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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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Ling YH, Chi NF, Pan LLH, Wang YF, Wu CH, Lirng JF, Fuh JL, Wang SJ, Chen SP. Association between impaired dynamic cerebral autoregulation and BBB disruption in reversible cerebral vasoconstriction syndrome. J Headache Pain 2023; 24:170. [PMID: 38114891 PMCID: PMC10729479 DOI: 10.1186/s10194-023-01694-y] [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: 10/06/2023] [Accepted: 11/17/2023] [Indexed: 12/21/2023] Open
Abstract
BACKGROUND Half of the sufferers of reversible cerebral vasoconstriction syndrome (RCVS) exhibit imaging-proven blood-brain barrier disruption. The pathogenesis of blood-brain barrier disruption in RCVS remains unclear and mechanism-specific intervention is lacking. We speculated that cerebrovascular dysregulation might be associated with blood-brain barrier disruption in RCVS. Hence, we aimed to evaluate whether the dynamic cerebral autoregulation is altered in patients with RCVS and could be associated with blood-brain barrier disruption. METHODS A cross-sectional study was conducted from 2019 to 2021 at headache clinics of a national tertiary medical center. Dynamic cerebral autoregulation was evaluated in all participants. The capacity of the dynamic cerebral autoregulation to damp the systemic hemodynamic changes, i.e., phase shift and gain between the cerebral blood flow and blood pressure waveforms in the very-low- and low-frequency bands were calculated by transfer function analysis. The mean flow correlation index was also calculated. Patients with RCVS received 3-dimensional isotropic contrast-enhanced T2 fluid-attenuated inversion recovery imaging to visualize blood-brain barrier disruption. RESULTS Forty-five patients with RCVS (41.9 ± 9.8 years old, 29 females) and 45 matched healthy controls (41.4 ± 12.5 years old, 29 females) completed the study. Nineteen of the patients had blood-brain barrier disruption. Compared to healthy controls, patients with RCVS had poorer dynamic cerebral autoregulation, indicated by higher gain in very-low-frequency band (left: 1.6 ± 0.7, p = 0.001; right: 1.5 ± 0.7, p = 0.003; healthy controls: 1.1 ± 0.4) and higher mean flow correlation index (left: 0.39 ± 0.20, p = 0.040; right: 0.40 ± 0.18, p = 0.017; healthy controls: 0.31 ± 0.17). Moreover, patients with RCVS with blood-brain barrier disruption had worse dynamic cerebral autoregulation, as compared to those without blood-brain barrier disruption, by having less phase shift in very-low- and low-frequency bands, and higher mean flow correlation index. CONCLUSIONS Dysfunctional dynamic cerebral autoregulation was observed in patients with RCVS, particularly in those with blood-brain barrier disruption. These findings suggest that impaired cerebral autoregulation plays a pivotal role in RCVS pathophysiology and may be relevant to complications associated with blood-brain barrier disruption by impaired capacity of maintaining stable cerebral blood flow under fluctuating blood pressure.
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Affiliation(s)
- Yu-Hsiang Ling
- Department of Neurology, Neurological Institute, Taipei Veterans General Hospital, No. 201, Section 2, Shipai Road, Beitou District, Taipei, Taiwan
- College of Medicine, National Yang Ming Chiao Tung University, No. 155, Sec. 2, Linong St, Beitou Dist, Taipei, Taiwan
| | - Nai-Fang Chi
- College of Medicine, National Yang Ming Chiao Tung University, No. 155, Sec. 2, Linong St, Beitou Dist, Taipei, Taiwan.
| | - Li-Ling Hope Pan
- Brain Research Center, National Yang Ming Chiao Tung University, No. 155, Sec. 2, Linong St, Beitou Dist, Taipei, Taiwan
| | - Yen-Feng Wang
- Department of Neurology, Neurological Institute, Taipei Veterans General Hospital, No. 201, Section 2, Shipai Road, Beitou District, Taipei, Taiwan
- College of Medicine, National Yang Ming Chiao Tung University, No. 155, Sec. 2, Linong St, Beitou Dist, Taipei, Taiwan
| | - Chia-Hung Wu
- College of Medicine, National Yang Ming Chiao Tung University, No. 155, Sec. 2, Linong St, Beitou Dist, Taipei, Taiwan
- Department of Radiology, Taipei Veterans General Hospital, No. 201, Section 2, Shipai Road, Beitou District, Taipei, Taiwan
| | - Jiing-Feng Lirng
- College of Medicine, National Yang Ming Chiao Tung University, No. 155, Sec. 2, Linong St, Beitou Dist, Taipei, Taiwan
- Department of Radiology, Taipei Veterans General Hospital, No. 201, Section 2, Shipai Road, Beitou District, Taipei, Taiwan
| | - Jong-Ling Fuh
- Department of Neurology, Neurological Institute, Taipei Veterans General Hospital, No. 201, Section 2, Shipai Road, Beitou District, Taipei, Taiwan
- College of Medicine, National Yang Ming Chiao Tung University, No. 155, Sec. 2, Linong St, Beitou Dist, Taipei, Taiwan
- Brain Research Center, National Yang Ming Chiao Tung University, No. 155, Sec. 2, Linong St, Beitou Dist, Taipei, Taiwan
| | - Shuu-Jiun Wang
- Department of Neurology, Neurological Institute, Taipei Veterans General Hospital, No. 201, Section 2, Shipai Road, Beitou District, Taipei, Taiwan.
- Brain Research Center, National Yang Ming Chiao Tung University, No. 155, Sec. 2, Linong St, Beitou Dist, Taipei, Taiwan.
| | - Shih-Pin Chen
- Institute of Clinical Medicine, National Yang Ming Chiao Tung University, No. 155, Sec. 2, Linong St, Beitou Dist, Taipei, Taiwan.
- Department of Medical Research, Taipei Veterans General Hospital, No. 201, Section 2, Shipai Road, Beitou District, Taipei, Taiwan.
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Toyama G, Tsuboguchi S, Igarashi K, Saji E, Konno T, Onodera O. A case report of reversible cerebral vasoconstriction syndrome with thunderclap headache significantly exacerbated in the supine position and alleviated in the standing position. BMC Neurol 2023; 23:348. [PMID: 37789263 PMCID: PMC10546625 DOI: 10.1186/s12883-023-03381-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/12/2023] [Accepted: 09/11/2023] [Indexed: 10/05/2023] Open
Abstract
BACKGROUND Reversible cerebral vasoconstriction syndrome (RCVS) is characterized by sudden onset thunderclap headache and multiple segmental reversible cerebral vasoconstrictions that improve within 3 months. The postpartum period is a well-known precipitating factor for the onset of RCVS. Cerebral venous thrombosis (CVT) causes thunderclap headaches in the postpartum period. While headache in CVT is sometimes exacerbated in the supine position, the severity of the headache in RCVS is usually independent of body position. In this study, we report a case of RCVS with thunderclap headache exacerbated in the supine position, and headache attacks that resolved quickly in the standing position during the postpartum period. CASE PRESENTATION A 33-year-old woman presented with a sudden increase in blood pressure and thunderclap headache on the fifth postpartum day (day 1: the first sick day). The headache was severe and pulsatile, with onset in the supine position in bed, and peaked at approximately 10 s. It was accompanied by nausea and chills but there were no scintillating scotomas or ophthalmic symptoms. The headache resolved in the standing or sitting position but was exacerbated and became unbearable within a few seconds when the patient was in the supine position. Therefore, she was unable to lie supine at night. Computed tomography angiography (CTA) of the head on day 2 and magnetic resonance imaging (MRI) and magnetic resonance angiography (MRA) on day 3 showed no abnormalities. However, considering the possibility of RCVS, verapamil was initiated on day 3. The headache resolved the following day. MRA of the head on day 10 revealed diffuse and segmental stenoses in the bilateral middle and posterior cerebral arteries and basilar artery. Therefore, the patient was diagnosed with RCVS. The headache gradually resolved and disappeared completely on day 42. Cerebral vasoconstriction was also improved on MRA on day 43. CONCLUSIONS This postpartum RCVS case was notable for the exacerbation of headaches in the supine position. For the diagnosis of thunderclap headache in the postpartum period, RCVS should be considered in addition to CVT when the patient presents with a headache that is exacerbated in the supine position.
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Affiliation(s)
- Genri Toyama
- Department of Neurology, Niigata University, 1-757 Asahimachidori, Chuo-ku, Niigata city, 951-8585, Niigata, Japan
| | - Shintaro Tsuboguchi
- Department of Neurology, Niigata University, 1-757 Asahimachidori, Chuo-ku, Niigata city, 951-8585, Niigata, Japan.
| | - Kazuya Igarashi
- Department of Neurology, Niigata University, 1-757 Asahimachidori, Chuo-ku, Niigata city, 951-8585, Niigata, Japan
| | - Etsuji Saji
- Department of Neurology, Niigata University, 1-757 Asahimachidori, Chuo-ku, Niigata city, 951-8585, Niigata, Japan
| | - Takuya Konno
- Department of Neurology, Niigata University, 1-757 Asahimachidori, Chuo-ku, Niigata city, 951-8585, Niigata, Japan
| | - Osamu Onodera
- Department of Neurology, Niigata University, 1-757 Asahimachidori, Chuo-ku, Niigata city, 951-8585, Niigata, Japan
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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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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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Yin X, Duan Y, Zhang L, Feng Z, Yin C, Zhu S, Chen J, Peng X. Eclampsia with hypothyroidism complicated with posterior reversible encephalopathy syndrome-a case report. BMC Neurol 2023; 23:63. [PMID: 36765280 PMCID: PMC9911940 DOI: 10.1186/s12883-023-03068-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/24/2022] [Accepted: 01/11/2023] [Indexed: 02/12/2023] Open
Abstract
BACKGROUND Posterior reversible encephalopathy syndrome (PRES) is a rare neurological disorder with complex physiopathological mechanisms that have not been fully understood. Early identification is of great prognostic significance, of which the symptoms and radiological abnormalities can be completely reversed. If the diagnosis and treatment are delayed, ischemia and massive infarction may be developed in some patients. Posterior reversible encephalopathy syndrome (PRES) has been reported mainly in association with postpartum eclampsia, which have been rarely reported, while the association with hypothyroidism has not been reported at home or abroad. CASE PRESENTATION Here we report on a pregnant 29-year-old with multipara and a chief complication of hypothyroidism. She presented in the emergency department with frequent attacks of severe headache symptoms resulting from reversible cerebral vasoconstriction syndrome (RCVS), accompanied with prenatal eclampsia. PRES was determined by radiological examination. CONCLUSION To the best of our knowledge, this is the first case of PRES complicated by hypothyroidism and prepartum eclampsia.Clinicians should be alert for the co-occurence of eclampsia, PRES, and RCVS when patients have convulsions after a typical throbbing headache. Moreover, regular monitoring of thyroid function during pregnancy should also occupy certain special attention.
