, Taiwan; Department of Applied Chemistry, National Yang Ming Chiao Tung University, Hsinchu, Taiwan
| | - Shih-Pin Chen
- Department of Neurology, Neurological Institute, Taipei Veterans General Hospital, Taipei, Taiwan; Brain Research Center, National Yang Ming Chiao Tung University, Taipei, Taiwan; Division of Translational Research, Department of Medical Research, Taipei Veterans General Hospital, Taipei, Taiwan; Institute of Clinical Medicine, College of Medicine, National Yang Ming Chiao Tung University, Taipei, Taiwan; College of Medicine, National Yang Ming Chiao Tung University, Taipei, Taiwan.
| | - Yen-Feng Wang
- Department of Neurology, Neurological Institute, Taipei Veterans General Hospital, Taipei, Taiwan; Brain Research Center, National Yang Ming Chiao Tung University, Taipei, Taiwan; College of Medicine, National Yang Ming Chiao Tung University, Taipei, Taiwan
| | - Chan-Hua Chang
- Institute of Chemistry, Academia Sinica, Taipei, Taiwan; Department of Chemistry, National Central University, Taoyuan, Taiwan
| | - Kun-Hao Chang
- Institute of Chemistry, Academia Sinica, Taipei, Taiwan; Molecular Science and Technology Program, Taiwan International Graduate Program, Academia Sinica, Taipei, Taiwan; Department of Chemistry, Institute of Chemistry, Academia Sinica, Naitonal Tsing Hua University, Hsinchu, Taiwan
| | - Jong-Ling Fuh
- Department of Neurology, Neurological Institute, Taipei Veterans General Hospital, Taipei, Taiwan; Brain Research Center, National Yang Ming Chiao Tung University, Taipei, Taiwan; College of Medicine, National Yang Ming Chiao Tung University, Taipei, Taiwan
| | - Lok-Hi Chow
- College of Medicine, National Yang Ming Chiao Tung University, Taipei, Taiwan; Department of Anesthesiology, Taipei Veterans General Hospital, Taipei, Taiwan
| | - Chia-Li Han
- Master Program in Clinical Genomics and Proteomics, College of Pharmacy, Taipei Medical University, Taipei, Taiwan.
| | - Yu-Ju Chen
- Institute of Chemistry, Academia Sinica, Taipei, Taiwan; Sustainable Chemical Science and Technology, Taiwan International Graduate Program, Academia Sinica, National Yang Ming Chiao Tung University, Taipei, Taiwan; Department of Chemistry, National Taiwan University, Taipei, Taiwan.
| | - Shuu-Jiun Wang
- Department of Neurology, Neurological Institute, Taipei Veterans General Hospital, Taipei, Taiwan; Brain Research Center, National Yang Ming Chiao Tung University, Taipei, Taiwan; College of Medicine, National Yang Ming Chiao Tung University, Taipei, Taiwan.
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Wu CH, Kuo Y, Ling YH, Wang YF, Fuh JL, Lirng JF, Wu HM, Wang SJ, Chen SP. Dynamic changes in glymphatic function in reversible cerebral vasoconstriction syndrome. J Headache Pain 2024; 25:17. [PMID: 38317074 PMCID: PMC10840154 DOI: 10.1186/s10194-024-01726-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/15/2023] [Accepted: 01/26/2024] [Indexed: 02/07/2024] Open
Abstract
BACKGROUND The pathophysiology of the reversible cerebral vasoconstriction syndrome (RCVS) remains enigmatic and the role of glymphatics in RCVS pathophysiology has not been evaluated. We aimed to investigate RCVS glymphatic dynamics and its clinical correlates. METHODS We prospectively evaluated the glymphatic function in RCVS patients, with RCVS subjects and healthy controls (HCs) recruited between August 2020 and November 2023, by calculating diffusion-tensor imaging along the perivascular space (DTI-ALPS) index under a 3-T MRI. Clinical and vascular (transcranial color-coded duplex sonography) investigations were conducted in RCVS subjects. RCVS participants were separated into acute (≤ 30 days) and remission (≥ 90 days) groups by disease onset to MRI interval. The time-trend, acute stage and longitudinal analyses of the DTI-ALPS index were conducted. Correlations between DTI-ALPS index and vascular and clinical parameters were performed. Bonferroni correction was applied to vascular investigations (q = 0.05/11). RESULTS A total of 138 RCVS patients (mean age, 46.8 years ± 11.8; 128 women) and 42 HCs (mean age, 46.0 years ± 4.5; 35 women) were evaluated. Acute RCVS demonstrated lower DTI-ALPS index than HCs (p < 0.001) and remission RCVS (p < 0.001). A continuously increasing DTI-ALPS trend after disease onset was demonstrated. The DTI-ALPS was lower when the internal carotid arteries resistance index and six-item Headache Impact test scores were higher. In contrast, during 50-100 days after disease onset, the DTI-ALPS index was higher when the middle cerebral artery flow velocity was higher. CONCLUSIONS Glymphatic function in patients with RCVS exhibited a unique dynamic evolution that was temporally coupled to different vascular indices and headache-related disabilities along the disease course. These findings may provide novel insights into the complex interactions between glymphatic transport, vasomotor control and pain modulation.
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Grants
- V112C-113 & V112E-004-1 (to SJW); V110C-102, VGH-111-C-158, V112C-053 & V112D67-001-MY3-1 (to SPC); V112B-007, V111B-032, V109B-009 (to CHW) Taipei Veterans General Hospital
- V112C-113 & V112E-004-1 (to SJW); V110C-102, VGH-111-C-158, V112C-053 & V112D67-001-MY3-1 (to SPC); V112B-007, V111B-032, V109B-009 (to CHW) Taipei Veterans General Hospital
- V112C-113 & V112E-004-1 (to SJW); V110C-102, VGH-111-C-158, V112C-053 & V112D67-001-MY3-1 (to SPC); V112B-007, V111B-032, V109B-009 (to CHW) Taipei Veterans General Hospital
- CI-112-2, CI-111-2, CI-109-3 (to CHW) Yen Tjing Ling Medical Foundation
- NSTC 108-2314-B-010-022 -MY3, 110-2326-B-A49A-501-MY3 & 112-2314-B-A49 -037 -MY3 (to SPC); 110-2321-B-010-005-, 111-2321-B-A49-004, 111-2321-B-A49-011, 111-2314-B-A49-069-MY3, 111-2314-B-075 -086-MY3 & 112-2321-B-075-007 (to SJW); 111-2314-B-075 -025 -MY3 & 110-2314-B-075-005 (to CHW) National Science and Technology Council
- NSTC 108-2314-B-010-022 -MY3, 110-2326-B-A49A-501-MY3 & 112-2314-B-A49 -037 -MY3 (to SPC); 110-2321-B-010-005-, 111-2321-B-A49-004, 111-2321-B-A49-011, 111-2314-B-A49-069-MY3, 111-2314-B-075 -086-MY3 & 112-2321-B-075-007 (to SJW); 111-2314-B-075 -025 -MY3 & 110-2314-B-075-005 (to CHW) National Science and Technology Council
- NSTC 108-2314-B-010-022 -MY3, 110-2326-B-A49A-501-MY3 & 112-2314-B-A49 -037 -MY3 (to SPC); 110-2321-B-010-005-, 111-2321-B-A49-004, 111-2321-B-A49-011, 111-2314-B-A49-069-MY3, 111-2314-B-075 -086-MY3 & 112-2321-B-075-007 (to SJW); 111-2314-B-075 -025 -MY3 & 110-2314-B-075-005 (to CHW) National Science and Technology Council
- MOHW107-TDU-B-211-123001, MOHW 108-TDU-B-211-133001 and MOHW112-TDU-B-211-144001 (to SJW) Ministry of Health and Welfare
- VGHUST-112-G1-2-1 (to SJW) Veterans General Hospitals and University System of Taiwan Joint Research Program
- Professor Tsuen CHANG’s Scholarship Program from Medical Scholarship Foundation In Memory Of Professor Albert Ly-Young Shen
- Vivian W. Yen Neurological Foundation
- Brain Research Center, National Yang Ming Chiao Tung University from The Featured Areas Research Center Program within the framework of the Higher Education Sprout Project by the Ministry of Education (MOE) in Taiwan
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Affiliation(s)
- Chia-Hung Wu
- Department of Radiology, Taipei Veterans General Hospital, No.201, Sec. 2, Shipai Rd., Taipei, Taiwan
- School of Medicine, National Yang Ming Chiao Tung University, No. 155, Sec. 2, Linong St, Taipei, Taiwan
| | - Yu Kuo
- Department of Radiology, Taipei Veterans General Hospital, No.201, Sec. 2, Shipai Rd., Taipei, Taiwan
- School of Medicine, National Yang Ming Chiao Tung University, No. 155, Sec. 2, Linong St, Taipei, Taiwan
- Department of Nuclear Medicine, Taipei Veterans General Hospital, No.201, Sec. 2, Shipai Rd., Taipei, Taiwan
| | - Yu-Hsiang Ling
- School of Medicine, National Yang Ming Chiao Tung University, No. 155, Sec. 2, Linong St, Taipei, Taiwan
- Department of Neurology, Neurological Institute, Taipei Veterans General Hospital, No.201, Sec. 2, Shipai Rd., Taipei, Taiwan
| | - Yen-Feng Wang
- School of Medicine, National Yang Ming Chiao Tung University, No. 155, Sec. 2, Linong St, Taipei, Taiwan
- Department of Neurology, Neurological Institute, Taipei Veterans General Hospital, No.201, Sec. 2, Shipai Rd., Taipei, Taiwan
- Brain Research Center, National Yang Ming Chiao Tung University, No. 155, Sec. 2, Linong St., Taipei, Taiwan
| | - Jong-Ling Fuh
- School of Medicine, National Yang Ming Chiao Tung University, No. 155, Sec. 2, Linong St, Taipei, Taiwan
- Department of Neurology, Neurological Institute, Taipei Veterans General Hospital, No.201, Sec. 2, Shipai Rd., Taipei, Taiwan
- Brain Research Center, National Yang Ming Chiao Tung University, No. 155, Sec. 2, Linong St., Taipei, Taiwan
| | - Jiing-Feng Lirng
- Department of Radiology, Taipei Veterans General Hospital, No.201, Sec. 2, Shipai Rd., Taipei, Taiwan
- School of Medicine, National Yang Ming Chiao Tung University, No. 155, Sec. 2, Linong St, Taipei, Taiwan
| | - Hsiu-Mei Wu
- Department of Radiology, Taipei Veterans General Hospital, No.201, Sec. 2, Shipai Rd., Taipei, Taiwan
- School of Medicine, National Yang Ming Chiao Tung University, No. 155, Sec. 2, Linong St, Taipei, Taiwan
| | - Shuu-Jiun Wang
- School of Medicine, National Yang Ming Chiao Tung University, No. 155, Sec. 2, Linong St, Taipei, Taiwan.
