Reversible Cerebral Vasoconstriction Syndrome: Treatment with Multiple Sessions of Intra-Arterial Nimodipine and Angioplasty

Reversible cerebral vasoconstriction syndrome (RCVS) is characterized by acute severe headache with or without additional neurological symptoms and reversible cerebral vasoconstriction. Unruptured aneurysms have been reported in some cases with RCVS. We describe a severe case of a 50-year-old woman with RCVS presenting as cortical subarachnoid hemorrhage. Cerebral angiogram demonstrated the typical angiographic findings of RCVS and two very small unruptured aneurysms of the left internal carotid artery. The patient was treated with calcium channel blockers and the two aneurysms were successfully treated endovascularly. On day 16 the patient developed new focal neurological symptoms (severe paraparesis) and was successfully treated with intraarterial nimodipine and angioplasty in multiple sessions.

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Management of Mobile Thrombus With Distal Protection Devices During Carotid Artery Angioplasty: 2-Dimensional Operative Video

Operative Neurosurgery ◽

10.1093/ons/opab131 ◽

2021 ◽

Author(s):

Salomon Cohen-Cohen ◽

Giuseppe Lanzino ◽

Waleed Brinjikji ◽

Adam Arthur ◽

Mark Bain ◽

...

Keyword(s):

Carotid Artery ◽

Internal Carotid Artery ◽

Internal Carotid ◽

Mechanical Thrombectomy ◽

Standard Of Care ◽

Video Production ◽

Left Internal Carotid Artery ◽

Left Middle Cerebral Artery ◽

Cerebral Angiogram ◽

Protection Devices

Abstract Embolic protection devices (EPDs) have become a standard of care during internal carotid artery revascularization.1,2 This video is about a 57-yr-old-male who presented with a wake-up stroke with a left hemispheric syndrome. Head computed tomography angiography (CTA) revealed tandem occlusions of the proximal left internal carotid artery (ICA) and of the distal left middle cerebral artery (MCA) with an ASPECT (Alberta Stroke Program Early CT Score) score of 6. The patient underwent a cerebral angiogram and was treated with balloon angioplasty with a distal EPD and mechanical thrombectomy. The EPD became occluded with thrombus from the ICA and was retrieved through a 6-Fr Sofia (MicroVention) under continuous aspiration. Successful revascularization of the proximal ICA and distal MCA was achieved. No procedure-related complications occurred, and the patient's neurological exam improved. Tandem occlusions can occur in up to 15% of strokes. The optimal treatment can be controversial, but mechanical thrombectomy and ICA revascularization with a distal EPD appear to be safe and effective in selected patients.3 Consent was obtained for the procedure and for the video production.

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The Need for a Rational Approach to Vasoconstrictive Syndromes: Transcranial Doppler and Calcium Channel Blockade in Reversible Cerebral Vasoconstriction Syndrome

Case Reports in Neurology ◽

10.1159/000447626 ◽

2016 ◽

Vol 8 (2) ◽

pp. 161-171 ◽

Cited By ~ 9

Author(s):

Elisabeth B. Marsh ◽

Wendy C. Ziai ◽

Rafael H. Llinas

Keyword(s):

Calcium Channel ◽

Calcium Channel Blockers ◽

Transcranial Doppler ◽

Reversible Cerebral Vasoconstriction Syndrome ◽

Rational Approach ◽

Channel Blockers ◽

Channel Blockade ◽

Calcium Channel Blockade ◽

Acute Setting ◽

Cerebral Vasoconstriction

Introduction: Reversible cerebral vasoconstriction syndrome (RCVS) typically affects young patients and left untreated can result in hemorrhage or ischemic stroke. Though the disorder has been well characterized in the literature, the most appropriate way to diagnose, treat, and evaluate therapeutic response remains unclear. In previous studies, transcranial Doppler ultrasound (TCD) has shown elevated velocities indicative of vasospasm. This imaging modality is noninvasive and inexpensive; an attractive option for diagnosis and therapeutic monitoring if it is sensitive enough to detect changes in the acute setting given that RCVS often affects the distal vessels early in the course of disease. There is also limited data that calcium channel blockade may be effective in treating vasospasm secondary to RCVS, though the agent of choice, formulation, and dose are unclear. Methods: We report a small cohort of seven patients presenting with thunderclap headache whose vascular imaging was consistent with RCVS. All were treated with calcium channel blockade and monitored with TCD performed every 1–2 days. Results: On presentation, TCD correlated with standard neuroimaging findings of vasospasm (on MR, CT, and conventional angiography). TCD was also able to detect improvement in velocities in the acute setting that correlated well with initiation of calcium channel blockade. Long-acting verapamil appeared to have the greatest effect on velocities compared to nimodipine and shorter-acting calcium channel blockers. Conclusion: Though small, our cohort demonstrates potential utility of TCD to monitor RCVS, and relative superiority of extended-release verapamil over other calcium channel blockers, illustrating the need for larger randomized trials.