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Affiliation(s)
- Xuejing Yin
- grid.254020.10000 0004 1798 4253Department of Neurology, Changzhi Medical College, Changzhi, Shanxi Province 046000 China
| | - Yu Duan
- grid.263452.40000 0004 1798 4018Department of Emergency Medicine, Changzhi People’s Hospital, The Affiliated Hospital of Shanxi Medical University, Changzhi, Shanxi Province 046000 China
| | - Lifang Zhang
- grid.263452.40000 0004 1798 4018Department of Neurology, Changzhi People’s Hospital, The Affiliated Hospital of Shanxi Medical University, Changzhi, Shanxi Province 046000 China
| | - Zhichao Feng
- grid.254020.10000 0004 1798 4253Department of Neurology, Changzhi Medical College, Changzhi, Shanxi Province 046000 China
| | - Caixia Yin
- grid.263452.40000 0004 1798 4018Department of Neurology, Shanxi Medical University, Taiyuan, Shanxi Province 030000 China
| | - Sujie Zhu
- grid.254020.10000 0004 1798 4253Department of Neurology, Changzhi Medical College, Changzhi, Shanxi Province 046000 China
| | - Jinhua Chen
- Department of Emergency Medicine, Changzhi People's Hospital, The Affiliated Hospital of Shanxi Medical University, Changzhi, Shanxi Province, 046000, China. .,Department of Neurology, Changzhi People's Hospital, The Affiliated Hospital of Shanxi Medical University, Changzhi, Shanxi Province, 046000, China. .,Department of Emergency Medicine and Neurology, The Affiliated Hospital of Shanxi Medical University, No. 502 Changxing Middle Road, Changzhi, Shanxi Province, 046000, China.
| | - Xinsen Peng
- grid.254020.10000 0004 1798 4253Department of Cardiovascular Medicine, Changzhi Medical College, Changzhi, Shanxi Province 046000 China
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Imai M, Shimoda M, Oda S, Hoshikawa K, Osada T, Aoki R, Sunaga A. Reversible Cerebral Vasoconstriction Syndrome Patients with a History of Migraine: A Retrospective Case-control Study. Intern Med 2023; 62:355-364. [PMID: 35831115 PMCID: PMC9970822 DOI: 10.2169/internalmedicine.9776-22] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/04/2023] Open
Abstract
Objective We investigated the clinical characteristics of patients with reversible cerebral vasoconstrictor syndrome who had a history of migraine before the onset and considered the relationship between these two pathologies. Methods We investigated 98 patients who underwent magnetic resonance angiography within 14 days of the onset of reversible cerebral vasoconstriction syndrome at our hospital. Of these, 11 cases involved recurrences, so data from 87 patients were analyzed. Materials All consecutive patients diagnosed with reversible cerebral vasoconstrictor syndrome at our institution between October 2010 and July 2021. Results Fifty of the 87 patients (57%) had a history of migraine. A multivariate analysis revealed that the following clinical factors were significantly more frequent in patients with a history of migraine than in those without such a history: female sex; emotional situations as a trigger of the onset; presence of deep and subcortical white matter hyperintensity, absence of vasoconstriction in the M1 portion of the middle cerebral artery, and absence of other cerebral lesions on initial magnetic resonance imaging; absence of vasoconstriction of the basilar artery on follow-up magnetic resonance imaging; and progression of deep and subcortical white matter hyperintensity in the chronic stage. Conclusion Reversible cerebral vasoconstrictor syndrome patients with a history of migraine showed clinical features of migraine, including one aspect of cerebral small-vessel disease due to endothelial dysfunction, as a common causative condition.
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Affiliation(s)
- Masaaki Imai
- Department of Neurosurgery, Tokai University Hachioji Hospital, Japan
| | - Masami Shimoda
- Department of Neurosurgery, Tokai University Hachioji Hospital, Japan
| | - Shinri Oda
- Department of Neurosurgery, Tokai University Hachioji Hospital, Japan
| | - Kaori Hoshikawa
- Department of Neurosurgery, Tokai University Hachioji Hospital, Japan
| | - Takahiro Osada
- Department of Neurosurgery, Tokai University Hachioji Hospital, Japan
| | - Rie Aoki
- Department of Neurosurgery, Tokai University Hachioji Hospital, Japan
| | - Azusa Sunaga
- Department of Neurosurgery, Tokai University Hachioji Hospital, Japan
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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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Kunitake K, Ogura A, Iwata-Hatanaka M, Inagaki R, Furukawa S, Suzuki J, Nakai N, Nishida S, Katsuno M, Ito Y. Persistent brain damage in reversible cerebral vasoconstriction syndrome on 99mTc-ethyl cysteinate dimer single-photon emission computed tomography: A long-term observational study. J Neurol Sci 2022; 442:120441. [PMID: 36209569 DOI: 10.1016/j.jns.2022.120441] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/27/2022] [Revised: 08/24/2022] [Accepted: 09/25/2022] [Indexed: 11/19/2022]
Abstract
BACKGROUND Blood-brain barrier (BBB) breakdown is considered a key step in the pathophysiology of reversible cerebral vasoconstriction syndrome (RCVS); however, its temporal course remains unclear. Based on the characteristics and dynamics of 99mTc-ethyl cysteinate dimer (99mTc-ECD) as a tracer, 99mTc-ECD single-photon emission computed tomography (SPECT) can detect not only hypoperfusion but also BBB breakdown and/or brain tissue damage. Therefore, this study aimed to investigate this course using 99mTc-ECD SPECT. METHODS Between 2011 and 2019, we enrolled seven patients (one male and six female patients) with RCVS without ischemic or hemorrhagic stroke or posterior reversible encephalopathy syndrome. 99mTc-ECD SPECT was performed repeatedly in each patient. SPECT data were statistically analyzed using an easy Z-score imaging system. RESULTS Thunderclap headache was the initial symptom in all the patients and was most commonly triggered by bathing (three patients). All the patients exhibited vasoconstriction and reduced cerebral uptake of 99mTc-ECD during the acute stage. Follow-up assessment from 3 to 16 months showed that reduced cerebral uptake persisted in all the patients, even after the vasoconstriction had resolved. CONCLUSION Reduced cerebral uptake of 99mTc-ECD persisted in the late stage of RCVS, even after vasoconstriction and headache subsided. BBB breakdown and/or brain tissue damage may underlie this phenomenon. 99mTc-ECD SPECT is an effective neuroimaging method to detect brain functional abnormalities, reflecting BBB breakdown or tissue damages, throughout the treatment course of RCVS.
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Affiliation(s)
- Katsuhiko Kunitake
- Department of Neurology, TOYOTA Memorial Hospital, Toyota, Aichi, Japan; Department of Molecular Therapy, National Institute of Neuroscience, National Center of Neurology and Psychiatry (NCNP), Kodaira, Tokyo, Japan; Department of NCNP Brain Physiology and Pathology, Graduate school of Medical and Dental Sciences, Tokyo Medical and Dental University (TMDU), Bunkyo, Tokyo, Japan.
| | - Aya Ogura
- Department of Neurology, Nagoya University Graduate School of Medicine, Nagoya, Aichi, Japan
| | - Mai Iwata-Hatanaka
- Department of Neurology, Nagoya University Graduate School of Medicine, Nagoya, Aichi, Japan
| | - Ryosuke Inagaki
- Department of Rehabilitation Medicine I, School of Medicine, Fujita Health University, Toyoake, Aichi, Japan
| | - Soma Furukawa
- Department of Neurology, Nagoya University Graduate School of Medicine, Nagoya, Aichi, Japan
| | - Junichiro Suzuki
- Department of Neurology, TOYOTA Memorial Hospital, Toyota, Aichi, Japan
| | - Noriyoshi Nakai
- Department of Neurology, TOYOTA Memorial Hospital, Toyota, Aichi, Japan
| | - Suguru Nishida
- Department of Neurology, Nishichita General Hospital, Tokai, Aichi, Japan
| | - Masahisa Katsuno
- Department of Neurology, Nagoya University Graduate School of Medicine, Nagoya, Aichi, Japan
| | - Yasuhiro Ito
- Department of Neurology, TOYOTA Memorial Hospital, Toyota, Aichi, Japan
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10
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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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11
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Sadeghizadeh A, Pourmoghaddas Z, Zandifar A, Tara SZ, Rahimi H, Saleh R, Ramezani S, Ghazavi M, Yaghini O, Hosseini N, Aslani N, Saadatnia M, Vossough A. Reversible Cerebral Vasoconstriction Syndrome and Multisystem Inflammatory Syndrome in Children With COVID-19. Pediatr Neurol 2022; 129:1-6. [PMID: 35124533 PMCID: PMC8730706 DOI: 10.1016/j.pediatrneurol.2021.12.013] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/05/2021] [Revised: 12/24/2021] [Accepted: 12/29/2021] [Indexed: 12/23/2022]
Abstract
BACKGROUND Multisystem inflammatory syndrome in children (MIS-C) involves multiple organs and shows increased inflammatory markers. Since the onset of the coronavirus disease 2019 (COVID-19) pandemic, several studies have reported the association between severe COVID-19 and MIS-C. Reversible cerebral vasoconstriction syndrome (RCVS) presents with thunderclap headaches and multifocal reversible vasoconstriction on imaging. RCVS is very rare in children. This article reports two cases of pediatric COVID-19 with severe MIS-C and clinical and imaging features indicative of RCVS. METHODS Clinical, laboratory, and imaging data of the patients were reviewed. The diagnosis of RCVS was confirmed based on clinical symptomatology and brain magnetic resonance imaging findings. RESULTS Two pediatric patients with clinical findings compatible with severe MIS-C and hemodynamic compromise presented to the hospital. During their hospitalization course, they developed thunderclap headaches and neurological deficits. Both were receiving vasoactive agents, intravenous immunoglobulin, and immunosuppressants. Imaging studies showed marked multifocal cerebral vasoconstriction in both cases and infarcts in one. The course and management of the patients will be presented. After controlling inflammation and elimination of triggers, both patients were ultimately symptom free upon discharge. Cerebral vasoconstriction had completely resolved on follow-up imaging. CONCLUSIONS Although a variety of symptoms including headaches may be seen in pediatric COVID-19 patients with MIS-C, RCVS should be considered as a differential diagnosis in cases of thunderclap headache accompanied by neurological signs in these patients. Imaging findings and follow-up are also key in establishing the diagnosis.
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Affiliation(s)
- Atefeh Sadeghizadeh
- Department of Pediatric Intensive Care, Isfahan University of Medical Sciences, Isfahan, Iran
| | - Zahra Pourmoghaddas
- Department of Pediatric Infectious, Isfahan University of Medical Sciences, Isfahan, Iran
| | - Alireza Zandifar
- Division of Neuroradiology, Department of Radiology, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania
| | - Seyedeh Zahra Tara
- Department of Pediatrics, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania
| | - Hamid Rahimi
- Department of Pediatric Infectious, Isfahan University of Medical Sciences, Isfahan, Iran
| | - Rana Saleh
- Department of Pediatrics, Isfahan University of Medical Sciences, Isfahan, Iran
| | - Saba Ramezani
- Department of Pediatrics, Isfahan University of Medical Sciences, Isfahan, Iran
| | - Mohammadreza Ghazavi
- Department of Pediatric Neurology, Isfahan University of Medical Sciences, Isfahan, Iran
| | - Omid Yaghini
- Department of Pediatric Neurology, Isfahan University of Medical Sciences, Isfahan, Iran
| | - Neda Hosseini
- Department of Pediatric Neurology, Isfahan University of Medical Sciences, Isfahan, Iran
| | - Nahid Aslani
- Department of Pediatric Rheumatology, Isfahan University of Medical Sciences, Isfahan, Iran
| | - Mohammad Saadatnia
- Department of Neurology, Isfahan Neurosciences Research Center, Isfahan University of Medical Sciences, Isfahan, Iran.
| | - Arastoo Vossough
- Division of Neuroradiology, Department of Radiology, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania
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Abstract
Posterior reversible encephalopathy syndrome (PRES) is a group of clinical syndromes typically characterized by bilateral reversible vasogenic edema of the subcortical white matter in the parieto-occipital region on neuroimaging that causes a wide variety of acute or subacute neurological symptoms, including headache, mental status alteration, seizures, and visual dysfunction. PRES is classically suspected in patients with severe hypertension, renal failure, autoimmune disorders, eclampsia, or immunosuppressant medications. Frequent neurological evaluations and neuroimaging examinations by computed tomography or magnetic resonance imaging are required for both the diagnosis and assessment of the condition. Early detection of the disease is key for a rapid recovery and good prognosis.