- Department of Neurology, Neurological Institute, Taipei Veterans General Hospital, No.201, Sec. 2, Shipai Rd., Taipei, Taiwan.
- Brain Research Center, National Yang Ming Chiao Tung University, No. 155, Sec. 2, Linong St., Taipei, Taiwan.
| | - Shih-Pin Chen
- School of Medicine, National Yang Ming Chiao Tung University, No. 155, Sec. 2, Linong St, Taipei, Taiwan.
- Department of Neurology, Neurological Institute, Taipei Veterans General Hospital, No.201, Sec. 2, Shipai Rd., Taipei, Taiwan.
- Brain Research Center, National Yang Ming Chiao Tung University, No. 155, Sec. 2, Linong St., Taipei, Taiwan.
- Institute of Clinical Medicine, National Yang Ming Chiao Tung University, No. 155, Sec. 2, Linong St., Taipei, Taiwan.
- Division of Translational Research, Department of Medical Research, Taipei Veterans General Hospital, No.201, Sec. 2, Shipai Rd., Taipei, Taiwan.
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Sowanou A, Ungureanu A, Aguesse C. Recurrent reversible cerebral vasoconstriction syndrome and antiphospholipid syndrome. Acta Neurol Belg 2024; 124:329-334. [PMID: 37392321 DOI: 10.1007/s13760-023-02324-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/21/2023] [Accepted: 06/21/2023] [Indexed: 07/03/2023]
Affiliation(s)
- Arlos Sowanou
- Neurology Department, Centre Hospitalier Alpes-Léman, Contamine Sur Arve, France
| | - Aurelian Ungureanu
- Neurology Department, Centre Hospitalier Alpes-Léman, Contamine Sur Arve, France.
| | - Claire Aguesse
- Neurology Department, Centre Hospitalier Alpes-Léman, Contamine Sur Arve, France
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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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Wu CH, Hsu TW, Lai KL, Wang YF, Fuh JL, Wu HM, Lirng JF, Wang SJ, Chen SP. Disrupted Brain Functional Status in Patients with Reversible Cerebral Vasoconstriction Syndrome. Ann Neurol 2023; 94:772-784. [PMID: 37345341 DOI: 10.1002/ana.26724] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/21/2023] [Revised: 06/11/2023] [Accepted: 06/15/2023] [Indexed: 06/23/2023]
Abstract
OBJECTIVES The aim of this study was to investigate the functional networks in subjects with reversible cerebral vasoconstriction syndrome (RCVS) using resting-state functional magnetic resonance imaging (rs-fMRI). METHODS We prospectively recruited patients with RCVS and healthy controls (HCs) between February 2017 and April 2021. The rs-fMRI data were analyzed using graph theory methods. We compared node-based global and regional topological metrics (Bundle 1) and network-based intranetwork and internetwork connectivity (Bundle 2) between RCVS patients and HCs. We also explored the associations of clinical and vascular (ie, the Lindegaard index, LI) parameters with significant rs-fMRI metrics. RESULTS A total of 104 RCVS patients and 93 HCs were included in the final analysis. We identified significantly decreased local efficiency of the left dorsal anterior insula (dAI; p = 0.0005) in RCVS patients within 30 days after disease onset as compared to HCs, which improved 1 month later. RCVS patients also had increased global efficiency (p = 0.009) and decreased average degree centrality (p = 0.045), clustering coefficient (p = 0.033), and assortativity values (p = 0.003) in node-based analysis. In addition, patients with RCVS had increased internetwork connectivity of the default mode network (DMN) with the salience (p = 0.027) and dorsal attention (p = 0.016) networks. Significant correlations between LI and regional local efficiency in left dAI (rs = -0.418, p = 0.042) was demonstrated. INTERPRETATION The significantly lower local efficiency of the left dAI, suggestive of impaired central autonomic modulation, was negatively correlated with vasoconstriction severity, which is highly plausible for the pathogenesis of RCVS. ANN NEUROL 2023;94:772-784.
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Affiliation(s)
- Chia-Hung Wu
- Department of Radiology, Taipei Veterans General Hospital, Taipei, Taiwan
- School of Medicine, National Yang Ming Chiao Tung University, Taipei, Taiwan
| | - Tun-Wei Hsu
- Department of Radiology, Taipei Veterans General Hospital, Taipei, Taiwan
- School of Medicine, National Yang Ming Chiao Tung University, Taipei, Taiwan
- Department of Nuclear Medicine, Taipei Veterans General Hospital, Taipei, Taiwan
| | - Kuan-Lin Lai
- School of Medicine, National Yang Ming Chiao Tung University, Taipei, Taiwan
- Department of Neurology, Neurological Institute, Taipei Veterans General Hospital, Taipei, Taiwan
- Brain Research Center, National Yang Ming Chiao Tung University, Taipei, Taiwan
| | - Yen-Feng Wang
- School of Medicine, National Yang Ming Chiao Tung University, Taipei, Taiwan
- Department of Neurology, Neurological Institute, Taipei Veterans General Hospital, Taipei, Taiwan
- Brain Research Center, National Yang Ming Chiao Tung University, Taipei, Taiwan
| | - Jong-Ling Fuh
- School of Medicine, National Yang Ming Chiao Tung University, Taipei, Taiwan
- Department of Neurology, Neurological Institute, Taipei Veterans General Hospital, Taipei, Taiwan
- Brain Research Center, National Yang Ming Chiao Tung University, Taipei, Taiwan
| | - Hsiu-Mei Wu
- Department of Radiology, Taipei Veterans General Hospital, Taipei, Taiwan
- School of Medicine, National Yang Ming Chiao Tung University, Taipei, Taiwan
| | - Jiing-Feng Lirng
- Department of Radiology, Taipei Veterans General Hospital, Taipei, Taiwan
- School of Medicine, National Yang Ming Chiao Tung University, Taipei, Taiwan
| | - Shuu-Jiun Wang
- School of Medicine, National Yang Ming Chiao Tung University, Taipei, Taiwan
- Department of Neurology, Neurological Institute, Taipei Veterans General Hospital, Taipei, Taiwan
- Brain Research Center, National Yang Ming Chiao Tung University, Taipei, Taiwan
| | - Shih-Pin Chen
- School of Medicine, National Yang Ming Chiao Tung University, Taipei, Taiwan
- Department of Neurology, Neurological Institute, Taipei Veterans General Hospital, Taipei, Taiwan
- Brain Research Center, National Yang Ming Chiao Tung University, Taipei, 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
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Khan WJ, Asif M, Aslam S, Nadeem I, Rossing W. Reversible Cerebral Vasoconstriction Syndrome Associated With Oxybutynin Use; a Brief Review of Pathophysiology. J Community Hosp Intern Med Perspect 2023; 13:31-34. [PMID: 37868238 PMCID: PMC10589016 DOI: 10.55729/2000-9666.1192] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/23/2023] [Revised: 03/08/2023] [Accepted: 03/16/2023] [Indexed: 10/24/2023] Open
Abstract
Reversible cerebral vasoconstriction syndrome (RCVS) is characterized by reversible vasospasm of the central nervous system vasculature. It usually presents as a classic thunderclap headache, but complications like a stroke, seizure, or intracranial hemorrhage may occur at the onset. Most cases are linked temporally to secondary agents. The most common suggested mechanism underlying the RCVS is vascular tone dysregulation. Our report describes the RCVS incidence associated with oxybutynin use in a young female. We aim to describe the potential pathophysiology linking oxybutynin use and RCVS.