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Thunderclap Headache

10.1093/med/9780190495541.003.0024 ◽

2016 ◽

Author(s):

Ji Y. Chong ◽

Michael P. Lerario

Keyword(s):

Subarachnoid Hemorrhage ◽

Clinical Presentation ◽

Clinical Symptoms ◽

Aneurysmal Subarachnoid Hemorrhage ◽

Thunderclap Headache ◽

Reversible Cerebral Vasoconstriction Syndrome ◽

Cerebral Vasoconstriction ◽

Vasoactive Medication ◽

Angiographic Findings

Reversible cerebral vasoconstriction syndrome can cause thunderclap headache, subarachnoid hemorrhage, and stroke. The clinical presentation can be similar to aneurysmal subarachnoid hemorrhage and therefore requires rapid angiography. Angiographic findings of vasculopathy and resolution of clinical symptoms and imaging abnormalities support this diagnosis. This syndrome is most often incited following pregnancy or the ingestion of a vasoactive medication.

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Reversible cerebral vasoconstriction syndrome (RCVS) caused by over-the-counter calcium supplement ingestion

BMJ Case Reports ◽

10.1136/bcr-2019-233877 ◽

2021 ◽

Vol 14 (1) ◽

pp. e233877 ◽

Cited By ~ 1

Author(s):

Adam Ross Schertz ◽

Anand Karthik Sarma ◽

Sudhir Datar ◽

Peter John Miller

Keyword(s):

Serum Calcium ◽

Pressure Control ◽

Reversible Cerebral Vasoconstriction Syndrome ◽

Albumin Concentration ◽

Herbal Supplements ◽

Over The Counter ◽

Cerebral Angiogram ◽

Cerebral Vasoconstriction ◽

Ct Angiogram ◽

Chronic Ingestion

A 59-year-old woman was found unresponsive at home. Initial neurologic examination revealed aphasia and right-sided weakness. Laboratory results demonstrated a serum calcium level of 17.3 mg/dL (corrected serum calcium for albumin concentration was 16.8 mg/dL). Extensive workup for intrinsic aetiology of hypercalcemia was unrevealing. Further discussion with family members and investigation of the patient’s home for over-the-counter medications and herbal supplements revealed chronic ingestion of calcium carbonate tablets. CT angiogram of the brain revealed multifocal intracranial vascular segmental narrowing, which resolved on a follow-up cerebral angiogram done 2 days later. These findings were consistent with reversible cerebral vasoconstriction syndrome.Appropriate blood pressure control with parenteral agents, calcium channel blockade with nimodipine and supportive care therapies resulted in significant improvement in neurologic status. By discharge, patient had near-complete resolution of neurologic symptoms.

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Reversible Cerebral Vasoconstriction Syndrome after Nifedipine Withdrawal

Case Reports in Neurology ◽

10.1159/000511204 ◽

2020 ◽

Vol 12 (3) ◽

pp. 440-446 ◽

Cited By ~ 1

Author(s):

Mohammed H. Alanazy ◽

Ali Alwadei ◽

Zaid F. Alsaaran ◽

Fahad A. Essbaiheen

Keyword(s):

Calcium Channel ◽

Calcium Channel Blockers ◽

Intracranial Haemorrhage ◽

Reversible Cerebral Vasoconstriction Syndrome ◽

Channel Blockers ◽

Cerebral Vasoconstriction ◽

Clinical Conditions

Reversible cerebral vasoconstriction syndrome (RCVS) is an essential but often unrecognized cause of intracranial haemorrhage. While there are no specific causes of the syndrome, associations with many clinical conditions and drugs have been observed, and calcium channel blockers (CCBs) are often used to relieve the symptoms. This is a case of RCVS that was triggered by the sudden withdrawal of nifedipine, a CCB.

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Abstract P116: Postpartum Catastrophe With Intracerebral Hemorrhage and Concurrent Cardiomyopathy

Hypertension ◽

10.1161/hyp.70.suppl_1.p116 ◽

2017 ◽

Vol 70 (suppl_1) ◽

Author(s):

Syed Rafay Ali Sabzwari ◽

Yan Lin ◽

Shengchuan Dai

Keyword(s):