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Affiliation(s)
- Yuya Ando
- Department of General Medicine, National Defense Medical College, Japan
- Department of Family Medicine, Graduated School of Medical and Dental Sciences, Tokyo Medical and Dental University, Japan
| | - Yosuke Ono
- Department of General Medicine, National Defense Medical College, Japan
| | - Azusa Sano
- Department of General Medicine, National Defense Medical College, Japan
| | - Naoya Fujita
- Department of General Medicine, National Defense Medical College, Japan
| | - Sachiko Ono
- Department of Eat-loss Medicine, Graduate School of Medicine, The University of Tokyo, Japan
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13
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Oguchi K, Fukushima K, Nakamura A, Takei YI. Reversible cerebral vasoconstriction syndrome with cardiac involvement during treatment for iron deficiency anemia: caser report. BMC Neurol 2021; 21:479. [PMID: 34893035 PMCID: PMC8660962 DOI: 10.1186/s12883-021-02509-w] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/27/2021] [Accepted: 11/30/2021] [Indexed: 11/15/2022] Open
Abstract
Background The diagnosis and therapy of reversible cerebral vasoconstriction syndrome (RCVS) tends to focus on neurological symptoms, but less attention has been paid the occurrence of extracerebral lesion such as the myocardium. Case presentation A 40-year-old woman taking iron supplements for iron deficiency anemia due to menorrhagia had suffered from a thunderclap headache and seizure. Brain magnetic resonance imaging revealed high-intensity lesions bilaterally in the cerebellar and cerebral hemispheres. Her symptoms once subsided with steroids and anticonvulsant therapy; however, she experienced a severe headache again while bathing and was transferred to our hospital. Based on the clinical course and imaging data, she was diagnosed as having RCVS triggered by a rapid improvement of anemia. At the same time, she had cardiac involvement revealed by electro and echocardiographs despite without chest symptoms. After the administration of a calcium channel blocker and nitrite, her cerebral and cardiac involvements were rapidly improved. Conclusions The case presented RCVS with transient myocardial damage. With RCVS, we should always pay attention to the complication of extracerebral lesions.
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Affiliation(s)
- Kenya Oguchi
- Department of Neurology, National Hospital Organization Matsumoto Medical Center, 2-20-30 Muraimachi-minami, Matsumoto, 399-8701, Japan
| | - Kazuhiro Fukushima
- Department of Neurology, National Hospital Organization Matsumoto Medical Center, 2-20-30 Muraimachi-minami, Matsumoto, 399-8701, Japan
| | - Akinori Nakamura
- Department of Neurology, National Hospital Organization Matsumoto Medical Center, 2-20-30 Muraimachi-minami, Matsumoto, 399-8701, Japan.
| | - Yo-Ichi Takei
- Department of Neurology, National Hospital Organization Matsumoto Medical Center, 2-20-30 Muraimachi-minami, Matsumoto, 399-8701, Japan
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14
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Imai M, Shimoda M, Oda S, Hoshikawa K, Osada T, Aoki R, Sunaga A. Hyperintense posterior cerebral artery sign in patients with reversible cerebral vasoconstriction syndrome. Surg Neurol Int 2021; 12:558. [PMID: 34877044 PMCID: PMC8645486 DOI: 10.25259/sni_1023_2021] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/08/2021] [Accepted: 11/03/2021] [Indexed: 12/03/2022] Open
Abstract
Background: This study investigated hyperintense vessel signs (HVS) on fluid-attenuated inversion recovery imaging in the P1–2 portions of posterior cerebral arteries (PCAs) as a “hyperintense PCA sign” and HVS of cortical arteries. We retrospectively examined whether these signs would be useful in diagnosing reversible cerebral vasoconstriction syndrome (RCVS) in the acute phase. Methods: Eighty patients with RCVS who underwent initial magnetic resonance imaging (MRI) within 7 days of onset were included in this study. HVS and related clinical factors were examined. Results: On initial MRI of RCVS patients, hyperintense PCA sign and HVS of cortical arteries were seen in 21 cases (26%) and 38 cases (48%), respectively. In patients showing hyperintense PCA sign, vasoconstriction of the A2–3 portion was a significant clinical factor. Conversely, vasoconstriction of the M1 and P1 portions and the presence of white matter hyperintensity on initial and chronic-stage MRI were significantly associated with the presence of HVS in cortical arteries. Conclusion: Because rich collateral flow exists around PCAs, the frequency of hyperintense PCA sign is not high. However, hyperintense PCA sign findings in patients with suspected RCVS offer credible evidence of extreme flow decreases due to vasoconstriction in peripheral PCAs and other arteries associated with the collateral circulation of PCAs. Conversely, HVS in cortical arteries tend to reflect slow antegrade circulation due to vasoconstriction of peripheral vessel and major trunks. Both signs appear useful for auxiliary diagnosis of acute-phase RCVS.
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Affiliation(s)
- Masaaki Imai
- Department of Neurosurgery, Tokai University Hachioji Hospital, Ishikawa Machi, Hachioji, Tokyo, Japan
| | - Masami Shimoda
- Department of Neurosurgery, Tokai University Hachioji Hospital, Ishikawa Machi, Hachioji, Tokyo, Japan
| | - Shinri Oda
- Department of Neurosurgery, Tokai University Hachioji Hospital, Ishikawa Machi, Hachioji, Tokyo, Japan
| | - Kaori Hoshikawa
- Department of Neurosurgery, Tokai University Hachioji Hospital, Ishikawa Machi, Hachioji, Tokyo, Japan
| | - Takahiro Osada
- Department of Neurosurgery, Tokai University Hachioji Hospital, Ishikawa Machi, Hachioji, Tokyo, Japan
| | - Rie Aoki
- Department of Neurosurgery, Tokai University Hachioji Hospital, Ishikawa Machi, Hachioji, Tokyo, Japan
| | - Azusa Sunaga
- Department of Neurosurgery, Tokai University Hachioji Hospital, Ishikawa Machi, Hachioji, Tokyo, Japan
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15
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Maldonado-Soto AR, Fryer RH. Reversible cerebral vasoconstriction syndrome in children: an update. Semin Pediatr Neurol 2021; 40:100936. [PMID: 34749919 DOI: 10.1016/j.spen.2021.100936] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/02/2021] [Revised: 09/14/2021] [Accepted: 09/15/2021] [Indexed: 10/20/2022]
Abstract
Headaches are one of the most common neurologic complaints leading to emergency room visits in pediatric patients. Of the different type of headache presentations, thunderclap headaches require a particularly urgent work-up. In children, recurrent thunderclap headaches are more often associated with reversible cerebral vasoconstriction syndrome (RCVS) than other etiologies such as subarachnoid hemorrhage. RCVS is a vascular disorder of incompletely understood etiology, characterized by diffuse vasoconstriction of the cerebral arterial vasculature, and commonly associated with recurrent severe headaches. Patients may experience focal neurological deficits, due to hemorrhages, infarcts, and even posterior reversible encephalopathy syndrome . Although RCVS has been best characterized in adults, it does occur in children. This review summarizes the presentation of RCVS in children and highlights some of the differences with the adult population.
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Affiliation(s)
| | - Robert H Fryer
- Columbia University Irving Medical Center, New York, NY.
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16
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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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17
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Yamakawa S, Kisimoto K, Wada K, Hashimoto Y, Ueda M. [A case of antepartum reversible cerebral vasoconstriction syndrome]. Rinsho Shinkeigaku 2021; 61:681-686. [PMID: 34565754 DOI: 10.5692/clinicalneurol.cn-001627] [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: 11/05/2022]
Abstract
A 35-year-old pregnant woman with mild migraine experienced thunderclap headache at 37 weeks of gestation. Her cerebral MRA showed arterial segmental narrowing of right middle cerebral artery and bilateral posterior cerebral artery. When admitted, she had no sign of eclampsia/preeclampsia. After 4 days, she had premature rupture of the membrane and gave birth by caesarean section. Caesarean section immediately resolved the headache. The postpartum course of the patient and her baby was uneventfull. One month after her onset, her cerebral MRA showed improvement in arterial segmental narrowing of cerebral artery. We diagnosed reversible cerebral vasoconstriction syndrome (RCVS) assoiated with pregnancy. Pregnancy-related RCVS develops primarily during the puerperal period, but our case was a rare case that developed just before delivery and was successful with aggressive intervention. When antepartum RCVS develops, early cesarean section with epidural anesthesia in parallel with active treatment for headache may lead to good outcomes for both mother and child.
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Affiliation(s)
| | - Kaori Kisimoto
- Department of Obstetrics and Gynecology, Kumamoto City Hospital
| | | | | | - Mitsuharu Ueda
- Department of Neurology, Graduate School of Medical Sciences, Kumamoto University
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18
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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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19
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Lin PT, Wang YF, Fuh JL, Lirng JF, Ling YH, Chen SP, Wang SJ. Diagnosis and classification of headache associated with sexual activity using a composite algorithm: A cohort study. Cephalalgia 2021; 41:1447-1457. [PMID: 34275353 DOI: 10.1177/03331024211028965] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/02/2023]
Abstract
BACKGROUND To differentiate primary headache associated with sexual activity from other devastating secondary causes. METHODS In this prospective cohort, we recruited consecutive patients with at least 2 attacks of headache associated with sexual activity from the headache clinics or emergency department of a national medical center from 2005 to 2020. Detailed interview, neurological examination, and serial thorough neuroimaging including brain magnetic resonance imaging and magnetic resonance angiography scans were performed on registration and during follow-ups. Patients were categorized into four groups, i.e. primary headache associated with sexual activity, reversible cerebral vasoconstriction syndrome, probable reversible cerebral vasoconstriction syndrome, and other secondary headache associated with sexual activity through a composite clinic-radiological diagnostic algorithm. We compared the clinical profiles among these groups, including sex, age of onset, duration, quality, and clinical course ("chronic" indicates disease course ≥ 1 year). In addition, we also calculated the score of the reversible cerebral vasoconstriction syndrome2, a scale developed to differentiate reversible cerebral vasoconstriction syndrome from other intracranial vascular disorders. RESULTS Overall, 245 patients with headache associated with sexual activity were enrolled. Our clinic-radiologic composite algorithm diagnosed and classified all patients into four groups, including 38 (15.5%) with primary headache associated with sexual activity, 174 (71.0%) with reversible cerebral vasoconstriction syndrome, 26 (10.6%) with probable reversible cerebral vasoconstriction syndrome, and 7 (2.9%) with other secondary causes (aneurysmal subarachnoid hemorrhage (n = 4), right internal carotid artery dissection (n = 1), Moyamoya disease (n = 1), and meningioma with hemorrhage (n = 1)). These four groups shared similar clinical profiles, except 26% of the patients with primary headache associated with sexual activity had a 3 times greater chance of running a chronic course (≥ 1 year) than patients with reversible cerebral vasoconstriction syndrome. Of note, the reversible cerebral vasoconstriction syndrome2 score could not differentiate reversible cerebral vasoconstriction syndrome from other groups. CONCLUSION Our composite clinic-radiological diagnostic algorithm successfully classified repeated headaches associated with sexual activity, which were predominantly secondary and related to vascular disorders, and predicted the prognosis. Primary headache associated with sexual activity and reversible cerebral vasoconstriction syndrome presented with repeated attacks of headache associated with sexual activity may be of the same disease spectrum.