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Affiliation(s)
- Wahab J. Khan
- The University of South Dakota Sanford School of Medicine, Sioux Falls, SD,
USA
| | - Muhammad Asif
- The University of South Dakota Sanford School of Medicine, Sioux Falls, SD,
USA
| | - Sadia Aslam
- Avera McKennan Hospital and University Health Center, Sioux Falls, SD,
USA
| | - Ifrah Nadeem
- The University of South Dakota Sanford School of Medicine, Sioux Falls, SD,
USA
| | - William Rossing
- The University of South Dakota Sanford School of Medicine, Sioux Falls, SD,
USA
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Lin PT, Chen SP, Wang SJ. Update on primary headache associated with sexual activity and primary thunderclap headache. Cephalalgia 2023; 43:3331024221148657. [PMID: 36786380 DOI: 10.1177/03331024221148657] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/15/2023]
Abstract
BACKGROUND This narrative review aims to provide an update on primary headache associated with sexual activity and primary thunderclap headache. METHODS We conducted a literature search on PubMed with the keywords "headache associated with sexual activity", "sexual headache", "orgasmic cephalalgia", and "coital cephalalgia" in addition to "thunderclap headache" to assess the appropriateness of all published articles in this review. RESULTS Primary headache associated with sexual activity is a "primary" headache precipitated by sexual activity, which occurs as sexual excitement increases (progressive at onset), or manifests as an abrupt and intense headache upon orgasm (thunderclap at onset) or combines these above two features. Primary headache associated with sexual activity is diagnosed after a thorough investigation, including appropriate neuroimaging studies, to exclude life-threatening secondary causes such as subarachnoid hemorrhage. According to the criteria of the third edition of the International Classification of Headache Disorders, primary thunderclap headache is also a diagnosis by exclusion. The pathophysiology of primary headache associated with sexual activity and primary thunderclap headache remains incompletely understood. Treatment may not be necessary for all patients since some patients with primary headache associated with sexual activity and primary thunderclap headache have a self-limiting course. CONCLUSION A comprehensive neuroimaging study is needed for distinguishing primary headache associated with sexual activity or primary thunderclap headache from secondary causes. Primary headache associated with sexual activity and primary thunderclap headache are self-limited diseases and the prognoses are good, but some patients with primary headache associated with sexual activity may have a prolonged course.
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Affiliation(s)
- Po-Tso Lin
- Department of Neurology, Neurological Institute, Taipei Veterans General Hospital, Taipei, Taiwan.,School of Medicine, National Yang Ming Chiao Tung University, Taipei, Taiwan.,Institute of Clinical 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, National Yang Ming Chiao Tung University, Taipei, Taiwan.,Institute of Clinical 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
| | - Shuu-Jiun Wang
- Department of Neurology, Neurological Institute, Taipei Veterans General Hospital, Taipei, Taiwan.,School of Medicine, National Yang Ming Chiao Tung University, Taipei, Taiwan.,Institute of Clinical Medicine, National Yang Ming Chiao Tung University, Taipei, Taiwan.,Brain Research Center, National Yang Ming Chiao Tung University, Taipei, Taiwan
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8
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RCVS: by clinicians for clinicians-a narrative review. J Neurol 2023; 270:673-688. [PMID: 36305970 PMCID: PMC9615630 DOI: 10.1007/s00415-022-11425-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/20/2022] [Revised: 10/12/2022] [Accepted: 10/13/2022] [Indexed: 02/02/2023]
Abstract
BACKGROUND/OBJECTIVE Reversible cerebral vasoconstriction syndrome may be underdiagnosed. It can be accompanied by various complications, mainly intracerebral hemorrhage and ischemic stroke. The clinical presentation of this condition varies according to its localization. The aims of this review are to raise awareness of the disease, especially in the presence of corresponding risk factors; to connect its precipitating factors, pathophysiology, and complications; and to compare various differential diagnoses of vasoconstriction. METHODS A review of the literature in PubMed/MEDLINE and Google Scholar was conducted from May 1997 until May 2022. RESULTS Reversible cerebral vasoconstriction syndrome, which is a clinical-radiological syndrome, is mainly characterized by the occurrence of thunderclap headache and widespread vasoconstriction. The most common precipitating factors are the use of vasoactive substances and postpartum status. The pathophysiology is currently assumed to include two mechanisms: sympathetic overactivity and endothelial dysfunction. From these mechanisms, it is possible to derive potential complications as well as the most important differential diagnoses: posterior reversible encephalopathy syndrome, convexity subarachnoid hemorrhage, ischemic and hemorrhagic stroke, and primary angiitis of the central nervous system. CONCLUSION In general, the outcome of reversible cerebral vasoconstriction syndrome is very good. Vasospasm as well as thunderclap headache attacks can be fully reversible, and > 90% of patients are functionally independent at discharge.
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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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10
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Reversible cerebral vasoconstriction syndrome: review of neuroimaging findings. Radiol Med 2022; 127:981-990. [PMID: 35932443 PMCID: PMC9362037 DOI: 10.1007/s11547-022-01532-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/15/2022] [Accepted: 07/22/2022] [Indexed: 12/04/2022]
Abstract
Reversible cerebral vasoconstriction syndrome (RCVS) is a group of disorders characterized by segmental narrowing and dilatation of medium-to-large cerebral arteries, clinically presenting with recurrent episodes of sudden-onset thunderclap headaches, with or without focal neurological deficits. Cerebral vasoconstriction is typically reversible, with spontaneous resolution within 3 months. Although the syndrome has generally a benign course, patients with neurological deficits may experience worse outcome. The main imaging finding is segmental constriction of intracranial arteries, which can be associated with subarachnoid hemorrhage and/or ischemic foci. Other possible findings are intracranial hemorrhage, subdural bleeding and cerebral edema. The latter may have a pattern which can resemble that of posterior reversible encephalopathy syndrome, a condition that can overlap with RCVS. New imaging techniques, such as vessel wall imaging and arterial spin labeling, are proving useful in RCVS and are giving new insights into the pathophysiology of this condition. In this paper, we aim to review neuroimaging findings of RCVS.
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11
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Omran SS, Gutierrez J, Mohr JP, Elkind MS. Structural and Functional Characteristics of Cerebral Arteries as an Explanation for Clinical Syndromes Limited to the Brain. Cerebrovasc Dis 2022; 52:52-60. [PMID: 35675791 PMCID: PMC9729387 DOI: 10.1159/000524724] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/13/2022] [Accepted: 04/25/2022] [Indexed: 02/04/2023] Open
Abstract
Vascular disease affects many different arterial beds throughout the body. Yet the brain is susceptible to several vascular disorders that either are not found in other parts of the body or when found are much less likely to cause clinical syndromes in other organs. This specific vulnerability of the brain may be explained by structural and functional differences between the vessels of the brain and those of vessels in other parts of the body. In this review, we focus on how cerebrovascular anatomy and physiology may make the brain and its vessels more susceptible to unique vascular pathologies. To highlight these differences, we use our knowledge of five diseases and syndromes that most commonly manifest in the intracranial vasculature. For each, we identify characteristics of the intracranial arteries that make them susceptible to these diseases, while noting areas of uncertainty requiring further research.
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Affiliation(s)
| | - Jose Gutierrez
- Vagelos College of Physicians and Surgeons, New York, NY
| | - Jay P. Mohr
- Vagelos College of Physicians and Surgeons, New York, NY
| | - Mitchell S.V. Elkind
- Vagelos College of Physicians and Surgeons, New York, NY
- Department of Epidemiology, Mailman School of Public Health, Columbia University Medical Center, New York, NY
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12
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Kim WJ, Samarage HM, Zarrin D, Goel K, Chan C, Qi X, Wang A, Shivkumar K, Ardell J, Colby GP. Superior cervical ganglion stimulation results in potent cerebral vasoconstriction in swine. JOURNAL OF VASCULAR AND INTERVENTIONAL NEUROLOGY 2022; 13:35-41. [PMID: 36447624 PMCID: PMC9703949] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Subscribe] [Scholar Register] [Indexed: 06/16/2023]
Abstract
INTRODUCTION Sympathetic activity from the superior cervical ganglion (SCG) has been shown to cause cerebral hypoperfusion in swine, similar to that seen with clinical cerebral vasospasm. Although the mechanism of such perfusion deficit has been speculated to be from pathologic cerebral vasoconstriction, the extent of sympathetic contribution to vasoconstriction has not been wellestablished. OBJECTIVE We aimed to demonstrate that SCG stimulation in swine leads to significant cerebral vasoconstriction on digital subtraction angiography (DSA). Additionally, we aimed to show that inhibition of SCG can mitigate the effects of sympathetic-mediated cerebral vasoconstriction. METHODS Five SCGs were surgically identified in Yorkshire swine and were electrically stimulated to achieve sympathetic activation. DSA was performed to measure and compare changes in cerebral vessel diameter. Syngo iFlow was also used to quantify changes in contrast flow through the cerebral and neck vessels. RESULTS SCG stimulation resulted in 35-45% narrowing of the ipsilateral ascending pharyngeal, anterior middle cerebral and anterior cerebral arteries. SCG stimulation also decreased contrast flow through ipsilateral ascending pharyngeal, internal carotid and anterior cerebral arteries as seen on iFLow. These effects were prevented with prior SCG blockade. Minimal vessel caliber changes were seen in the posterior cerebral, posterior middle cerebral and internal carotid arteries with SCG stimulation. CONCLUSION SCG stimulation results in significant luminal narrowing and reduction in flow through various intracranial arteries in swine. The results of sympathetic hyperactivity from the SCG closely models cerebral vasoconstriction seen in human cerebral vasospasm. SCG inhibition is a potential promising therapeutic approach to treating cerebral vasospasm.