Intracerebral Hemorrhage ◽

Brain Death ◽

Systolic Function ◽

Neurological Status ◽

Channel Blockers ◽

Apnea Test ◽

Cerebral Angiogram ◽

Cerebral Vasoconstriction ◽

Repeat Angiography ◽

Ct Brain

Introduction: Postpartum Cerebral Angiopathy (PCA) or Reversible Cerebral Vasoconstriction Syndrome (RCVS) is a rare but important postpartum syndrome characterized by severe headaches with complications including seizures and intracranial hemorrhages. Peripartum cardiomyopathy (PPCM) is a known non-ischemic cardiomyopathy occurring mostly in the immediate postpartum period. This case is one of its kind to show the unique combination of PPCM and PCA. Case Report: 32 years old Hispanic female with no past medical history presented with worsening headache since epidural anesthesia used for her uneventful spontaneous vaginal delivery six days ago. While in ED she suddenly developed left hemiplegia and an immediate CT head showed right basal ganglia intracerebral hemorrhage causing 10mm right to left midline shift. An emergent frontotemporal craniotomy and evacuation of hemorrhage was done. A cerebral angiogram the next day showed diffuse cerebral arterial vasoconstriction responding to intra-arterial verapamil suggestive of RCVS. An echocardiogram was completely normal and vasculitis workup was negative. Patient was started on nimodipine however she became hypotensive requiring pressors. A week later repeat angiography showed persistent vasospasm and a repeat echocardiogram showed dilated left and right ventricles with global impairment in systolic function and an EF of 15-20%. The subsequent day there was a change in her neurological status where she lost all brain and brainstem reflexes, pupils got fixed and dilated. CT brain showed global edema and tonsillar herniation. Apnea test was done which was consistent with the diagnosis of brain death. Discussion: The pathophysiologic mechanism of RCVS is believed to be related to altered cerebral auto regulation in response to endothelial injury that usually resolves in 3 months. The diagnosis can be made by cerebral angiography, MRA or CTA that shows multifocal segmental arterial constrictive lesions. It is likely that a combination of diffuse persistent cerebral vasospasm accompanied by poor cardiac function that culminated in eventual brain death of this healthy, postpartum patient. Management includes calcium channel blockers, sequential cerebral angiograms and supportive care.

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A near-fatal consequence of chiropractor massage: massive stroke from carotid arterial dissection and bilateral vertebral arterial oedema

BMJ Case Reports ◽

10.1136/bcr-2021-243976 ◽

2021 ◽

Vol 14 (8) ◽

pp. e243976

Author(s):

Timothy Yap ◽

Li Feng ◽

Dan Xu ◽

Jian Zhang

Keyword(s):

Risk Factors ◽

Internal Carotid ◽

Arterial Dissection ◽

Artery Dissection ◽

Left Internal Carotid Artery ◽

Left Middle Cerebral Artery ◽

Cerebrovascular Event ◽

Cerebral Angiogram ◽

History Of ◽

Carotid Arterial

A 35-year-old Chinese man with no risk factors for stroke presented with a 2-day history of expressive dysphasia and a 1-day history of right-sided weakness. The presentation was preceded by multiple sessions of neck, shoulder girdle and upper back massage for pain relief in the prior 2 weeks. CT of the brain demonstrated an acute left middle cerebral artery infarct and left internal carotid artery dissection. MRI cerebral angiogram confirmed left carotid arterial dissection and intimal oedema of bilateral vertebral arteries. In the absence of other vascular comorbidities and risk factors, massage-induced internal carotid arterial dissection will most likely precipitate the near-fatal cerebrovascular event. The differential diagnosis of stroke in a younger population was consequently reviewed and discussed.

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Stellate ganglion block used to treat reversible cerebral vasoconstriction syndrome

Regional Anesthesia and Pain Medicine ◽

10.1136/rapm-2021-102675 ◽

2021 ◽

pp. rapm-2021-102675

Author(s):

Jeffrey Davis ◽

Mehmet S Ozcan ◽

Jay K Kamdar ◽

Maria Shoaib

Keyword(s):

Case Report ◽

Transcranial Doppler ◽

Rescue Therapy ◽

Stellate Ganglion ◽

Stellate Ganglion Block ◽

Neurological Symptoms ◽

Reversible Cerebral Vasoconstriction Syndrome ◽

Ganglion Block ◽

Cerebral Vasoconstriction ◽

Typical Treatment

BackgroundWe present a case report of a patient who developed severe reversible cerebral vasoconstriction syndrome, which was worsening despite typical interventional and supportive care. We administered a stellate ganglion block (SGB) and monitored the vasospasm with transcranial Doppler measurements.Case reportA 25-year-old woman was admitted with recurrent headaches and neurological symptoms, which angiography showed to be caused by diffuse, multifocal, segmental narrowing of the cerebral arteries leading to severe ischemia in multiple regions. Typical treatment was initiated with arterial verapamil followed by supportive critical care, including nimodipine, intravenous fluids, permissive hypertension, and analgesia. Vasospasm was monitored daily via transcranial Doppler ultrasound (TCD). After symptoms and monitoring suggested worsening vasospasm, an SGB was administered under ultrasound guidance. Block success was confirmed via pupillometry, and repeat TCD showed improved flow through the cerebral vasculature. Improvement in vascular flow was accompanied by a gradual reduction in acute neurological symptoms, with the patient reporting no headaches the following morning.ConclusionsFor patients with reversible cerebral vasoconstriction syndrome who develop severe signs or symptoms despite typical treatment, sympathetic blockade may be a possible rescue therapy. This may extend to other causes of severe vasospasm as well, and further study is needed to determine if the SGB should be included in routine or rescue therapy.