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Affiliation(s)
- Po-Tso Lin
- Department of Neurology, 46615Taipei Veterans General Hospital, 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, 46615Taipei Veterans General Hospital, 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
| | - Jong-Ling Fuh
- Department of Neurology, 46615Taipei Veterans General Hospital, 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
| | - Jiing-Feng Lirng
- School of Medicine, National Yang Ming Chiao Tung University, Taipei, Taiwan.,Department of Radiology, 46615Taipei Veterans General Hospital, Taipei Veterans General Hospital, Taipei, Taiwan
| | - Yu-Hsiang Ling
- Department of Neurology, 46615Taipei Veterans General Hospital, Neurological Institute, Taipei Veterans General Hospital, Taipei, Taiwan.,School of Medicine, National Yang Ming Chiao Tung University, Taipei, Taiwan
| | - Shih-Pin Chen
- Department of Neurology, 46615Taipei Veterans General Hospital, 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
| | - Shuu-Jiun Wang
- Department of Neurology, 46615Taipei Veterans General Hospital, 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
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20
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Matsubayashi T, Oniki A, Furuki M, Obayashi M. Reversible Cerebral Vasoconstriction Syndrome without Headache That Was Initially Suspected of Being Primary Angiitis of the Central Nervous System. Intern Med 2021; 60:2321-2326. [PMID: 33612678 PMCID: PMC8355395 DOI: 10.2169/internalmedicine.6560-20] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/21/2022] Open
Abstract
A 48-year-old man had convulsions, and magnetic resonance angiography (MRA) showed diffuse constriction of the cerebral arteries. He was suspected of having primary angiitis of the central nervous system (PACNS) and treated with steroid for three days. The MRA abnormality disappeared after a week. After 69 days, he developed dizziness, and MRA revealed recurrence of cerebral artery stenosis. Nevertheless, the symptoms and abnormal MRA findings recovered promptly without treatment. He was diagnosed with reversible cerebral vasoconstriction syndrome (RCVS) without headache. This case suggests that RCVS should be a differential diagnosis in patients without headache whose MRA findings show multiple cerebral artery stenosis.
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Affiliation(s)
- Taiki Matsubayashi
- Department of Neurology, National Hospital Organization Disaster Medical Center, Japan
| | - Ayako Oniki
- Department of Neurology, National Hospital Organization Disaster Medical Center, Japan
| | - Misako Furuki
- Department of Neurology, National Hospital Organization Disaster Medical Center, Japan
| | - Masato Obayashi
- Department of Neurology, National Hospital Organization Disaster Medical Center, Japan
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21
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Yoshida Y, Kobayashi E, Kubota M, Adachi A, Iwadate Y. Two Patients with Reversible Cerebral Vasoconstriction after Carotid Artery Stenting. JOURNAL OF NEUROENDOVASCULAR THERAPY 2021; 16:106-115. [PMID: 37502649 PMCID: PMC10370963 DOI: 10.5797/jnet.cr.2019-0123] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/24/2019] [Accepted: 05/15/2021] [Indexed: 07/29/2023]
Abstract
OBJECTIVE We herein report two cases of transient cerebral vasoconstriction after carotid artery stenting (CAS). CASE PRESENTATION An 81-year-old man presented with asymptomatic severe stenosis in the right carotid artery accompanied by a slight reduction in cerebrovascular reactivity. CAS was performed, but the patient had a generalized seizure because of transient cerebral ischemia caused by intolerance to carotid artery occlusion with balloon protection. Confusion and left hemiparesis persisted. DSA suggested cerebral ischemia due to vasoconstriction as the cause of these prolonged symptoms. A 66-year-old man presented with asymptomatic severe stenosis in the right carotid artery with slight hypoperfusion. CAS was performed. The patient developed left hemispatial neglect, dysarthria, and left hemiparesis 12 hours after the procedure. DSA revealed cerebral vasoconstriction in the responsible territory. The conditions of both patients improved within several days with medical treatment and they were discharged without neurological deficits. CONCLUSION The cases presented herein show that transient ischemic complications caused by cerebral vasoconstriction may develop after CAS.
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Affiliation(s)
- Yoichi Yoshida
- Department of Neurological Surgery, Graduate School of Medicine, Chiba University, Chiba, Chiba, Japan
| | - Eiichi Kobayashi
- Department of Neurological Surgery, Graduate School of Medicine, Chiba University, Chiba, Chiba, Japan
| | - Masaaki Kubota
- Department of Neurological Surgery, Graduate School of Medicine, Chiba University, Chiba, Chiba, Japan
| | - Akihiko Adachi
- Department of Neurological Surgery, Graduate School of Medicine, Chiba University, Chiba, Chiba, Japan
| | - Yasuo Iwadate
- Department of Neurological Surgery, Graduate School of Medicine, Chiba University, Chiba, Chiba, Japan
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22
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RCVS-TCH score can predict reversible cerebral vasoconstriction syndrome in patients with thunderclap headache. Sci Rep 2021; 11:7750. [PMID: 33833341 PMCID: PMC8032806 DOI: 10.1038/s41598-021-87412-7] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/19/2020] [Accepted: 03/22/2021] [Indexed: 01/03/2023] Open
Abstract
Reversible cerebral vasoconstriction syndrome (RCVS) is one of the most important differential diagnosis in patients with thunderclap headache (TCH). We aimed to develop a new scoring system for RCVS in patients with TCH. We retrospectively analyzed 72 patients enrolled in the prospective study of TCH conducted in 2015–2016 (derivation set). We identified possible predictors for the diagnosis of RCVS and constructed a prediction model (RCVS–TCH score) using the multivariable logistic regression model. Diagnostic performance was validated to an independent validation set from our headache registry. The derivation set comprised 41 patients with RCVS and 31 with non-RCVS, and the validation set included 253 patients with TCH (165 with RCVS and 88 with non-RCVS). The RCVS–TCH score (range: 0–12) contained four predictors: recurrent TCHs, female sex, triggering factor for TCH (single or multi) and blood pressure surge. The C-index of RCVS–TCH score was 0.929 (95% CI = 0.874–0.984). The RCVS–TCH score ≥ 7 had a sensitivity of 80% and a specificity of 97% in discriminating RCVS from non-RCVS. In the validation set, RCVS–TCH score showed a C-index of 0.861 (95% CI = 0.815–0.908). In our study, the RCVS–TCH showed good performance, which may aid the diagnosis of RCVS among patients with TCH.
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23
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Togha M, Babaei M, Ghelichi PG. Reversible cerebral vasoconstriction syndrome (RCVS): an interesting case report. J Headache Pain 2021; 22:20. [PMID: 33823785 PMCID: PMC8025334 DOI: 10.1186/s10194-021-01225-7] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/29/2020] [Accepted: 03/12/2021] [Indexed: 12/22/2022] Open
Abstract
Background Reversible Cerebral Vasoconstriction Syndrome is a condition of transient cerebral vascular spasms, which usually presents with recurrent thunderclap headaches and recovers within 3 months. Several probable triggers and underlying factors, such as sex hormones, vasoactive drugs, head trauma or surgery, and tumors, have been implicated. Case presentation In this paper, we present a 53-year-old woman with thunderclap headaches and normal lab tests who was radio-clinically diagnosed with reversible cerebral vasoconstriction syndrome and treated accordingly. Then, she experienced the recurrence of RCVS after about 2 years and headaches after 1 year in association with high blood pressure, high blood sugar, hypothyroidism, hyperlipidemia, and a urine metanephrine level of 5 times higher than the normal limit, suggesting a diagnosis of pheochromocytoma. After confirmation of the diagnosis with further imaging studies, surgical removal of the tumor resolved all the signs and symptoms. Conclusion Often underdiagnosed, pheochromocytoma could be an important condition associated with RCVS. It is important for clinicians to bear this diagnosis in mind while dealing with similar cases of recurrent thunderclap headaches.
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Affiliation(s)
- Mansoureh Togha
- Neurology ward, Sina Hospital, School of Medicine, Tehran University of Medical Sciences, Tehran, Iran. .,Headache department, Irainian Center of Neurological Researches, Institute of Neuroscience, Tehran University of Medical Sciences, Tehran, Iran.
| | - Mahsa Babaei
- Department of Medicine, Shahid Beheshti University of Medical Sciences, Tehran, Iran
| | - Parvin Ganji Ghelichi
- Department of medicine, Division of obstetrics & Gynecology, Milad hospital, Tehran, Iran
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24
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Kweh BTS, Tan T, Morokoff A. Reversible cerebral vasoconstriction syndrome associated with hyperosmolar hyperglycaemic state: A case report and literature review. J Clin Neurosci 2021; 84:38-41. [PMID: 33485596 DOI: 10.1016/j.jocn.2020.12.013] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/01/2020] [Revised: 10/25/2020] [Accepted: 12/07/2020] [Indexed: 11/19/2022]
Abstract
Reversible cerebral vasoconstriction syndrome (RCVS) is an uncommon disorder characterised by thunderclap headache and self-resolving angiographic vasospasm in the presence or absence of neurological deficit. We present the first case of RCVS likely precipitated by a complex array of confounding factors including a hyperosmolar hyperglycaemic state (HHS), induction chemotherapy with cyclophosphamide, non-Hodgkin's lymphoma, pancytopenia and previous blood transfusions. However, the clinical presentation in this case of altered conscious state followed by thunderclap headache was highly suggestive of HHS being the crucial inciting factor. This report of RCVS associated with HHS lends unique insight into key underlying pathophysiological mechanisms, and warns of the need to maintain a high index of suspicion for this elusive condition given the dynamic and transient nature of its clinical and radiological features.
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Affiliation(s)
- Barry Ting Sheen Kweh
- Department of Neurosurgery, Royal Melbourne Hospital, 300 Grattan Street, Parkville, Victoria 3000, Australia; National Trauma Research Institute, 85-89 Commercial Road, Melbourne, VIC 3004, Australia.
| | - Terence Tan
- Department of Neurosurgery, Royal Melbourne Hospital, 300 Grattan Street, Parkville, Victoria 3000, Australia; National Trauma Research Institute, 85-89 Commercial Road, Melbourne, VIC 3004, Australia
| | - Andrew Morokoff
- Department of Neurosurgery, Royal Melbourne Hospital, 300 Grattan Street, Parkville, Victoria 3000, Australia; Department of Surgery, University of Melbourne, Parkville, VIC 3010, Australia.
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25
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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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26
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Muramatsu T, Tono T, Kanayama Y, Hasegawa Y, Kondo J, Hoshiyama T, Wada T, Arinuma Y, Tanaka S, Yamaoka K. A case of anti-MDA5 antibody-positive dermatomyositis developing reversible cerebral vasospasm syndrome successfully treated by multi-immunosuppressant combination including mycophenolate mofetil. Mod Rheumatol Case Rep 2020; 5:69-75. [PMID: 32811369 DOI: 10.1080/24725625.2020.1810398] [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: 10/23/2022]
Abstract
A 39-year-old woman admitted with multiple joint pain, hand rashes, and shortness of breath was diagnosed with anti-melanoma differentiation-associated gene 5 (MDA5) antibody-positive dermatomyositis (DM) with interstitial pneumonia (IP). Because of progressive dyspnoea and hypoxaemia, her IP was considered rapidly progressive interstitial lung disease. Initially, prednisolone 60 mg/day, cyclosporine A (CyA), and intravenous cyclophosphamide (IVCY) were initiated. A few days following the initiation of treatment, she experienced massive thunderclap headache, which was diagnosed as reversible cerebral vasospasm syndrome based on the findings of contraction in cerebral arteries with brain magnetic resonance imaging. Treatment with CyA and IVCY was discontinued, and diltiazem and mycophenolate mofetil (MMF) were initiated as an alternative immunosuppressant. Considering IVCY as the cause of Reversible cerebral vasospasm syndrome based on her clinical course, tacrolimus was commenced, which improved both DM and IP. DM patients who are anti-MDA5 antibody-positive are considered to have poor prognosis and require aggressive immunosuppressive treatments. In patients experiencing adverse events with standard IVCY, MMF with high-dose steroids and alternative calcineurin inhibitor should be considered.