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Affiliation(s)
- Wi Jin Kim
- Department of Neurosurgery, University of California Los Angeles, Los Angeles, California, USA
| | - Hasitha Milan Samarage
- Department of Neurosurgery, University of California Los Angeles, Los Angeles, California, USA
| | - David Zarrin
- David Geffen School of Medicine, University of California Los Angeles, Los Angeles, California, USA
| | - Keshav Goel
- David Geffen School of Medicine, University of California Los Angeles, Los Angeles, California, USA
| | - Christopher Chan
- Cardiac Arrhythmia Center, Department of Medicine, University of California Los Angeles, Los Angeles, California, USA
| | - Xin Qi
- David Geffen School of Medicine, University of California Los Angeles, Los Angeles, California, USA
| | - Anthony Wang
- Department of Neurosurgery, University of California Los Angeles, Los Angeles, California, USA
| | - Kalyanam Shivkumar
- Cardiac Arrhythmia Center, Department of Medicine, University of California Los Angeles, Los Angeles, California, USA
| | - Jeffrey Ardell
- Cardiac Arrhythmia Center, Department of Medicine, University of California Los Angeles, Los Angeles, California, USA
| | - Geoffrey P. Colby
- Department of Neurosurgery, University of California Los Angeles, Los Angeles, California, USA
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13
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Wu CH, Lirng JF, Wu HM, Ling YH, Wang YF, Fuh JL, Lin CJ, Ling K, Wang SJ, Chen SP. Blood-Brain Barrier Permeability in Patients With Reversible Cerebral Vasoconstriction Syndrome Assessed With Dynamic Contrast-Enhanced MRI. Neurology 2021; 97:e1847-e1859. [PMID: 34504032 DOI: 10.1212/wnl.0000000000012776] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/14/2021] [Accepted: 08/23/2021] [Indexed: 12/13/2022] Open
Abstract
BACKGROUND AND OBJECTIVES Blood-brain barrier (BBB) disruption has been proposed to be important in the pathogenesis of reversible cerebral vasoconstriction syndrome (RCVS), but not all patients present an identifiable macroscopic BBB disruption; that is, visible contrast leakage on contrast-enhanced T2 fluid-attenuated inversion recovery imaging. This study aimed to evaluate microscopic BBB permeability and its dynamic change in patients with RCVS. METHODS This prospective cohort implemented 3T dynamic contrast-enhanced MRI. We measured microscopic BBB permeability by determining the whole-brain and white matter hyperintensity (WMH) Ktrans values and evaluated the correlation of whole-brain Ktrans permeability with clinical and vascular measures in transcranial color-coded sonography. RESULTS In total, 176 patients (363 scans) were analyzed and separated into acute (≦30 days) and remission (≧90 days) groups based on the onset-to-examination time. Whole-brain Ktrans values were similar between patients with and without macroscopic BBB disruption in either acute or remission stage. The whole-brain Ktrans was significantly decreased (p < 0.001) from acute to remission stages. The WMH Ktrans was significantly higher than mirror references and decreased from acute to remission stages (p < 0.001). Whole-brain Ktrans correlated with mean pulsatility index (r s = 0.5, p = 0.029), mean resistance index (r s = 0.662, p = 0.002), and distal-to-proximal ratio of resistance index (r s = 0.801, p < 0.001) of M1 segment of middle cerebral arteries at around 10-15 days after onset. The time-trend curve of whole-brain Ktrans depicted dynamic changes during disease course, similar to temporal trends of vasoconstrictions and WMH. DISCUSSION Patients with RCVS presented increased microscopic brain permeability during acute stage, even without discernible macroscopic BBB disruption. The dynamic changes in BBB permeability may be related to impaired cerebral microvascular compliance and WMH formation.
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Affiliation(s)
- Chia-Hung Wu
- From the Department of Radiology (C.-H.W., J.-F.L., H.-M.W., C.-J.L., K.L.), Department of Neurology, Neurological Institute (Y.-H.L., Y.-F.W., J.-L.F., S.-J.W., S.-P.C.), and Division of Translational Research, Department of Medical Research (S.-P.C.), Taipei Veterans General Hospital; and Institute of Clinical Medicine (C.-H.W., S.-P.C.), School of Medicine (C.-H.W., J.-F.L., H.-M.W., Y.-H.L., Y.-F.W., J.-L.F., C.-J.L., K.L., S.-J.W., S.-P.C.), and Brain Research Center (Y.-F.W., J.-L.F., S.-J.W., S.-P.C.), National Yang Ming Chiao Tung University, Taipei, Taiwan
| | - Jiing-Feng Lirng
- From the Department of Radiology (C.-H.W., J.-F.L., H.-M.W., C.-J.L., K.L.), Department of Neurology, Neurological Institute (Y.-H.L., Y.-F.W., J.-L.F., S.-J.W., S.-P.C.), and Division of Translational Research, Department of Medical Research (S.-P.C.), Taipei Veterans General Hospital; and Institute of Clinical Medicine (C.-H.W., S.-P.C.), School of Medicine (C.-H.W., J.-F.L., H.-M.W., Y.-H.L., Y.-F.W., J.-L.F., C.-J.L., K.L., S.-J.W., S.-P.C.), and Brain Research Center (Y.-F.W., J.-L.F., S.-J.W., S.-P.C.), National Yang Ming Chiao Tung University, Taipei, Taiwan
| | - Hsiu-Mei Wu
- From the Department of Radiology (C.-H.W., J.-F.L., H.-M.W., C.-J.L., K.L.), Department of Neurology, Neurological Institute (Y.-H.L., Y.-F.W., J.-L.F., S.-J.W., S.-P.C.), and Division of Translational Research, Department of Medical Research (S.-P.C.), Taipei Veterans General Hospital; and Institute of Clinical Medicine (C.-H.W., S.-P.C.), School of Medicine (C.-H.W., J.-F.L., H.-M.W., Y.-H.L., Y.-F.W., J.-L.F., C.-J.L., K.L., S.-J.W., S.-P.C.), and Brain Research Center (Y.-F.W., J.-L.F., S.-J.W., S.-P.C.), National Yang Ming Chiao Tung University, Taipei, Taiwan
| | - Yu-Hsiang Ling
- From the Department of Radiology (C.-H.W., J.-F.L., H.-M.W., C.-J.L., K.L.), Department of Neurology, Neurological Institute (Y.-H.L., Y.-F.W., J.-L.F., S.-J.W., S.-P.C.), and Division of Translational Research, Department of Medical Research (S.-P.C.), Taipei Veterans General Hospital; and Institute of Clinical Medicine (C.-H.W., S.-P.C.), School of Medicine (C.-H.W., J.-F.L., H.-M.W., Y.-H.L., Y.-F.W., J.-L.F., C.-J.L., K.L., S.-J.W., S.-P.C.), and Brain Research Center (Y.-F.W., J.-L.F., S.-J.W., S.-P.C.), National Yang Ming Chiao Tung University, Taipei, Taiwan
| | - Yen-Feng Wang
- From the Department of Radiology (C.-H.W., J.-F.L., H.-M.W., C.-J.L., K.L.), Department of Neurology, Neurological Institute (Y.-H.L., Y.-F.W., J.-L.F., S.-J.W., S.-P.C.), and Division of Translational Research, Department of Medical Research (S.-P.C.), Taipei Veterans General Hospital; and Institute of Clinical Medicine (C.-H.W., S.-P.C.), School of Medicine (C.-H.W., J.-F.L., H.-M.W., Y.-H.L., Y.-F.W., J.-L.F., C.-J.L., K.L., S.-J.W., S.-P.C.), and Brain Research Center (Y.-F.W., J.-L.F., S.-J.W., S.-P.C.), National Yang Ming Chiao Tung University, Taipei, Taiwan
| | - Jong-Ling Fuh
- From the Department of Radiology (C.-H.W., J.-F.L., H.-M.W., C.-J.L., K.L.), Department of Neurology, Neurological Institute (Y.-H.L., Y.-F.W., J.-L.F., S.-J.W., S.-P.C.), and Division of Translational Research, Department of Medical Research (S.-P.C.), Taipei Veterans General Hospital; and Institute of Clinical Medicine (C.-H.W., S.-P.C.), School of Medicine (C.-H.W., J.-F.L., H.-M.W., Y.-H.L., Y.-F.W., J.-L.F., C.-J.L., K.L., S.-J.W., S.-P.C.), and Brain Research Center (Y.-F.W., J.-L.F., S.-J.W., S.-P.C.), National Yang Ming Chiao Tung University, Taipei, Taiwan
| | - Chung-Jung Lin
- From the Department of Radiology (C.-H.W., J.-F.L., H.-M.W., C.-J.L., K.L.), Department of Neurology, Neurological Institute (Y.-H.L., Y.-F.W., J.-L.F., S.-J.W., S.-P.C.), and Division of Translational Research, Department of Medical Research (S.-P.C.), Taipei Veterans General Hospital; and Institute of Clinical Medicine (C.-H.W., S.-P.C.), School of Medicine (C.-H.W., J.-F.L., H.-M.W., Y.-H.L., Y.-F.W., J.-L.F., C.-J.L., K.L., S.-J.W., S.-P.C.), and Brain Research Center (Y.-F.W., J.-L.F., S.-J.W., S.-P.C.), National Yang Ming Chiao Tung University, Taipei, Taiwan
| | - Kan Ling
- From the Department of Radiology (C.-H.W., J.-F.L., H.-M.W., C.-J.L., K.L.), Department of Neurology, Neurological Institute (Y.-H.L., Y.-F.W., J.-L.F., S.-J.W., S.-P.C.), and Division of Translational Research, Department of Medical Research (S.-P.C.), Taipei Veterans General Hospital; and Institute of Clinical Medicine (C.-H.W., S.-P.C.), School of Medicine (C.-H.W., J.-F.L., H.-M.W., Y.-H.L., Y.-F.W., J.-L.F., C.-J.L., K.L., S.-J.W., S.-P.C.), and Brain Research Center (Y.-F.W., J.-L.F., S.-J.W., S.-P.C.), National Yang Ming Chiao Tung University, Taipei, Taiwan
| | - Shuu-Jiun Wang
- From the Department of Radiology (C.-H.W., J.-F.L., H.-M.W., C.-J.L., K.L.), Department of Neurology, Neurological Institute (Y.-H.L., Y.-F.W., J.-L.F., S.-J.W., S.-P.C.), and Division of Translational Research, Department of Medical Research (S.-P.C.), Taipei Veterans General Hospital; and Institute of Clinical Medicine (C.-H.W., S.-P.C.), School of Medicine (C.-H.W., J.-F.L., H.-M.W., Y.-H.L., Y.-F.W., J.-L.F., C.-J.L., K.L., S.-J.W., S.-P.C.), and Brain Research Center (Y.-F.W., J.-L.F., S.-J.W., S.-P.C.), National Yang Ming Chiao Tung University, Taipei, Taiwan
| | - Shih-Pin Chen
- From the Department of Radiology (C.-H.W., J.-F.L., H.-M.W., C.-J.L., K.L.), Department of Neurology, Neurological Institute (Y.-H.L., Y.-F.W., J.-L.F., S.-J.W., S.-P.C.), and Division of Translational Research, Department of Medical Research (S.-P.C.), Taipei Veterans General Hospital; and Institute of Clinical Medicine (C.-H.W., S.-P.C.), School of Medicine (C.-H.W., J.-F.L., H.-M.W., Y.-H.L., Y.-F.W., J.-L.F., C.-J.L., K.L., S.-J.W., S.-P.C.), and Brain Research Center (Y.-F.W., J.-L.F., S.-J.W., S.-P.C.), National Yang Ming Chiao Tung University, Taipei, Taiwan.
