Reversible cerebral angiopathy after blood transfusion

Treatment-Related Reversible Cerebral Vasoconstriction Syndrome

Reversible cerebral vasoconstriction syndrome (RCVS) is a rare but significant cause of intracranial arteriopathy and stroke in young adults. The syndrome encompasses a spectrum of disorders radiologically characterized by reversible narrowing and dilation of intracranial arteries, often triggered by vasoactive drugs or the postpartum period. The hallmark clinical feature of RCVS is thunderclap headache with or without other neurological signs. Though endothelial dysfunction and sympathetic hyperactivation are hypothesized to be key mechanisms, the exact pathogenesis of RCVS is still unclear. RCVS's diagnosis could be challenging, since vasospasm proceeds centripetally, initially involving distal small pial and cortical arteries, and angiographic studies, especially brain magnetic resonance angiography (MRA) and computed tomography angiography (CTA), may miss it in the early phase of the disease, while early signs such as vascular hyperintensities may be visible on T2/FLAIR sequences before vasospasm onset. Catheter angiography is the gold standard and it could be used to assess vasospasm reversibility post-intra-arterial vasodilator administration. Treatment is mainly symptomatic, and nimodipine is the most commonly administered therapy, given orally or intra-arterially in severe cases. Since many aspects of RCVS remain partially known, further research is needed to better understand the complex pathophysiology of this unique clinical condition and to optimize specific management strategies.

Chronic Glomerulonephritis and Malignant Hypertension With PRES (Posterior Reversible Encephalopathy Syndrome) Presenting As Status Epilepticus: A Case Report

Hypertension risk is a common complication of chronic glomerulonephritis (GN), which includes focal segmental glomerulosclerosis and proliferative forms of GN such as IgA nephropathy. The clinical-radiological phenomenon known as posterior reversible encephalopathy syndrome (PRES) is frequently linked to renal disorders, particularly chronic kidney disease and hypertension. PRES is an acute clinical condition characterized by multiple neurological symptoms such as seizures, impaired consciousness, headaches, visual abnormalities, nausea, and vomiting. In this case report, we discuss status epilepticus due to PRES in a 20-year-old girl who presented with nephrotic syndrome after renal biopsy chronic GN was confirmed. Repeated neuroimaging performed following proper blood pressure management revealed that the lesions had vanished, supporting the diagnosis of PRES. Presumably, PRES remained for 5-7 days in our case. Nephrologists must be familiar with the atypical characteristics of PRES as it is frequently associated with kidney disease. Prompt identification and care prevent irreparable consequences and pointless investigations.

Transfusion-Related Acute Brain Injury: A Case Report on Reversible Cerebral Vasoconstriction Syndrome

Reversible cerebral vasoconstriction syndrome (RCVS) manifests with a thunderclap headache and reversible vascular abnormalities. Red blood cell transfusions have not been well identified as a risk factor for RCVS. We report a rare case of acute brain injury resulting from RCVS after a packed red blood cell (PRBC) transfusion. A 49-year-old female with a history of menorrhagia initially presented with generalized weakness. She was found to have a hemoglobin (Hgb) of 1.7 g/dL in the setting of a fundal fibroid for which she received five units of PRBCs. Post transfusion, she complained of several days of thunderclap headache and later returned with new-onset seizures. She was admitted to the neurocritical care unit for the treatment of status epilepticus. Metabolic, infectious and toxic work-up were unremarkable except for an elevated lactate. MRI of the brain with contrast showed extensive bilateral hemispheric and cerebellar white matter T2-weighted fluid-attenuated inversion recovery (T2/FLAIR) hyperintensities with areas of enhancement. A diagnostic cerebral angiogram was performed to evaluate for a vascular etiology and revealed focal segmental stenoses in bilateral A1 segments of the anterior cerebral arteries and in branches of the bilateral middle cerebral arteries. These findings were suggestive of RCVS. Clinicians should have a high degree of suspicion for RCVS in patients presenting with neurological manifestations, such as thunderclap headache or seizures after recent transfusion. The window for injury may be longer than that seen in other organs, such as in transfusion-related acute lung injury (TRALI). 

Neurological Complications following Blood Transfusions in Sickle Cell Anemia

In Sickle Cell Anemia (SCA) patient blood transfusions are an important part of treatment for stroke and its prevention. However, blood transfusions can also lead to complications such as Reversible Posterior Leukoencephalopathy Syndrome (RPLS). This brief report highlights two cases of SCA who developed such neurological complications after a blood transfusion. RLPS should be considered as the cause of neurologic finding in patients with SCA and hypertension following a blood transfusion.