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Affiliation(s)
- Takumi Muramatsu
- Department of Rheumatology and Infectious Diseases, Kitasato University School of medicine, Sagamihara, Japan
| | - Toshihiro Tono
- Department of Rheumatology and Infectious Diseases, Kitasato University School of medicine, Sagamihara, Japan
| | - Yoshiro Kanayama
- Department of Rheumatology and Infectious Diseases, Kitasato University School of medicine, Sagamihara, Japan
| | - Yasuhiro Hasegawa
- Department of Rheumatology and Infectious Diseases, Kitasato University School of medicine, Sagamihara, Japan
| | - Junichi Kondo
- Department of Rheumatology and Infectious Diseases, Kitasato University School of medicine, Sagamihara, Japan
| | - Takayuki Hoshiyama
- Department of Rheumatology and Infectious Diseases, Kitasato University School of medicine, Sagamihara, Japan
| | - Tatsuhiko Wada
- Department of Rheumatology and Infectious Diseases, Kitasato University School of medicine, Sagamihara, Japan
| | - Yoshiyuki Arinuma
- Department of Rheumatology and Infectious Diseases, Kitasato University School of medicine, Sagamihara, Japan
| | - Sumiaki Tanaka
- Division of Rheumatology, Kitasato University Medical Center, Kitamoto, Japan
| | - Kunihiro Yamaoka
- Department of Rheumatology and Infectious Diseases, Kitasato University School of medicine, Sagamihara, Japan
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27
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Ueno S, Takeda J, Maruyama Y, Makino S, Miyamoto N, Itakura A. Antepartum eclampsia with reversible cerebral vasoconstriction and posterior reversible encephalopathy syndromes. J Obstet Gynaecol Res 2020; 46:2147-2152. [PMID: 32779348 DOI: 10.1111/jog.14410] [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] [Received: 07/16/2019] [Revised: 06/20/2020] [Accepted: 07/09/2020] [Indexed: 11/30/2022]
Abstract
A 39-year-old pregnant woman was experienced thunderclap headache due to reversible cerebral vasoconstriction syndrome (RCVS) as a prodromal symptom. Two days after, she was brought to our hospital after an eclamptic seizure at 35 weeks of gestation. After management with magnesium sulphate, a cesarean delivery was performed, and passed without eclamptic seizure recurrence with calcium channel blocker (CCB) administration for hypertension and prophylaxis of another seizure. Antepartum eclampsia is sometimes complicated by headache as a prodromal symptom. Cerebrovascular diseases in the perinatal period include eclampsia, RCVS and posterior reversible encephalopathy syndrome, which have potentially overlapping pathologies. Here, we first report a case of overlapping those three diseases in the antepartum period. Our best literature review showed that antepartum RCVS is severe and has complications besides thunderclap headache, and there is a case report which CCB administration was shown to be effective in the treatment of antepartum RCVS. If thunderclap headache is recognized, prediction of eclampsia and getting better course of RCVS with CCB administration may be possible.
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Affiliation(s)
- Shuntaro Ueno
- Clinical Training Center, Juntendo University Faculty of Medicine, Tokyo, Japan.,Department of Neurology, Kurume University School of Medicine, Fukuoka, Japan
| | - Jun Takeda
- Department of Obstetrics and Gynecology, Juntendo University Faculty of Medicine, Tokyo, Japan
| | - Yojiro Maruyama
- Department of Obstetrics and Gynecology, Juntendo Nerima Hospital, Tokyo, Japan
| | - Shintaro Makino
- Department of Obstetrics and Gynecology, Juntendo University Faculty of Medicine, Tokyo, Japan
| | - Nobukazu Miyamoto
- Department of Neurology, Juntendo University Faculty of Medicine, Tokyo, Japan
| | - Atsuo Itakura
- Department of Obstetrics and Gynecology, Juntendo University Faculty of Medicine, Tokyo, Japan
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28
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Schmidbauer ML, Wollenweber FA, Straube A, Kamm K. [Drug-induced reversible cerebral vasoconstriction syndrome : Ustekinumab as possible trigger?]. Schmerz 2020; 34:350-353. [PMID: 32435940 DOI: 10.1007/s00482-020-00479-5] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
The reversible cerebral vasoconstriction syndrome (RCVS) is a common cause of thunderclap headache. Many trigger factors, such as the intake of vasoactive and less commonly immunosuppressive medication have previously been described. This article reports the first case of the occurrence of RCVS after the intake of ustekinumab in a female patient with a history of Crohn's disease.
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Affiliation(s)
- Moritz Luigi Schmidbauer
- Klinik und Poliklinik für Neurologie, Klinikum der Universität München, Campus Großhadern, Ludwig-Maximilians-Universität München, Marchioninistraße 15, 81377, München, Deutschland
| | - Frank Arne Wollenweber
- Klinik und Poliklinik für Neurologie, Klinikum der Universität München, Campus Großhadern, Ludwig-Maximilians-Universität München, Marchioninistraße 15, 81377, München, Deutschland.,Klinik für Neurologie, Helios Dr. Horst Schmidt Kliniken Wiesbaden, Wiesbaden, Deutschland
| | - Andreas Straube
- Klinik und Poliklinik für Neurologie, Klinikum der Universität München, Campus Großhadern, Ludwig-Maximilians-Universität München, Marchioninistraße 15, 81377, München, Deutschland
| | - Katharina Kamm
- Klinik und Poliklinik für Neurologie, Klinikum der Universität München, Campus Großhadern, Ludwig-Maximilians-Universität München, Marchioninistraße 15, 81377, München, Deutschland.
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29
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Kim JT, Won SY, Kang K, Kim SH, Park MS, Choi KH, Nam TS, Denis SW, Ferdinandusse S, Lee JE, Choi SY, Kim MK. ACOX3 Dysfunction as a Potential Cause of Recurrent Spontaneous Vasospasm of Internal Carotid Artery. Transl Stroke Res 2020; 11:1041-1051. [PMID: 31975215 DOI: 10.1007/s12975-020-00779-z] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/29/2019] [Revised: 12/30/2019] [Accepted: 01/02/2020] [Indexed: 11/24/2022]
Abstract
Recurrent spontaneous vasospasm of the extracranial internal carotid artery (RSV-eICA) is a rarely recognized cause of ischemic stroke in young adults. However, its pathophysiology remains largely unknown. Through whole-exome sequencing of the ACOX3 gene of two dizygotic Korean twin brothers affected by RSV-eICA, we identified two compound heterozygous missense variants c.235 T > G (p.F79 V) and c.665G > A (p.G222E). In silico analysis indicated that both variants were classified as pathogenic. In vitro ACOX3 enzyme assay indicated practically no enzyme activity in both F79 V and G222E mutants. To determine the effect of the mutants on vasospasm, we used a collagen contraction assay on human aortic smooth muscle cells (HASMC). Carbachol, a cholinergic agonist, induces contraction of HASMC. Knockdown of ACOX3 in HASMC, using siRNA, significantly repressed HASMC contraction triggered by carbachol. The carbachol-induced HASMC contraction was restored by transfection with plasmids encoding siRNA-resistant wild-type ACOX3, but not by transfection with ACOX3 G222E or by co-transfection with ACOX3 F79 V and ACOX3 G222E, indicating that the two ACOX3 mutants suppress carbachol-induced HASMC contraction. We propose that an ACOX3 dysfunction elicits a prolonged loss of the basal aortic myogenic tone. As a result, smooth muscles of the ICA's intermediate segment, in which the sympathetic innervation is especially rich, becomes hypersensitive to sympathomimetic stimuli (e.g., heavy exercise) leading to a recurrent vasospasm. Therefore, ACOX3 dysfunction would be a causal mechanism of RSV-eICA. For the first time, we report the possible involvement of ACOX3 in maintaining the basal myogenic tone of human arterial smooth muscle.
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Affiliation(s)
- Joon-Tae Kim
- Department of Neurology, Chonnam National University Medical School, Gwangju, 61469, South Korea
| | - So Yeon Won
- Department of Health Sciences and Technology, SAIHST, Sungkyunkwan University, Seoul, 06351, South Korea
| | - KyungWook Kang
- Department of Neurology, Chonnam National University Medical School, Gwangju, 61469, South Korea
| | - Sang-Hoon Kim
- Department of Neurology, Chonnam National University Medical School, Gwangju, 61469, South Korea
| | - Man-Seok Park
- Department of Neurology, Chonnam National University Medical School, Gwangju, 61469, South Korea
| | - Kang-Ho Choi
- Department of Neurology, Chonnam National University Medical School, Gwangju, 61469, South Korea
| | - Tai-Seung Nam
- Department of Neurology, Chonnam National University Medical School, Gwangju, 61469, South Korea
| | - Simone W Denis
- Department of Clinical Chemistry, Laboratory Genetic Metabolic Diseases, Amsterdam University Medical Centers, Academic Medical Center, Amsterdam, The Netherlands
| | - Sacha Ferdinandusse
- Department of Clinical Chemistry, Laboratory Genetic Metabolic Diseases, Amsterdam University Medical Centers, Academic Medical Center, Amsterdam, The Netherlands
| | - Ji Eun Lee
- Department of Health Sciences and Technology, SAIHST, Sungkyunkwan University, Seoul, 06351, South Korea.
| | - Seok-Yong Choi
- Department of Biomedical Sciences, Chonnam National University Medical School, Gwangju, 61469, South Korea.
| | - Myeong-Kyu Kim
- Department of Neurology, Chonnam National University Medical School, Gwangju, 61469, South Korea.
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30
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Reversible Cerebral Vasoconstriction Syndrome: an Update of Recent Research. CURRENT TREATMENT OPTIONS IN RHEUMATOLOGY 2020. [DOI: 10.1007/s40674-020-00137-y] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
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31
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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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32
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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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33
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Chen SP, Chou KH, Fuh JL, Huang YH, Huang CC, Lirng JF, Wang YF, Lin CP, Wang SJ. Dynamic Changes in White Matter Hyperintensities in Reversible Cerebral Vasoconstriction Syndrome. JAMA Neurol 2019; 75:1106-1113. [PMID: 29868878 DOI: 10.1001/jamaneurol.2018.1321] [Citation(s) in RCA: 28] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/03/2023]
Abstract
Importance White matter hyperintense lesions (WMHs) are highly prevalent in patients with reversible cerebral vasoconstriction syndrome (RCVS); however, their characteristics and underlying pathophysiology are unclear. Objective To investigate the spatiotemporal distribution and pathomechanisms of WMHs in patients with RCVS. Design, Setting, and Participants We prospectively recruited patients with RCVS over a 3-year period from January 2010 through December 2012 from the headache center or emergency department of Taipei Veterans General Hospital, Taipei, Taiwan, a 2947-bed national medical center. In total, 85 patients with RCVS were approached, of whom 4 declined to participate, 5 declined follow-up scans, 6 were lost to follow-up, and 5 had suboptimal images. Patients received serial isotropic 3-dimension fluid-attenuated inversion recovery sequence imaging (1-mm slice thickness) with a 3-T magnetic resonance imaging machine as well as transcranial and extracranial color-coded sonography on registration and during follow-ups (at 1 and 2 months, with variations adapting to clinical condition). Data were analyzed from January 2015 to May 2017. Main Outcomes and Measures The fluid-attenuated inversion recovery lesion segmentation toolbox was used to segment WMHs automatically. The WMHs were classified as periventricular or deep and were segmented into 13 anatomical locations. The neuroimaging scientists who executed the program were blinded to clinical information. Vascular parameters, including the Lindegaard index (vasoconstriction severity), pulsatility index, and resistance index of the internal carotid artery, were independently collected for comparison. Results Sixty-five patients with RCVS completed the study and underwent a total of 162 magnetic resonance imaging examinations. Of the 65 included patients, 58 (89%) were women, and the mean (SD) age was 50.1 (8.9) years. The total mean (SD) WMH load peaked at 3.2 (4.4) cm3 in the third week postonset and fell to 0.8 (0.6) cm3 in the fourth week. White matter hyperintensities were predominantly frontal and periventricular. White matter hyperintensity load correlated strongly with Lindegaard index during the second week of the disease course (r = 0.908; P < .001) and also correlated with the pulsatility index and resistance index of the internal carotid artery. Conclusions and Relevance White matter hyperintensities in patients with RCVS have a dynamic temporal evolution that parallels disease severity. The finding of partially reversible WMHs deserves attention and should be known by clinicians taking care of patients with RCVS. White matter hyperintensities in RCVS may be attributed, at least partially, to regional hypoperfusion and impaired dampening capacity to central pulsatile flow.