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14
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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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15
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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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16
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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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17
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Fatal reversible cerebral vasoconstriction syndrome: An unusual presentation of a rare disease. ACTA ACUST UNITED AC 2021; 41:225-233. [PMID: 34214263 PMCID: PMC8372843 DOI: 10.7705/biomedica.5774] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/10/2020] [Indexed: 11/21/2022]
Abstract
The reversible cerebral vasoconstriction syndrome is a variable, segmental, and multifocal constriction of brain arteries, usually with a benign course.
We describe the case of a 49-year-old woman who presented with headaches, visual symptoms, and seizures. Three days after admission, vasoconstriction areas were found in at least two vascular territories in two segments of the same arteries. The patient was admitted to the intensive care unit where her blood pressure was monitored and she received medical treatment. Surprisingly, the patient presented an unpredicted evolution in developing malignant cerebral edema on the seventh day after admission. She then suffered brain death and was taken to organ donation. A guided nervous system necropsy was later performed. The pathology discarded vasculitis and exhibited hemorrhage areas in the cerebral convexity.
Herein, we discuss the most relevant aspects of cases with fulminant evolution reported in the literature. The reversible cerebral vasoconstriction syndrome is usually associated with fatal outcomes when patients exhibit focalization, their first neuroimaging typically shows disturbances, and a rapid clinical deterioration occurs. It is crucial to identify factors linked to poor prognosis and set intervention strategies and early prevention.
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18
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Davis J, Ozcan MS, Kamdar JK, Shoaib M. Stellate ganglion block used to treat reversible cerebral vasoconstriction syndrome. Reg Anesth Pain Med 2021; 46:732-734. [PMID: 33875578 DOI: 10.1136/rapm-2021-102675] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/04/2021] [Revised: 03/31/2021] [Accepted: 04/02/2021] [Indexed: 11/03/2022]
Abstract
BACKGROUND We present a case report of a patient who developed severe reversible cerebral vasoconstriction syndrome, which was worsening despite typical interventional and supportive care. We administered a stellate ganglion block (SGB) and monitored the vasospasm with transcranial Doppler measurements. CASE REPORT A 25-year-old woman was admitted with recurrent headaches and neurological symptoms, which angiography showed to be caused by diffuse, multifocal, segmental narrowing of the cerebral arteries leading to severe ischemia in multiple regions. Typical treatment was initiated with arterial verapamil followed by supportive critical care, including nimodipine, intravenous fluids, permissive hypertension, and analgesia. Vasospasm was monitored daily via transcranial Doppler ultrasound (TCD). After symptoms and monitoring suggested worsening vasospasm, an SGB was administered under ultrasound guidance. Block success was confirmed via pupillometry, and repeat TCD showed improved flow through the cerebral vasculature. Improvement in vascular flow was accompanied by a gradual reduction in acute neurological symptoms, with the patient reporting no headaches the following morning. CONCLUSIONS For patients with reversible cerebral vasoconstriction syndrome who develop severe signs or symptoms despite typical treatment, sympathetic blockade may be a possible rescue therapy. This may extend to other causes of severe vasospasm as well, and further study is needed to determine if the SGB should be included in routine or rescue therapy.
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Affiliation(s)
- Jeffrey Davis
- Anesthesiology, The University of Oklahoma Health Sciences Center, Oklahoma City, Oklahoma, USA
| | - Mehmet S Ozcan
- Anesthesiology, Yale School of Medicine, New Haven, Connecticut, USA
| | - Jay K Kamdar
- Anesthesiology, The University of Oklahoma Health Sciences Center, Oklahoma City, Oklahoma, USA
| | - Maria Shoaib
- Neurology, The University of Oklahoma Health Sciences Center, Oklahoma City, Oklahoma, USA
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Ling YH, Wang YF, Lirng JF, Fuh JL, Wang SJ, Chen SP. Post-reversible cerebral vasoconstriction syndrome headache. J Headache Pain 2021; 22:14. [PMID: 33765906 PMCID: PMC7992969 DOI: 10.1186/s10194-021-01223-9] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/06/2021] [Accepted: 03/12/2021] [Indexed: 12/03/2022] Open
Abstract
Background Chronic headache may persist after the remission of reversible cerebral vasoconstriction syndrome (RCVS) in some patients. We aimed to investigate the prevalence, characteristics, risk factors, and the impact of post-RCVS headache. Methods We prospectively recruited patients with RCVS and collected their baseline demographics, including psychological distress measured by Hospital Anxiety and Depression scale. We evaluated whether the patients developed post-RCVS headache 3 months after RCVS onset. The manifestations of post-RCVS headache and headache-related disability measured by Migraine Disability Assessment (MIDAS) scores were recorded. Results From 2017 to 2019, 134 patients with RCVS were recruited, of whom, 123 finished follow-up interviews (response rate 91.8%). Sixty (48.8%) patients had post-RCVS headache. Migrainous features were common in post-RCVS headache. Post-RCVS headache caused moderate-to-severe headache-related disability (MIDAS score > 10) in seven (11.7%) patients. Higher anxiety level (odds ratio 1.21, p = 0.009) and a history of migraine (odds ratio 2.59, p = 0.049) are associated with post-RCVS headache. Survival analysis estimated that 50% post-RCVS headache would recover in 389 days (95% confidence interval: 198.5–579) after disease onset. Conclusions Post-RCVS headache is common, affecting half of patients and being disabling in one-tenth. Higher anxiety level and migraine history are risk factors. Half of the patients with post-RCVS headache would recover in about a year.
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Affiliation(s)
- Yu-Hsiang Ling
- Department of Neurology, Neurological Institute, Taipei Veterans General Hospital, Taipei, Taiwan.,School of Medicine, National Yang Ming Chiao Tung University, Taipei, Taiwan
| | - Yen-Feng Wang
- Department of Neurology, Neurological Institute, Taipei Veterans General Hospital, Taipei, Taiwan.,School of Medicine, National Yang Ming Chiao Tung University, Taipei, Taiwan
| | - Jiing-Feng Lirng
- School of Medicine, National Yang Ming Chiao Tung University, Taipei, Taiwan.,Department of Radiology, Taipei Veterans General Hospital, Taipei, Taiwan
| | - Jong-Ling Fuh
- Department of Neurology, Neurological Institute, Taipei Veterans General Hospital, Taipei, Taiwan.,School of Medicine, National Yang Ming Chiao Tung University, Taipei, Taiwan.,Brain Research Center, National Yang Ming Chiao Tung University, Taipei, Taiwan
| | - Shuu-Jiun Wang
- Department of Neurology, Neurological Institute, Taipei Veterans General Hospital, Taipei, Taiwan.,School of Medicine, National Yang Ming Chiao Tung University, Taipei, Taiwan.,Brain Research Center, 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, 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, National Yang Ming Chiao Tung University, Taipei, Taiwan.
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20
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Chen SP, Chang YA, Chou CH, Juan CC, Lee HC, Chen LK, Wu PC, Wang YF, Fuh JL, Lirng JF, Ducros A, Huang HD, Wang SJ. Circulating microRNAs Associated With Reversible Cerebral Vasoconstriction Syndrome. Ann Neurol 2020; 89:459-473. [PMID: 33314303 DOI: 10.1002/ana.25965] [Citation(s) in RCA: 20] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/20/2020] [Revised: 11/17/2020] [Accepted: 11/18/2020] [Indexed: 12/15/2022]
Abstract
OBJECTIVE The purpose of this study was to investigate the significance of circulating micro RNAs (miRNAs) in the pathogenesis of reversible cerebral vasoconstriction syndrome (RCVS). METHODS We prospectively recruited 3 independent cohorts of patients with RCVS and age-matched and sex-matched controls in a single medical center. Next-generation small RNA sequencing followed by quantitative polymerase chain reaction (PCR) was used to identify and validate differentially expressed miRNAs, which was cross-validated in migraine patients in ictal stage or interictal stage. Computational analysis was used to predict the target genes of miRNAs, followed by in vitro functional analysis. RESULTS We identified a panel of miRNAs including miR-130a-3p, miR-130b-3p, let-7a-5p, let-7b-5p, and let-7f-5p that well differentiated patients with RCVS from controls (area under the receiver operating characteristics curve [AUC] was 0.906, 0.890, and 0.867 in the 3 cohorts, respectively). The abundance of let-7a-5p, let-7b-5p, and let-7f-5p, but not miR-130a-3p nor miR-130b-3p, was significantly higher in patients with ictal migraine compared with that of controls and patients with interictal migraine. Target prediction and pathway enrichment analysis suggested that the transforming growth factor-β signaling pathway and endothelin-1 responsible for vasomotor control might link these miRNAs to RCVS pathogenesis, which was confirmed in vitro by transfecting miRNAs mimics or incubating the patients' cerebrospinal fluid (CSF) in 3 different vascular endothelial cells. Moreover, miR-130a-3p was associated with imaging-proven disruption of the blood-brain barrier (BBB) in patients with RCVS and its overexpression led to reduced transendothelial electrical resistance (ie, increased permeability) in in vitro human BBB model. INTERPRETATION We identified the circulating miRNA signatures associated with RCVS, which may be functionally linked to its headache, BBB integrity, and vasomotor function. ANN NEUROL 2021;89:459-473.