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B-01 Cognitive Deficits Following Hemorrhagic Stroke in Reversible Cerebral Vasoconstriction Syndrome: A Case Study

Archives of Clinical Neuropsychology ◽

10.1093/arclin/acz034.84 ◽

2019 ◽

Vol 34 (6) ◽

pp. 944-944

Author(s):

E Schultz ◽

S DeDios-Stern ◽

G Ovsiew ◽

N Pliskin

Keyword(s):

Hemorrhagic Stroke ◽

Case Reports ◽

Cerebral Arteries ◽

Rare Condition ◽

Reversible Cerebral Vasoconstriction Syndrome ◽

Neurological Deficits ◽

Thalamic Lesion ◽

Neurocognitive Deficits ◽

Cerebral Angiogram ◽

Cerebral Vasoconstriction

Abstract Objective Reversible cerebral vasoconstriction syndrome (RCVS), a relatively rare condition presenting as severe thunderclap headache with or without neurological deficits, is characterized by vasoconstriction of cerebral arteries which often resolves within three months and may be associated with stroke. Previous case reports examining neuropsychological profiles of RCVS patients demonstrated stroke-specific and/or diffuse global impairments that often exceed impairment expected post-acute phase of clinical stroke and possibly suggest residual deficits related to RCVS alone (Perdices & Herkes, 2018). Method The present case is a 36-year-old right-handed African-American male who sustained a left thalamic hemorrhage with extension into the ventricular system following marijuana use. Cerebral angiogram was suggestive of RCVS. The Montreal Cognitive Assessment (MoCA), Western Aphasia Battery (WAB), Repeatable Battery for the Assessment of Neuropsychological Status- Update (RBANS), and Peabody Picture Vocabulary Teat- 4th edition (PPVT-4) were administered at bedside. Results Neuropsychological testing was abnormal with severe global impairments on tasks requiring attention and processing speed, visuospatial abilities, immediate and delayed memory, and executive functioning. The patient’s expressive speech was characterized by fluent output with pronounced provoked and unprovoked phonemic and semantic paraphasias. Additionally, he evidenced confabulatory responses during memory testing and lost mental set during tasks requiring simultaneous attention. Conclusions Considering the patients clear sensorium at the time of the evaluation, these deficits extend beyond what would be expected by a single thalamic lesion and implicate more generalized cerebral dysfunction secondary to his RCVS. Consistent with previous case studies, this case demonstrates how RCVS may confound and contribute to neurocognitive deficits even after hemorrhagic stroke.

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Unique combination of hyperintense vessel sign on initial FLAIR and delayed vasoconstriction on MRA in reversible cerebral vasoconstriction syndrome: A case report

Cephalalgia ◽

10.1177/0333102414529197 ◽

2014 ◽

Vol 34 (13) ◽

pp. 1093-1096 ◽

Cited By ~ 6

Author(s):

Tomoaki Kameda ◽

Michito Namekawa ◽

Haruo Shimazaki ◽

Daisuke Minakata ◽

Tohru Matsuura ◽

...

Keyword(s):

Brain Mri ◽

Sudden Onset ◽

Arterial Stenosis ◽

Thunderclap Headache ◽

Reversible Cerebral Vasoconstriction Syndrome ◽

Unique Combination ◽

Cerebral Vasoconstriction ◽

Fluid Attenuated Inversion Recovery ◽

Angiographic Findings

Background Reversible cerebral vasoconstriction syndrome is characterized by thunderclap headache and reversible cerebral vasoconstriction on angiographic findings. It can be difficult to diagnose when initial angiography is normal. Case results A 30-year-old woman was admitted because of sudden-onset thunderclap headache and seizure on postpartum day 7. Brain MRI on fluid-attenuated inversion recovery (FLAIR) showed hyperintense vessel sign (HVS), which usually means slow flow due to severe proximal arterial stenosis. However, magnetic resonance angiography (MRA) indicated that proximal arteries was normal. After nicardipine treatment, her symptoms improved dramatically. Follow-up FLAIR on day 7 showed complete resolution of HVS, while a series of MRAs revealed reversible multifocal segmental vasoconstriction. Conclusions HVS on initial FLAIR is useful for an early diagnosis of reversible cerebral vasoconstriction syndrome. As the delayed vasoconstriction on MRA can be observed, reversible cerebral vasoconstriction syndrome may progress from distal small to proximal larger arteries.

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