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Affiliation(s)
- Shih-Pin Chen
- Institute of Clinical Medicine, National Yang-Ming University School of Medicine, Taipei, Taiwan.,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.,Faculty of Medicine, National Yang-Ming University, Taipei, Taiwan.,Brain Research Center, National Yang-Ming University, Taipei, Taiwan
| | - Kun-Hsien Chou
- Brain Research Center, National Yang-Ming University, Taipei, Taiwan.,Institute of Neuroscience, National Yang-Ming University, Taipei, Taiwan
| | - Jong-Ling Fuh
- Department of Neurology, Neurological Institute, Taipei Veterans General Hospital, Taipei, Taiwan.,Faculty of Medicine, National Yang-Ming University, Taipei, Taiwan.,Brain Research Center, National Yang-Ming University, Taipei, Taiwan
| | - Yi-Hua Huang
- Institute of Biomedical Engineering, National Taiwan University, Taipei, Taiwan
| | - Chu-Chung Huang
- Institute of Neuroscience, National Yang-Ming University, Taipei, Taiwan
| | - Jiing-Feng Lirng
- Faculty of Medicine, National Yang-Ming University, Taipei, Taiwan.,Department of Radiology, Taipei Veterans General Hospital, Taipei, Taiwan
| | - Yen-Feng Wang
- Department of Neurology, Neurological Institute, Taipei Veterans General Hospital, Taipei, Taiwan.,Faculty of Medicine, National Yang-Ming University, Taipei, Taiwan.,Brain Research Center, National Yang-Ming University, Taipei, Taiwan
| | - Ching-Po Lin
- Brain Research Center, National Yang-Ming University, Taipei, Taiwan.,Institute of Neuroscience, National Yang-Ming University, Taipei, Taiwan.,Department of Biomedical Imaging and Radiological Sciences, National Yang-Ming University, Taipei, Taiwan.,Institute of Brain Science, National Yang-Ming University, Taipei, Taiwan
| | - Shuu-Jiun Wang
- Department of Neurology, Neurological Institute, Taipei Veterans General Hospital, Taipei, Taiwan.,Faculty of Medicine, National Yang-Ming University, Taipei, Taiwan.,Brain Research Center, National Yang-Ming University, Taipei, Taiwan
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Raucci U, Della Vecchia N, Ossella C, Paolino MC, Villa MP, Reale A, Parisi P. Management of Childhood Headache in the Emergency Department. Review of the Literature. Front Neurol 2019; 10:886. [PMID: 31507509 PMCID: PMC6716213 DOI: 10.3389/fneur.2019.00886] [Citation(s) in RCA: 39] [Impact Index Per Article: 7.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/30/2018] [Accepted: 07/30/2019] [Indexed: 12/16/2022] Open
Abstract
Headache is the third cause of visits to pediatric emergency departments (ED). According to a systematic review, headaches in children evaluated in the ED are primarily due to benign conditions that tend to be self-limiting or resolve with appropriate pharmacological treatment. The more frequent causes of non-traumatic headache in the ED include primitive headaches (21.8–66.3%) and benign secondary headaches (35.4–63.2%), whereas potentially life-threatening (LT) secondary headaches are less frequent (2–15.3%). Worrying conditions include brain tumors, central nervous system infections, dysfunction of ventriculo-peritoneal shunts, hydrocephalus, idiopathic intracranial hypertension, and intracranial hemorrhage. In the emergency setting, the main goal is to intercept potentially LT conditions that require immediate medical attention. The initial assessment begins with an in-depth, appropriate history followed by a complete, oriented physical and neurological examination. The literature describes the following red flags requiring further investigation (for example neuroimaging) for recognition of LT conditions: abnormal neurological examination; atypical presentation of headaches: subjective vertigo, intractable vomiting or headaches that wake the child from sleep; recent and progressive severe headache (<6 months); age of the child <6 years; no family history for migraine or primary headache; occipital headache; change of headache; new headache in an immunocompromised child; first or worst headache; symptoms and signs of systemic disease; headaches associated with changes in mental status or focal neurological disorders. In evaluating a child or adolescent who is being treated for headache, physicians should consider using appropriate diagnostic tests. Diagnostic tests are varied, and include routine laboratory analysis, cerebral spinal fluid examination, electroencephalography, and computerized tomography or magnetic resonance neuroimaging. The management of headache in the ED depends on the patient's general conditions and the presumable cause of the headache. There are few randomized, controlled trials on pharmacological treatment of headache in the pediatric population. Only ibuprofen and sumatriptan are significantly more effective than placebo in determining headache relief.
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Affiliation(s)
- Umberto Raucci
- Pediatric Emergency Department, Bambino Gesù Children's Hospital, IRCCS, Rome, Italy
| | - Nicoletta Della Vecchia
- Department of Pediatrics, University of "Studi della Campania Luigi Vanvitelli", Naples, Italy
| | - Chiara Ossella
- Pediatric Emergency Department, Bambino Gesù Children's Hospital, IRCCS, Rome, Italy
| | - Maria Chiara Paolino
- Chair of Pediatrics, NESMOS Department, Faculty of Medicine and Psychology, Sapienza University, Sant' Andrea Hospital, Rome, Italy
| | - Maria Pia Villa
- Chair of Pediatrics, NESMOS Department, Faculty of Medicine and Psychology, Sapienza University, Sant' Andrea Hospital, Rome, Italy
| | - Antonino Reale
- Pediatric Emergency Department, Bambino Gesù Children's Hospital, IRCCS, Rome, Italy
| | - Pasquale Parisi
- Chair of Pediatrics, NESMOS Department, Faculty of Medicine and Psychology, Sapienza University, Sant' Andrea Hospital, Rome, Italy
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Cho S, Lee MJ, Chung CS. Effect of Nimodipine Treatment on the Clinical Course of Reversible Cerebral Vasoconstriction Syndrome. Front Neurol 2019; 10:644. [PMID: 31275233 PMCID: PMC6591369 DOI: 10.3389/fneur.2019.00644] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/19/2019] [Accepted: 05/31/2019] [Indexed: 12/17/2022] Open
Abstract
Background: In reversible cerebral vasoconstriction syndrome (RCVS), nimodipine is currently used for the treatment, although no evidence is available to support its disease-modifying effect. In this prospective observational study, we investigated whether earlier nimodipine treatment can modify the clinical course of reversible cerebral vasoconstriction syndrome. Methods: We prospectively observed patients with angiogram-proven RCVS within 1 month after onset in the Samsung Medical Center between October 2015 and January 2018. Nimodipine was started in all patients immediately after diagnosis. Time from onset to the first nimodipine treatment was categorized as tertiles. We analyzed Kaplan-Meier curve and Cox proportional hazard model to test if the timing of nimodipine treatment can affect the clinical course of thunderclap headaches (TCHs) defined as the duration from onset to remission of thunderclap headaches. Results: In 82 patients included in this study, 71 (86.6%) patients showed remission of TCHs after starting nimodipine treatment. When categorized into earliest (<6 days), early (6–13 days), and late (≥14 days) treatment groups, earlier treatment was significantly associated with shorter clinical courses (median, 2 days [interquartile range 1–3] vs. 7 days [4–10] vs. 10 days [5–15]; log-rank p < 0.001). Univariable and multivariable Cox regression analyses also demonstrated an independent effect of earlier nimodipine treatment on earlier remission of TCHs (adjusted hazard ratio, 0.75 per 1-day delay in treatment; 95% CI, 0.693–0.802, p < 0.001). Conclusions: The clinical course of RCVS differed according to the timing of nimodipine treatment, suggesting the effect of earlier nimodipine treatment. In addition to preventing TCHs, beneficial effects of earlier nimodipine treatment on the progression of vasoconstriction and development of neurological complications should be investigated in future studies.
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Affiliation(s)
- Soohyun Cho
- Department of Neurology, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, South Korea
| | - Mi Ji Lee
- Department of Neurology, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, South Korea.,Neuroscience Center, Samsung Medical Center, Seoul, South Korea
| | - Chin-Sang Chung
- Department of Neurology, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, South Korea.,Neuroscience Center, Samsung Medical Center, Seoul, South Korea
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Seizures in patients with a phaeochromocytoma/paraganglioma (PPGL): A review of clinical cases and postulated pathological mechanisms. Rev Neurol (Paris) 2019; 175:495-505. [PMID: 31133278 DOI: 10.1016/j.neurol.2018.11.007] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/18/2018] [Revised: 06/30/2018] [Accepted: 11/05/2018] [Indexed: 11/24/2022]
Abstract
The purpose of this work was to expound on the postulated pathological mechanisms through which pheochromocytoma/paraganglioma (PPGL) can cause seizures by conducting a comprehensive review of ten cases and several pathogenic mechanisms. The goal was to enhance awareness amongst doctors and researchers about patients with PPGL presenting with seizures. This would help decrease the risk of misdiagnosis and mismanagement in future clinics. Additionally, this review was written with the purpose to attract more attention to etiological explorations, particularly concerning rare causes of seizures, which is consistent with the idea that League Against Epilepsy (ILAE) has emphasized in the new version of the ILAE position paper published in 2017. It is of great importance to keep in mind the fact that seizures can constitute an atypical presentation of PPGL and to establish early diagnosis and accurate cure for these patients, especially in the presence of paroxysmal hypertension or other suggestive symptoms of PPGL.
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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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Kasuya C, Suzuki M, Koda Y, Sato H, Kashima K, Honda K, Kazama Y, Akiyama K, Seki Y, Yoneoka Y. A headache-free reversible cerebral vasoconstriction syndrome (RCVS) with symptomatic brain stem ischemia at late pregnancy as a rare manifestation of RCVS resolved with termination of pregnancy by semi-urgent cesarean section. Oxf Med Case Reports 2018; 2018:omy101. [PMID: 30487987 PMCID: PMC6247141 DOI: 10.1093/omcr/omy101] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/03/2018] [Revised: 09/05/2018] [Accepted: 09/18/2018] [Indexed: 11/13/2022] Open
Abstract
A 32-year-old pregnant woman in her 39th week of pregnancy presented at the emergency room complaining of sudden-onset dizziness with gaze disturbance and was admitted to our hospital. Her past medical history included hypertension, diabetes mellitus and infarction in the right medulla oblongata 18 months prior to this event. Magnetic resonance (MR) angiography showed multiple irregular stenosis of the intracranial arterial system. Although MR images revealed no fresh ischemic or hemorrhagic lesions, she was diagnosed with reversible cerebral vasoconstriction syndrome (RVCS) associated with pregnancy. Cesarean section immediately resolved the headache-free ischemic RCVS. The postpartum course of the patient was uneventful as well as that of her baby. Follow-up MR angiography showed improvement of intracranial vasoconstriction and follow-up MR imaging showed improvement of a left medial pontine ischemic lesion on diffusion-weighted image. This report describes a rare manifestation of pregnancy-related RCVS.