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Affiliation(s)
- Shih-Pin Chen
- Department of Neurology, Neurological Institute, Taipei Veterans General Hospital, Taipei, Taiwan.,Division of Translational Research, Department of Medical Research, Taipei Veterans General Hospital, Taipei, Taiwan.,Institute of Clinical Medicine, School of Medicine, National Yang-Ming University, Taipei, Taiwan.,Brain Research Center, National Yang-Ming University, Taipei, Taiwan.,Faculty of Medicine, School of Medicine, National Yang-Ming University, Taipei, Taiwan
| | - Yi-An Chang
- Department of Biological Science and Technology, National Chiao Tung University, HsinChu, Taiwan
| | - Chih-Hung Chou
- Department of Biological Science and Technology, National Chiao Tung University, HsinChu, Taiwan.,Center for Intelligent Drug Systems and Smart Bio-devices (IDS2B), National Chiao Tung University, HsinChu, Taiwan
| | - Chi-Chang Juan
- Institute of Physiology, School of Medicine, National Yang-Ming University, Taipei, Taiwan
| | - Hsin-Chen Lee
- Department and Institute of Pharmacology, School of Medicine, National Yang-Ming University, Taipei, Taiwan
| | - Luen-Kui Chen
- Institute of Physiology, School of Medicine, National Yang-Ming University, Taipei, Taiwan
| | - Pei-Chun Wu
- Brain Research Center, National Yang-Ming University, Taipei, Taiwan
| | - Yen-Feng Wang
- Department of Neurology, Neurological Institute, Taipei Veterans General Hospital, Taipei, Taiwan.,Brain Research Center, National Yang-Ming University, Taipei, Taiwan.,Faculty of Medicine, School of Medicine, National Yang-Ming University, Taipei, Taiwan
| | - Jong-Ling Fuh
- Department of Neurology, Neurological Institute, Taipei Veterans General Hospital, Taipei, Taiwan.,Brain Research Center, National Yang-Ming University, Taipei, Taiwan.,Faculty of Medicine, School of Medicine, National Yang-Ming University, Taipei, Taiwan
| | - Jiing-Feng Lirng
- Faculty of Medicine, School of Medicine, National Yang-Ming University, Taipei, Taiwan.,Department of Radiology, Neurological Institute, Taipei Veterans General Hospital, Taipei, Taiwan
| | - Anne Ducros
- Neurology Department, Montpellier University Hospital, Montpellier, France.,Charles Coulomb Laboratory (L2C), UMR5221CNRS, Montpellier University, Montpellier, France
| | - Hsien-Da Huang
- Department of Biological Science and Technology, National Chiao Tung University, HsinChu, Taiwan.,School of Life and Health Sciences, The Chinese University of Hong Kong, Shenzhen, China.,Warshel Institute for Computational Biology, The Chinese University of Hong Kong, Shenzhen, China
| | - Shuu-Jiun Wang
- Department of Neurology, Neurological Institute, Taipei Veterans General Hospital, Taipei, Taiwan.,Brain Research Center, National Yang-Ming University, Taipei, Taiwan.,Faculty of Medicine, School of Medicine, National Yang-Ming University, Taipei, Taiwan
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21
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Ling YH, Chen SP. Narrative Review: Headaches After Reversible Cerebral Vasoconstriction Syndrome. Curr Pain Headache Rep 2020; 24:74. [PMID: 33161482 DOI: 10.1007/s11916-020-00908-1] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/28/2020] [Indexed: 11/29/2022]
Abstract
PURPOSE OF REVIEW Reversible cerebral vasoconstriction syndrome (RCVS) is a disorder with distinct features: recurrent thunderclap headaches with reversible vasoconstriction of intracranial arteries. Substantial studies regarding outcomes after RCVS were conducted, showing favorable functional outcomes in most patients despite the potentially life-threatening complications of RCVS, including ischemic stroke, intracranial hemorrhage, or convexity subarachnoid hemorrhage. However, patients may report headaches after the resolution of RCVS while relative studies were scarce. RECENT FINDINGS Two prospective studies from different cohorts consistently revealed that RCVS recurred in at least 5% of patients. Patients with prior migraine history and patients whose thunderclap headaches are elicited by sexual activity or exertion are at higher risk for RCVS recurrence. On the other hand, several retrospective studies and case reports reported that chronic headaches are common in RCVS patients after the resolution of acute bouts. The chronic headaches after RCVS are sometimes disabling in certain patients. Headaches after RCVS are not uncommon but usually overseen. Medical attention and examinations are warranted in patient with RCVS who reported recurrence of thunderclap headaches or chronic headaches after RCVS.
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Affiliation(s)
- Yu-Hsiang Ling
- Department of Neurology, Neurological Institute, Taipei Veterans General Hospital, Taipei, Taiwan.,Faculty of Medicine, School of Medicine, National Yang-Ming University, Taipei, Taiwan
| | - Shih-Pin Chen
- Department of Neurology, Neurological Institute, Taipei Veterans General Hospital, Taipei, Taiwan. .,Faculty of Medicine, School of Medicine, National Yang-Ming University, Taipei, Taiwan. .,Division of Translational Research, Department of Medical Research, Taipei Veterans General Hospital, Taipei, Taiwan. .,Institute of Clinical Medicine, National Yang-Ming University, Taipei, Taiwan. .,Brain Research Center, National Yang-Ming University, Taipei, Taiwan.
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22
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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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23
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Hsu WH, Wang SJ, Chao YM, Chen CJ, Wang YF, Fuh JL, Chen SP, Lin YL. Urine metabolomics signatures in reversible cerebral vasoconstriction syndrome. Cephalalgia 2020; 40:735-747. [DOI: 10.1177/0333102419897621] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Background The pathophysiology of reversible cerebral vasoconstriction syndrome is unclear. An unbiased systems-based approach might help to illustrate the metabolite profiling and underlying pathophysiology. Methods Urine samples were collected from reversible cerebral vasoconstriction syndrome patients and matched controls recruited in Taipei Veterans General Hospital. 1H-Nuclear magnetic resonance was used to initially explore the metabolic profile, and liquid chromatography tandem mass spectrometry was then used to identify metabolic alterations in reversible cerebral vasoconstriction syndrome. Untargeted metabolite screening was randomly performed on 10 reversible cerebral vasoconstriction syndrome patients and 10 control subjects in the discovery phase. The selected untargeted metabolites were further validated on 47 reversible cerebral vasoconstriction syndrome patients during their ictal stage (with 40 of them having remission samples) and 47 controls in the replication phase. Results and conclusion Six metabolites-hippurate, citrate, 1,3,7-trimethyluric acid, ascorbic acid, D-glucurono-6,3-lactone, and D- threo-isocitric acid-with t-test derived p-value < 0.05 and VIP score >1, were identified as potential urine signatures that can well distinguish reversible cerebral vasoconstriction syndrome subjects at ictal stage from controls. Among them, citrate, hippurate, ascorbic acid, and D-glucurono-6,3-lactone were significantly lower, and 1,3,7-trimethyluric acid and D- threo-isocitric acid were higher in reversible cerebral vasoconstriction syndrome patients. Of these, four selected metabolites, citrate, D-glucurono-6,3-lactone, ascorbic acid, and 1,3,7-trimethyluric acid, returned to normal levels in remission. These metabolites are related to pathways associated with free radical scavenging, with the hub molecules being associated with endothelial dysfunction or sympathetic overactivity. Whether these metabolites and their implicated networks play a role in the pathogenesis of reversible cerebral vasoconstriction syndrome remains to be confirmed.