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Affiliation(s)
- Chisato Kasuya
- Department of Obstetrics and Gynecology, Uonuma Institute of Community Medicine, Niigata University Medical and Dental Hospital, Minami-Uonuma, Niigata, Japan
| | - Mina Suzuki
- Department of Obstetrics and Gynecology, Uonuma Institute of Community Medicine, Niigata University Medical and Dental Hospital, Minami-Uonuma, Niigata, Japan
| | - Yukako Koda
- Department of Obstetrics and Gynecology, Uonuma Institute of Community Medicine, Niigata University Medical and Dental Hospital, Minami-Uonuma, Niigata, Japan
| | - Hitomi Sato
- Department of Obstetrics and Gynecology, Uonuma Institute of Community Medicine, Niigata University Medical and Dental Hospital, Minami-Uonuma, Niigata, Japan
| | - Katsunori Kashima
- Department of Obstetrics and Gynecology, Uonuma Institute of Community Medicine, Niigata University Medical and Dental Hospital, Minami-Uonuma, Niigata, Japan
| | - Keisuke Honda
- Department of Obstetrics and Gynecology, Uonuma Institute of Community Medicine, Niigata University Medical and Dental Hospital, Minami-Uonuma, Niigata, Japan
| | - Yoshiki Kazama
- Department of Obstetrics and Gynecology, Uonuma Institute of Community Medicine, Niigata University Medical and Dental Hospital, Minami-Uonuma, Niigata, Japan
| | - Katsuhiko Akiyama
- Department of Neurosurgery, Uonuma Institute of Community Medicine, Niigata University Medical and Dental Hospital, Minami-Uonuma, Niigata, Japan
| | - Yasuhiro Seki
- Department of Neurosurgery, Uonuma Institute of Community Medicine, Niigata University Medical and Dental Hospital, Minami-Uonuma, Niigata, Japan
| | - Yuichiro Yoneoka
- Department of Neurosurgery, Uonuma Institute of Community Medicine, Niigata University Medical and Dental Hospital, Minami-Uonuma, Niigata, Japan
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Chen CY, Chen SP, Fuh JL, Lirng JF, Chang FC, Wang YF, Wang SJ. Vascular wall imaging in reversible cerebral vasoconstriction syndrome - a 3-T contrast-enhanced MRI study. J Headache Pain 2018; 19:74. [PMID: 30167985 PMCID: PMC6117223 DOI: 10.1186/s10194-018-0906-7] [Citation(s) in RCA: 33] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/11/2018] [Accepted: 08/13/2018] [Indexed: 01/03/2023] Open
Abstract
Background Limited histopathology studies have suggested that reversible cerebral vasoconstriction syndromes (RCVS) does not present with vascular wall inflammation. Previous vascular imaging studies have had inconsistent vascular wall enhancement findings in RCVS patients. The aim of this study was to determine whether absence of arterial wall pathology on imaging is a universal finding in patients with RCVS. Methods We recruited patients with RCVS from Taipei Veterans General Hospital prospectively from 2010 to 2012, with follow-up until 2017 (n = 48). We analyzed the characteristics of vascular wall enhancement in these patients without comparisons to a control group. All participants received vascular wall imaging by contrasted T1 fluid-attenuated inversion recovery with a 3-T magnetic resonance machine. The vascular wall enhancement was rated as marked, mild or absent. Results Of 48 patients with RCVS, 22 (45.8%) had vascular wall enhancement (5 marked and 17 mild). Demographics, clinical profiles, and cerebral artery flow velocities were similar across patients with versus without vascular wall enhancement, except that patients with vascular wall enhancement had fewer headache attacks than those without (p = 0.04). Follow-up imaging completed in 14 patients (median interval, 7 months) showed reduced enhancement in 9 patients, but persistent enhancement in 5. Conclusion Almost half of our RCVS patients exhibited imaging enhancement of diseased vessels, and it was persistent for approximately a third of those patients with follow-up imaging. Both acute and persistent vascular wall enhancement may be unhelpful for differentiating RCVS from central nervous system vasculitis or subclinical atherosclerosis.
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Affiliation(s)
- Chun-Yu Chen
- Department of Neurology, Neurological Institute, Taipei Veterans General Hospital, Taipei, 112, Taiwan.,Faculty of Medicine, National Yang-Ming University School of Medicine, Taipei, Taiwan
| | - Shih-Pin Chen
- Department of Neurology, Neurological Institute, Taipei Veterans General Hospital, Taipei, 112, Taiwan. .,Faculty of Medicine, National Yang-Ming University School of Medicine, 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.
| | - Jong-Ling Fuh
- Department of Neurology, Neurological Institute, Taipei Veterans General Hospital, Taipei, 112, Taiwan.,Faculty of Medicine, National Yang-Ming University School of Medicine, Taipei, Taiwan
| | - Jiing-Feng Lirng
- Faculty of Medicine, National Yang-Ming University School of Medicine, Taipei, Taiwan.,Department of Radiology, Taipei Veterans General Hospital, Taipei, Taiwan
| | - Feng-Chi Chang
- Faculty of Medicine, National Yang-Ming University School of Medicine, Taipei, Taiwan.,Department of Radiology, Taipei Veterans General Hospital, Taipei, Taiwan
| | - Yen-Feng Wang
- Department of Neurology, Neurological Institute, Taipei Veterans General Hospital, Taipei, 112, Taiwan.,Faculty of Medicine, National Yang-Ming University School of Medicine, Taipei, Taiwan
| | - Shuu-Jiun Wang
- Department of Neurology, Neurological Institute, Taipei Veterans General Hospital, Taipei, 112, Taiwan.,Faculty of Medicine, National Yang-Ming University School of Medicine, Taipei, Taiwan.,Brain Research Center, National Yang-Ming University, Taipei, Taiwan
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40
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Higashi E, Uwatoko T, Mizokami T, Sakaki Y, Sakata S, Sugimori H. Reversible cerebral vasoconstriction complicated with brain infarction immediately after carotid artery stenting. Interv Neuroradiol 2018; 24:688-692. [PMID: 29969956 DOI: 10.1177/1591019918781778] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
Reversible cerebral vasoconstriction is a very rare complication after carotid artery stenting (CAS). It has been reported to occur more than several hours after CAS and to have a good clinical course. A 73-year-old man underwent CAS for a high-grade symptomatic stenosis of his left carotid artery. Immediately after CAS, he had consciousness disturbance and right hemiparesis. We first suspected hyperperfusion syndrome, but antihypertensive therapy exacerbated his symptoms. On repeated postoperative angiography, the middle cerebral artery (MCA) appeared to become progressively narrower. Perfusion computed tomography indicated hypoperfusion in the left MCA territory, so we diagnosed the patient with ischemic symptoms due to hypoperfusion associated with MCA vasoconstriction. Although these findings were temporary, right weakness and cognitive dysfunction lingered and caused severe disability. As vasoconstriction after CAS may result in a poor outcome, it must be promptly distinguished and treated accordingly.
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Affiliation(s)
- Eiji Higashi
- 1 Department of Cerebrovascular Medicine, Saga Medical Centre, Saga, Japan
| | - Takeshi Uwatoko
- 1 Department of Cerebrovascular Medicine, Saga Medical Centre, Saga, Japan
| | - Taichiro Mizokami
- 2 Department of Neurosurgery, Saga Medical Centre Koseikan, Saga, Japan
| | - Yusuke Sakaki
- 1 Department of Cerebrovascular Medicine, Saga Medical Centre, Saga, Japan
| | - Shuji Sakata
- 2 Department of Neurosurgery, Saga Medical Centre Koseikan, Saga, Japan
| | - Hiroshi Sugimori
- 1 Department of Cerebrovascular Medicine, Saga Medical Centre, Saga, Japan
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Abstract
BACKGROUND Paroxysmal neurological symptoms occurring with sex cause considerable anxiety and sometimes have a serious cause. Thunderclap headache is the most well-known and requires urgent investigation at first presentation for subarachnoid haemorrhage and other significant pathologies. After exclusion of underlying causes, many prove to be primary headache associated with sexual activity. Orgasmic migraine aura without headache is not currently recognised as a clinical entity. CASE REPORTS We report two patients with acephalgic orgasmic neurological symptoms fulfilling the criteria for migraine aura. CONCLUSIONS The incidence of acephalgic orgasmic migraine aura is unknown. It should be considered as part of the differential of paroxysmal sex-related neurological symptoms, and clinically differentiated from fixed deficits, reversible cerebral vasoconstriction syndrome and post-orgasmic illness syndrome.
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Affiliation(s)
- Heather Angus-Leppan
- 1 Clinical Neurosciences, Royal Free London NHS Foundation Trust, London, UK.,2 University College London, London, UK.,3 Centre for Research in Public Health and Community Care, University of Hertfordshire, Hatfield, UK
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Shimoda M, Oda S, Shigematsu H, Hoshikawa K, Imai M, Komatsu F, Hirayama A, Osada T. Clinical significance of centripetal propagation of vasoconstriction in patients with reversible cerebral vasoconstriction syndrome: A retrospective case-control study. Cephalalgia 2018; 38:1864-1875. [PMID: 29495882 PMCID: PMC6380735 DOI: 10.1177/0333102418762471] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/03/2023]
Abstract
Introduction We previously reported centripetal propagation of vasoconstriction at the
time of thunderclap headache remission in patients with reversible cerebral
vasoconstriction syndrome. Here we examine the clinical significance of
centripetal propagation of vasoconstriction. Methods Participants comprised 48 patients who underwent magnetic resonance
angiography within 72 h of reversible cerebral vasoconstriction syndrome
onset and within 48 h of thunderclap headache remission. Results In 24 of the 48 patients (50%), centripetal propagation of vasoconstriction
occurred on magnetic resonance angiography at the time of thunderclap
headache remission. The interval from first to last thunderclap headache in
patients with centripetal propagation of vasoconstriction (14 ± 10 days) was
significantly longer than that of patients without centripetal propagation
of vasoconstriction (4 ± 2 days). In the patients with centripetal
propagation of vasoconstriction at the time of thunderclap headache
remission, the incidence of another cerebral lesion (38%, 9 of 24 cases) was
significantly higher than in patients without centripetal propagation of
vasoconstriction (0%). From findings of sequential magnetic resonance
angiography before and after thunderclap headache remission, we observed
tendencies in which centripetal propagation of vasoconstriction gradually
progressed after the onset of reversible cerebral vasoconstriction syndrome
and peaked at the time of thunderclap headache remission. The progress of
centripetal propagation of vasoconstriction concluded with thunderclap
headache remission. Conclusions Centripetal propagation of vasoconstriction has clinical significance as an
indicator of the severity of reversible cerebral vasoconstriction syndrome.
The presence of centripetal propagation of vasoconstriction is associated
with an increased risk of brain lesions and a longer interval from first to
last thunderclap headache. Moreover, repeat magnetic resonance angiography
to assess centripetal propagation of vasoconstriction during the time from
onset to thunderclap headache remission can help diagnose reversible
cerebral vasoconstriction syndrome.
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Affiliation(s)
- Masami Shimoda
- 1 Department of Neurosurgery, Tokai University Hachioji Hospital, Tokyo, Japan
| | - Shinri Oda
- 1 Department of Neurosurgery, Tokai University Hachioji Hospital, Tokyo, Japan
| | - Hideaki Shigematsu
- 1 Department of Neurosurgery, Tokai University Hachioji Hospital, Tokyo, Japan
| | - Kaori Hoshikawa
- 1 Department of Neurosurgery, Tokai University Hachioji Hospital, Tokyo, Japan
| | - Masaaki Imai
- 1 Department of Neurosurgery, Tokai University Hachioji Hospital, Tokyo, Japan
| | - Fuminari Komatsu
- 1 Department of Neurosurgery, Tokai University Hachioji Hospital, Tokyo, Japan
| | - Akihiro Hirayama
- 2 Department of Neurosurgery, Tokai University School of Medicine, Kanagawa, Japan
| | - Takahiro Osada
- 2 Department of Neurosurgery, Tokai University School of Medicine, Kanagawa, Japan
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Sergeev AV. [Migraine 'masks': differential diagnosis of acute headache]. Zh Nevrol Psikhiatr Im S S Korsakova 2018; 118:96-102. [PMID: 29460913 DOI: 10.17116/jnevro20181181196-102] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Abstract
Differential diagnosis of migraine, can be difficult, especially of migraine with aura. On the one hand, some diseases can produce symptoms similar to migraine (cerebral aneurysm before rupture, reversible cerebral vasoconstriction syndrome). On the other hand, migraine with aura and some other disorders are conditions that have common pathophysiological mechanisms (e.g., CADASIL and MELAS syndrome, antiphospholipid syndrome). Thirdly, clinical presentations of migraine are often difficult to distinguish from features of other headache conditions (migraine with aura - transient ischemic attack, migraine with visual aura - occipital epilepsy). The author discusses the differential diagnosis of acute headache, especially thunderclap headache, and main strategies of effective treatment of migraine attacks.
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Affiliation(s)
- A V Sergeev
- Sechenov First Moscow State Medical University, Moscow, Russia
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44
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Abstract
Life-threatening headaches in children can present in an apoplectic manner that garners immediate medical attention, or in an insidious, more dangerous form that may go unnoticed for a relatively long period of time. The recognition of certain clinical characteristics that accompany the headache should prompt recognition and referral to an institution equipped with neuroimaging facilities, pediatric neurosurgeons, and neurologists. Thunderclap headaches, which reach a peak within a very short period of time, may be the presenting feature of conditions such as arterial dissection, venous sinus thrombosis, and reversible cerebral vasoconstriction syndrome, which can be addressed by specific pharmacological options instituted in an intensive care setting. On the other hand, subacute to chronic headaches that are accompanied by focal neurological signs, such as abducens nerve palsy, restriction of upward gaze, or papilledema, may be indicative of the need for urgent imaging and neurosurgical referral. [Pediatr Ann. 2018;47(2):e74-e80.].
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Reversible cerebral vasoconstriction syndrome: an important and common cause of thunderclap and recurrent headaches. Clin Radiol 2017; 73:417-427. [PMID: 29274685 DOI: 10.1016/j.crad.2017.11.017] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/11/2017] [Accepted: 11/20/2017] [Indexed: 12/23/2022]
Abstract
Reversible cerebral vasoconstriction syndrome is an intracranial vascular manifestation of a wide variety of diseases. It is the second most common cause of thunderclap headache, the most common cause of recurrent severe secondary headaches, and, in patients <60 years of age, has been reported as the commonest cause of isolated convexity subarachnoid haemorrhage. Radiologically, its key feature is vasoconstriction of the intracranial vessels, a dynamic process that is typically maximal at 2 weeks, varies in its distribution over the course of the disease, and typically resolves after 3 months. It can have haemorrhagic and ischaemic complications and sometimes occurs in concert with posterior reversible encephalopathy syndrome. It also has important associations with dissection and migraine. Rarer atypical cases can present with mild headache, no headache at all, or even a comatose state. This paper provides a detailed review of this syndrome, its pathophysiology, differential diagnosis, imaging findings, and work-up. It also describes the role that high-resolution magnetic resonance imaging (MRI) techniques can have in diagnosing the disease and emphasises the central role that all radiologists have in detecting this important and underdiagnosed condition.
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Coffino SW, Fryer RH. Reversible Cerebral Vasoconstriction Syndrome in Pediatrics: A Case Series and Review. J Child Neurol 2017; 32:614-623. [PMID: 28511631 DOI: 10.1177/0883073817696817] [Citation(s) in RCA: 28] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Reversible cerebral vasoconstriction syndrome is a transient vasculopathy associated with severe headaches and stroke. In most cases of reversible cerebral vasoconstriction syndrome, there is a precipitating event or trigger, such as pregnancy, serotonin agonist treatment or illicit drug use. The authors present 2 pediatric cases of reversible cerebral vasoconstriction syndrome and review the previous 11 pediatric cases in the literature. In many instances, the clinical and radiographic features are similar in both pediatric and adult cases. In the pediatric group, reported potential triggers include trauma (1/13), exercise (2/13), water to the face (3/13), hypertension (3/13), and medication or substance use (4/13). One surprising difference is that 11 out of 13 pediatric patients with reversible cerebral vasoconstriction syndrome are male while most cases in adults are female. Many of the pediatric patients with reversible cerebral vasoconstriction syndrome were treated with a calcium channel blocker and the overall outcome of pediatric reversible cerebral vasoconstriction syndrome was good, with most patients experiencing a full recovery.
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Affiliation(s)
- Samantha W Coffino
- 1 Department of Neurology, Columbia University Medical Center, New York, NY, USA
| | - Robert H Fryer
- 1 Department of Neurology, Columbia University Medical Center, New York, NY, USA
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Cappelen-Smith C, Calic Z, Cordato D. Reversible Cerebral Vasoconstriction Syndrome: Recognition and Treatment. Curr Treat Options Neurol 2017; 19:21. [DOI: 10.1007/s11940-017-0460-7] [Citation(s) in RCA: 48] [Impact Index Per Article: 6.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
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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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Topcuoglu MA, Jha RM, George J, Frosch MP, Singhal AB. Hemorrhagic primary CNS angiitis and vasoconstrictive drug exposure. Neurol Clin Pract 2017; 7:26-34. [PMID: 28243503 DOI: 10.1212/cpj.0000000000000324] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
BACKGROUND Primary angiitis of the CNS (PACNS) typically manifests with accumulating neurologic deficits from ischemic strokes. Intracerebral hemorrhage (ICH) is an uncommon complication. There is limited knowledge about the risk factors and features of hemorrhagic PACNS. METHODS We identified 49 patients (20 biopsy-proven) with PACNS diagnosed at our hospital from 1993 to 2015. We compared the features of hemorrhagic and nonhemorrhagic PACNS and analyzed the hemorrhagic PACNS cases in detail. RESULTS The mean age was 51 ± 15 years; 13 patients were men. Five patients had ICH (mean age 52 ± 14 years; 4 men) including 4 where ICH was the first manifestation of PACNS. All ICH patients reported recent exposure to sympathomimetic drugs (e.g., diet pills, nasal decongestants). Patients with ICH had higher rates of headache (100% vs 43%, p = 0.022), especially thunderclap headache (60% vs 0%, p = 0.001), and eosinophilic vascular infiltrates on brain biopsy (50% vs 9%, p = 0.084). In all ICH patients, brain MRI showed lobar hemorrhages with concurrent punctate diffusion-restricted lesions, suggesting an acute inflammatory process. Four received a short course of immunosuppressive therapy. All patients showed complete clinical resolution or significant improvement within weeks. CONCLUSIONS In this study, hemorrhagic PACNS was exclusively associated with sympathomimetic drug exposure. The high rate of thunderclap headache, lobar hemorrhages, and the self-limited clinical course suggests a shared mechanism between hemorrhagic PACNS and the reversible cerebral vasoconstriction syndrome (RCVS), a PACNS mimic. This RCVS-PACNS overlap syndrome may result from sympathomimetic drug-induced prolonged distal vasoconstriction, culminating in inflammation.
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Affiliation(s)
- Mehmet A Topcuoglu
- Massachusetts General Hospital and Harvard Medical School (MAT, MPF, ABS), Boston; Neurology Department (MAT), Hacettepe University Hospitals, Ankara, Turkey; Safar Center for Resuscitation (RMJ), University of Pittsburgh Medical Center, PA; and Government Medical College (JG), Kottayam, India
| | - Ruchira M Jha
- Massachusetts General Hospital and Harvard Medical School (MAT, MPF, ABS), Boston; Neurology Department (MAT), Hacettepe University Hospitals, Ankara, Turkey; Safar Center for Resuscitation (RMJ), University of Pittsburgh Medical Center, PA; and Government Medical College (JG), Kottayam, India
| | - Jacob George
- Massachusetts General Hospital and Harvard Medical School (MAT, MPF, ABS), Boston; Neurology Department (MAT), Hacettepe University Hospitals, Ankara, Turkey; Safar Center for Resuscitation (RMJ), University of Pittsburgh Medical Center, PA; and Government Medical College (JG), Kottayam, India
| | - Matthew P Frosch
- Massachusetts General Hospital and Harvard Medical School (MAT, MPF, ABS), Boston; Neurology Department (MAT), Hacettepe University Hospitals, Ankara, Turkey; Safar Center for Resuscitation (RMJ), University of Pittsburgh Medical Center, PA; and Government Medical College (JG), Kottayam, India
| | - Aneesh B Singhal
- Massachusetts General Hospital and Harvard Medical School (MAT, MPF, ABS), Boston; Neurology Department (MAT), Hacettepe University Hospitals, Ankara, Turkey; Safar Center for Resuscitation (RMJ), University of Pittsburgh Medical Center, PA; and Government Medical College (JG), Kottayam, India
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Wang M, Wang L, Liu C, Bian X, Dong Z, Yu S. Cardiac cephalalgia: one case with cortical hypoperfusion in headaches and literature review. J Headache Pain 2017; 18:24. [PMID: 28220375 PMCID: PMC5318311 DOI: 10.1186/s10194-017-0732-3] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/15/2016] [Accepted: 02/07/2017] [Indexed: 01/03/2023] Open
Abstract
BACKGROUND Cardiac cephalalgia (CC) is a rare disease occurring during an episode of myocardial ischemia and relieved by nitroglycerine. Though more than 30 cases of CC have been reported since 1997, the mechanism is yet obscure. Herein, a case of CC is presented and discussed in relevance with previous literature to propose a novel hypothesis about the mechanism of CC. METHOD A CC patient with cortical hypoperfusion during headache attacks was presented, which has never been reported. All published cases of CC via PubMed ( http://www.ncbi.nlm.nih.gov/pubmed ) in English literature, between 1997 and 2016, were reviewed. RESULTS A patient suffering from CC presented a cerebral hypoperfusion during a headache attack. This phenomenon had not been observed since CC was introduced in 1997. The literature review summarized the clinical presentations, neuroimaging features, ECG, and coronary angiography features of 35 CC patients. CONCLUSION Based on the phenomenon of hypoperfusion in the event of a headache, the vessel constriction hypothesis was proposed including two potential physiological mechanisms underlying the pathophysiology of CC.
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Affiliation(s)
- Miao Wang
- The Department of Geriatric Neurology, Chinese PLA General Hospital, Beijing, China
| | - Lu Wang
- The Outpatient Department of Fuxing Road No. 7, the First Affiliated Hospital of PLA General Hospital, Beijing, China
| | - Changfu Liu
- The Department of of Cardiology, Chinese PLA General Hospital, Beijing, China
| | - Xiangbing Bian
- The Department of of Radiology, Chinese PLA General Hospital, Beijing, China
| | - Zhao Dong
- Department of Neurology, Chinese PLA General Hospital, Fuxing Road 28, Haidian District, Beijing, 100853, China.
| | - Shengyuan Yu
- Department of Neurology, Chinese PLA General Hospital, Fuxing Road 28, Haidian District, Beijing, 100853, China
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