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Affiliation(s)
- Wei-Hsiang Hsu
- Department of Chinese Pharmaceutical Sciences and Chinese Medicine Resources, China Medical University, Taichung
| | - Shuu-Jiun Wang
- Department of Neurology, Neurological Institute, Taipei Veterans General Hospital, Taipei
- Brain Research Center, National Yang-Ming University, Taipei
- Faculty of Medicine, School of Medicine, National Yang-Ming University, Taipei
- Institute of Brain Science, National Yang-Ming University, Taipei
| | - Yen-Ming Chao
- Department of Chinese Pharmaceutical Sciences and Chinese Medicine Resources, China Medical University, Taichung
| | - Chao-Jung Chen
- Graduate Institute of Integrated Medicine, China Medical University, Taichung
| | - Yen-Feng Wang
- Department of Neurology, Neurological Institute, Taipei Veterans General Hospital, Taipei
- Brain Research Center, National Yang-Ming University, Taipei
- Faculty of Medicine, School of Medicine, National Yang-Ming University, Taipei
| | - Jong-Ling Fuh
- Department of Neurology, Neurological Institute, Taipei Veterans General Hospital, Taipei
- Brain Research Center, National Yang-Ming University, Taipei
- Faculty of Medicine, School of Medicine, National Yang-Ming University, Taipei
| | - Shih-Pin Chen
- Department of Neurology, Neurological Institute, Taipei Veterans General Hospital, Taipei
- Brain Research Center, National Yang-Ming University, Taipei
- Faculty of Medicine, School of Medicine, National Yang-Ming University, Taipei
- Division of Translational Research, Department of Medical Research, Taipei Veterans General Hospital, Taipei
- Institute of Clinical Medicine, National Yang-Ming University, Taipei
| | - Yun-Lian Lin
- Department of Chinese Pharmaceutical Sciences and Chinese Medicine Resources, China Medical University, Taichung
- Department of Pharmacy, National Taiwan University, Taipei
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24
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Ospel JM, Wright CH, Jung R, Vidal LLM, Manjila S, Singh G, Heck DV, Ray A, Blackham KA. Intra-Arterial Verapamil Treatment in Oral Therapy-Refractory Reversible Cerebral Vasoconstriction Syndrome. AJNR Am J Neuroradiol 2019; 41:293-299. [PMID: 31879333 DOI: 10.3174/ajnr.a6378] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/31/2018] [Accepted: 11/16/2019] [Indexed: 12/31/2022]
Abstract
Reversible vasoconstriction syndrome is a complex of clinical symptoms and angiographic findings, which, while having a mostly benign clinical course, has clinical and imaging overlap with more serious disorders such as vasculitis and aneurysmal SAH and itself includes a minority of patients with fulminant vasoconstriction resulting in severe intracranial complications. Endovascular options for patients with refractory reversible cerebral vasoconstriction syndrome include intra-arterial vasodilator infusion similar to therapy for patients with vasospasm after SAH. To date, only case reports and 1 small series have discussed the utility of intra-arterial vasodilators for the treatment of reversible cerebral vasoconstriction syndrome. We report an additional series of 11 medically refractory cases of presumed or proved reversible cerebral vasoconstriction syndrome successfully treated with intra-arterial verapamil infusion. Furthermore, we propose that the reversal of vasoconstriction, as seen on angiography, could fulfill a diagnostic criterion.
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Affiliation(s)
- J M Ospel
- From the Department of Radiology (J.M.O., K.A.B.), Section of Neuroradiology and Interventional Neuroradiology, Basel University Hospital, University of Basel, Basel, Switzerland
| | - C H Wright
- Departments of Neurological Surgery (C.H.W.)
| | - R Jung
- Department of Neurology (R.J.), The Sandra and Malcolm Berman Brain & Spine Institute, Sinai Hospital of Baltimore, LIfebridge Health, Baltimore, Maryland
| | - L L M Vidal
- Department of Diagnostic Radiology and Nuclear Medicine (L.L.M.V.), University of Maryland Medical Center, Baltimore, Maryland
| | - S Manjila
- Department of Neurosurgery and Neurosciences (S.M.), McLaren Bay Region Hospital, Bay City, Michigan
| | - G Singh
- Department of Radiology (G.S.), Section of Neuroradiology, Newark Beth Israel Medical Center, Newark, New Jersey
| | - D V Heck
- Forsyth Radiological Associates (D.V.H.), Winston-Salem, North Carolina
| | - A Ray
- Neurosurgery (A.R.), University Hospitals of Cleveland Case Medical Center, Cleveland, Ohio
| | - K A Blackham
- From the Department of Radiology (J.M.O., K.A.B.), Section of Neuroradiology and Interventional Neuroradiology, Basel University Hospital, University of Basel, Basel, Switzerland
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25
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Valencia-Mendoza M, Ramírez-Rodríguez N, Vargas-Avila N, Peña-Ortiz A, Corzo-Villamizar M, Serna-Ramírez L, Góez-Mogollón L, Martínez-Rubio C, Bayona-Ortiz HF. Fatal reversible cerebral vasoconstriction syndrome: A systematic review of case series and case reports. J Clin Neurosci 2019; 70:183-188. [PMID: 31416730 DOI: 10.1016/j.jocn.2019.08.014] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/16/2019] [Accepted: 08/04/2019] [Indexed: 12/29/2022]
Abstract
OBJECTIVE To describe patient characteristics, radiological findings and the clinical course of adults with fatal reversible cerebral vasoconstriction syndrome (RCVS). METHODS A systematic literature search from January 1, 2000, until December 31, 2018, was performed using PubMed, EMBASE, Scopus, Cochrane reviews, LILACS and Scielo. Studies reporting RCVS in adult patients with fatal outcomes were included. RESULTS 430 studies were initially identified, 179 full-text articles were reviewed, and 9 publications describing 12 subjects were included. The vast majority of the reports were from the U.S. Most of the female cases occurred during postpartum. All patients had a headache on initial presentation, although only 42% had thunderclap headache. A CT scan was performed on 67% of the patients. Imaging results were diverse, with a tendency toward cerebral hemorrhage followed by mixed cases. The main course of treatment included steroids (58% of the patients), with only 42% receiving nimodipine. The time to death ranged from 4 to 14 days, with a median of 9.2 days (SD ± 3.2). CONCLUSION We found that the majority of fatal cases reported in the literature are most likely related to postpartum angiopathy. We established a tendency in the onset of brain hemorrhage and the combination of infarction and brain hemorrhage. We described various markers for poor prognosis, including focal signs, the presence of hemorrhage and infarct in the first diagnostic image obtained and the need for invasive interventions. The majority of fatal cases in our report occurred in women, with over half of those cases during the puerperium period.
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Affiliation(s)
| | | | | | | | | | | | | | - Carlos Martínez-Rubio
- Department of Neurology, Hospital Universitario Fundación Santa Fe, Bogotá, Colombia; School of Medicine, Universidad de los Andes, Bogotá, Colombia; School of Medicine, Universidad El Bosque, Bogotá, Colombia
| | - Hernán F Bayona-Ortiz
- Department of Neurology, Hospital Universitario Fundación Santa Fe, Bogotá, Colombia; School of Medicine, Universidad de los Andes, Bogotá, Colombia; School of Medicine, Universidad El Bosque, Bogotá, Colombia.
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26
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Shih YC, Chen SP, Fuh JL, Wang YF, Wang SJ. Influence of Climate on the Incidence of RCVS - A Retrospective Study From Taiwan. Headache 2019; 59:567-575. [PMID: 30866069 DOI: 10.1111/head.13504] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/30/2019] [Indexed: 12/27/2022]
Abstract
BACKGROUND Cold weather is reportedly a precipitator of reversible cerebral vasoconstriction syndrome (RCVS) in a few cases. We systematically investigated whether meteorological factors correlate with the occurrence of RCVS. METHODS We conducted a retrospective analysis of a cohort of patients diagnosed with RCVS or probable RCVS, based on International Classification of Headache Disorders, third edition (ICHD-3) criteria, in a hospital-based headache center from March 2005 to February 2014. Monthly averages of local weather data measured in Taipei were obtained from the Central Weather Bureau in Taiwan. Primary weather variables were compared with the number of monthly new-onset cases of RCVS. RESULTS We recruited 226 patients with established RCVS and 72 patients with probable RCVS during a 108-month study period. Incidence of RCVS was higher in winter than summer months (3.3 persons/month [SD: 2.0] vs 2.1 persons/month [SD: 1.5], P = .013). The monthly incidence of RCVS correlated negatively with mean daily temperature (r = -0.231, P = .016) and average precipitation (r = -0.269, P = .005), but positively with barometric pressure (r = 0.274, P = .004). These 3 correlated meteorological factors together explained about 10% of the variance in RCVS monthly incidence (R2 = 0.095, P = .015). CONCLUSION RCVS was found to be more common in winter months and to be associated with weather variables in Taiwan. Further studies are needed to explore the underlying mechanisms of these associations.
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Affiliation(s)
- Yen-Cheng Shih
- Faculty of Medicine, National Yang-Ming University School of Medicine, Taipei, Taiwan.,Department of Neurology, Neurological Institute, Taipei Veterans General Hospital, Taipei, Taiwan
| | - Shih-Pin Chen
- Faculty of Medicine, National Yang-Ming University School of Medicine, Taipei, Taiwan.,Department of Neurology, Neurological Institute, Taipei Veterans General Hospital, Taipei, Taiwan.,Institute of Clinical Medicine, National Yang-Ming University, Taipei, Taiwan.,Division of Translational Research, Department of Medical Research, Taipei Veterans General Hospital, Taipei, Taiwan.,Brain Research Center, National Yang-Ming University, Taipei, Taiwan
| | - Jong-Ling Fuh
- Faculty of Medicine, National Yang-Ming University School of Medicine, Taipei, Taiwan.,Department of Neurology, Neurological Institute, Taipei Veterans General Hospital, Taipei, Taiwan.,Brain Research Center, National Yang-Ming University, Taipei, Taiwan
| | - Yen-Feng Wang
- Faculty of Medicine, National Yang-Ming University School of Medicine, Taipei, Taiwan.,Department of Neurology, Neurological Institute, Taipei Veterans General Hospital, Taipei, Taiwan.,Brain Research Center, National Yang-Ming University, Taipei, Taiwan
| | - Shuu-Jiun Wang
- Faculty of Medicine, National Yang-Ming University School of Medicine, Taipei, Taiwan.,Department of Neurology, Neurological Institute, Taipei Veterans General Hospital, Taipei, Taiwan.,Brain Research Center, National Yang-Ming University, Taipei, Taiwan
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27
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Affiliation(s)
- Chih-Wen Yang
- Department of Neurology, National Yang-Ming University Hospital, Ilan, Taiwan
- Faculty of Medicine, National Yang-Ming University School of Medicine, Taipei, Taiwan
| | - Jong-Ling Fuh
- Faculty of Medicine, National Yang-Ming University School of Medicine, Taipei, Taiwan
- Department of Neurology, Neurological Institute, Taipei Veterans General Hospital, Taipei, Taiwan
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28
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Choi HA, Lee MJ, Choi H, Chung CS. Characteristics and demographics of reversible cerebral vasoconstriction syndrome: A large prospective series of Korean patients. Cephalalgia 2017; 38:765-775. [DOI: 10.1177/0333102417715223] [Citation(s) in RCA: 35] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022]
Abstract
Objectives To report demographics and characteristics of reversible cerebral vasoconstriction syndrome (RCVS) in the Korean cohort. Methods We prospectively recruited patients with definite (imaging-proven) RCVS and probable (imaging-negative) RCVS who visited Samsung Medical Center between June 2012 and September 2016. Clinical manifestations, neuroimaging, treatment, and clinical outcomes were evaluated in all patients. Characteristics of RCVS without typical causes (“idiopathic RCVS”) were compared with those of RCVS with identifiable causes (“secondary RCVS”). International Classification of Headache Disorders (ICHD)-3 beta criteria for 6.7.3 RCVS and 6.7.3.1 probable RCVS were tested. Results A total of 138 patients (104 definite and 34 probable RCVS) were included in this study. Patients with definite RCVS were predominantly female (85.6%) and middle-aged (mean, 50.7 [range, 23–82] years). Probable RCVS was associated with less female predominance (70.6%, p = 0.049), more typical manifestations ( p < 0.001), and none of neurological complications. One-hundred and one (97.1%) patients with definite RCVS had headache, but the typical “recurrent and/or triggered” thunderclap headache was reported in only 83 (82.2%). In most patients with definite RCVS (84.6%), RCVS was idiopathic, while only 16 (15.4%) had secondary causes. Compared to those with secondary RCVS, patients with idiopathic RCVS were older (52.8 ± 11.42 vs. 39.1 ± 9.55 years, p < 0.001). Patients with secondary RCVS had more complications than those with idiopathic RCVS (40.5% vs. 12.5%, p = 0.018). Among idiopathic RCVS patients, 33 (37.5%) reported a preceding event or a change in lifestyle, environment, health, or medication within one month before onset. Conclusion In our cohort, RCVS was benign and idiopathic in most patients, and occurred frequently in middle-aged women. Manifestations of RCVS were more diverse than previously recognized, and forms without any headache existed. Different genetic, social, and environmental factors should be taken into account to unveil the spectrum and pathophysiology of RCVS.
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Affiliation(s)
- Hyun Ah Choi
- Department of Neurology, Neuroscience Center, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Mi Ji Lee
- Department of Neurology, Neuroscience Center, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Hanna Choi
- Department of Neurology, Eulji University Hospital, Eulji University School of Medicine, Daejeon, Korea
| | - Chin-Sang Chung
- Department of Neurology, Neuroscience Center, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
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29
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Lee MJ, Cha J, Choi HA, Woo SY, Kim S, Wang SJ, Chung CS. Blood-brain barrier breakdown in reversible cerebral vasoconstriction syndrome: Implications for pathophysiology and diagnosis. Ann Neurol 2017; 81:454-466. [DOI: 10.1002/ana.24891] [Citation(s) in RCA: 70] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/03/2016] [Revised: 01/30/2017] [Accepted: 02/08/2017] [Indexed: 12/28/2022]
Affiliation(s)
- Mi Ji Lee
- Department of Neurology, Neuroscience Center, Samsung Medical Center; Sungkyunkwan University School of Medicine; Seoul Korea
| | - Jihoon Cha
- Department of Radiology, Imaging Center, Heart Stroke Vascular Institute, Samsung Medical Center; Sungkyunkwan University School of Medicine; Seoul Korea
| | - Hyun Ah Choi
- Department of Neurology, Neuroscience Center, Samsung Medical Center; Sungkyunkwan University School of Medicine; Seoul Korea
| | - Sook-Young Woo
- Biostatistics Team, Samsung Biomedical Research Institute; Seoul Korea
| | - Seonwoo Kim
- Biostatistics Team, Samsung Biomedical Research Institute; Seoul Korea
| | - Shuu-Jiun Wang
- Neurological Institute, Taipei Veterans General Hospital; Taipei Taiwan
- Faculty of Medicine; National Yang-Ming University School of Medicine; Taipei Taiwan
| | - Chin-Sang Chung
- Department of Neurology, Neuroscience Center, Samsung Medical Center; Sungkyunkwan University School of Medicine; Seoul Korea
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30
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Cerebral endothelial dysfunction in reversible cerebral vasoconstriction syndrome: a case-control study. J Headache Pain 2017; 18:29. [PMID: 28229321 PMCID: PMC5321640 DOI: 10.1186/s10194-017-0738-x] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/13/2016] [Accepted: 02/15/2017] [Indexed: 01/03/2023] Open
Abstract
Background The aim of this study is to investigate cerebral endothelial dysfunction in patients with reversible cerebral vasoconstriction syndrome (RCVS). Methods We prospectively recruited patients with RCVS, age-matched controls with episodic migraine, and age-matched healthy controls at Samsung Medical Center from Apr 2015 to Jul 2016. All participants underwent transcranial Doppler evaluation, with a breath-holding maneuver, for the evaluation of bilateral middle cerebral arteries (MCAs), posterior cerebral arteries (PCAs), and the basilar artery (BA). The breath-holding index (BHI) was used to measure cerebral endothelium-dependent vasodilation. Follow-up BHIs were recorded in selected patients with RCVS after 3 months. Results A total of 84 subjects were recruited for this study (n = 28 in each group of RCVS, episodic migraine, and healthy control; mean age, 49.8 years). The RCVS group showed lower BHIs in all basal arteries, in comparison to healthy controls (p < 0.001, 0.009 for bilateral MCAs, p < 0.001 and 0.028 for bilateral PCAs, and p = 0.060 for the BA). Compared to migraineurs, RCVS patients had lower BHIs only in the anterior circulation (p = 0.002 and 0.038 for bilateral MCAs; p = 0.069 and 0.247 for bilateral PCAs; p = 0.120 for the BA). Of the 10 patients who had follow-up BHIs at 3 months, 7 showed complete normalization, while three did not. Conclusions Cerebral endothelial function is impaired in a widespread distribution in RCVS. Its role in the pathogenesis and clinical outcome of RCVS should be determined in further studies. Electronic supplementary material The online version of this article (doi:10.1186/s10194-017-0738-x) contains supplementary material, which is available to authorized users.
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31
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Chen SP, Wang YF, Huang PH, Chi CW, Fuh JL, Wang SJ. Reduced circulating endothelial progenitor cells in reversible cerebral vasoconstriction syndrome. J Headache Pain 2014; 15:82. [PMID: 25466718 PMCID: PMC4266547 DOI: 10.1186/1129-2377-15-82] [Citation(s) in RCA: 27] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/28/2014] [Accepted: 11/20/2014] [Indexed: 02/02/2023] Open
Abstract
BACKGROUND The pathophysiology of reversible cerebral vasoconstriction syndrome (RCVS) remains elusive. Endothelial dysfunction might play a role, but direct evidence is lacking. This study aimed to explore whether patients with RCVS have a reduced level of circulating circulating endothelial progenitor cells (EPCs) to repair the dysfunctional endothelial vasomotor control. METHODS We prospectively recruited 24 patients with RCVS within one month of disease onset and 24 healthy age- and sex-matched controls. Flow cytometry was used to quantify the numbers of circulating EPCs, defined as KDR+CD133+, CD34+CD133+, and CD34+KDR+ double-positive mononuclear cells. The Lindegaard index, an index of vasoconstriction, was calculated by measuring the mean flow velocity of middle cerebral arteries and distal extracranial internal carotid arteries via color-coded sonography on the same day as blood drawing. A Lindegaard index of 2 was chosen as the cutoff value for significant vasoconstriction of middle cerebral arteries based on our previous study. RESULTS Patients with RCVS had a reduced number of CD34+KDR+ cells (0.009 ± 0.006% vs. 0.014 ± 0.010%, p = 0.031) but not KDR+CD133+ cells or CD34+CD133+ EPCs, in comparison with controls. The number of CD34+KDR+ cells was inversely correlated with the Lindegaard index (rs = -0.418, p = 0.047). Of note, compared to controls, patients with a Lindegaard index > 2 (n = 13) had a reduced number of CD34+KDR+ cells (0.007 ± 0.005% vs. 0.014 ± 0.010%, p = 0.010), but those with a Lindegaard index ≤ 2 did not. CONCLUSIONS Patients with RCVS had reduced circulating CD34+KDR+ EPCs, which were correlated with the severity of vasoconstriction. Endothelial dysfunction might contribute to the pathogenesis of RCVS.
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Affiliation(s)
| | | | | | | | - Jong-Ling Fuh
- Faculty of Medicine, School of Medicine, National Yang-Ming University, Taipei, Taiwan.
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Mehdi A, Hajj-Ali RA. Reversible Cerebral Vasoconstriction Syndrome: a Comprehensive Update. Curr Pain Headache Rep 2014; 18:443. [DOI: 10.1007/s11916-014-0443-2] [Citation(s) in RCA: 27] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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