Central nervous system vasculitis in the intensive care unit

Syndrome de vasoconstriction cérébrale segmentale réversible ou angéite primitive du Systeme nerveux central?

Background:

Reversible Cerebral Vasoconstriction Syndrome (RCVS) may present as thunderclap headache (TCH), accompanied by reversible cerebral vasospasm and focal neurological deficits, often without a clear precipitant. RCVS may be mistaken for Primary Angiitis of the Central Nervous System (PACNS) due to the presence of similar angiographic features of segmental narrowing of cerebral arteries. We discuss the clinical features of a young female migraine patient who developed TCH and was found to have RCVS following initial treatment with corticosteroids for PACNS, in the context of a systematic review of the available medical literature.

Methods:

A Medline™ search was performed to identify all case reports since 1966 describing RCVS and PACNS that provide sufficient clinical detail to permit diagnostic classification according to published criteria. RCVS included case studies in which there was angiographic or transcranial Doppler ultrasound evidence of near-to-complete resolution of cerebral vasoconstriction in the absence of a well-recognized secondary cause. PACNS included reports of histologically confirmed PACNS either through biopsy or necropsy.

Results:

Reversible Cerebral Vasoconstriction Syndrome occurs primarily in females and is characterized by sudden, severe headache at onset, normal CSF analysis, vasoconstriction involving the Circle of Willis and its immediate branches, and angiographic or TCD ultrasound evidence of near-to-complete vasospastic resolution within 1-4 weeks. It occurs typically in the context of vasoconstrictive drug use, the peripartum period, bathing, and physical exertion.

Conclusion:

Initial and follow-up (within 4 weeks) non-invasive angiographic studies are indicated in patients who present with TCH or who have clinical presentations that could be consistent with RCVS or PACNS in the absence of a well-recognized secondary cause, such as subarachnoid haemorrhage. Early reversibility of cerebral vasospasm is the key neuroradiological feature that supports the clinical diagnosis of RCVS.

Reversible cerebral vasoconstriction syndrome: a thunderclap headache-associated condition

Reversible cerebral vasoconstriction syndrome (RCVS) is characterized by a sudden, severe headache at onset, vascular narrowing involving the circle of Willis and its immediate branches, and angiographic evidence of vasoconstriction reversibility within minutes to weeks of onset. RCVS is underrecognized and often misdiagnosed; it can defy clinical detection because it can mimic common conditions such as migraine and ischemic stroke. A lack of shared nosology has hampered awareness and understanding of the syndrome. Clinicians must consider primary angiitis of the central nervous system because of its high rates of morbidity and mortality if left untreated. RCVS has a number of primary and secondary associations (cerebral hemorrhage, vasoactive substances, the peripartum period, bathing, and physical exertion) but also occurs in isolation. RCVS can present in conjunction with hypertensive encephalopathy, preeclampsia, and reversible posterior leukoencephalopathy. This review provides an up-to-date account of RCVS.

Posterior reversible encephalopathy syndrome in intensive care medicine

BACKGROUND

Posterior reversible encephalopathy syndrome (PRES) is a well-recognized clinico-neuroradiological transient condition. Early recognition is of paramount importance for prompt control of blood pressure or removal of precipitating factors and treatment of epileptic seizures or status epilepticus. Delay in the diagnosis and treatment may in fact results in death or in irreversible neurological sequelae.

DISCUSSION

PRES is characterized by headache, altered mental status, seizures, and visual disturbances and is associated with a number of different causes, most commonly acute hypertension, preeclampsia/eclampsia, and immunosuppressive agents. Clinical symptoms and neuroradiological findings are typically indistinguishable among the cases of PRES, regardless of underlying cause. Magnetic resonance studies typically show edema involving the white matter of cerebral posterior regions, especially parieto-occipital lobes but frontal and temporal lobes, and other encephalic structures may be involved.

CONCLUSIONS

Intensivists and other physicians involved in the evaluation of patients with presumed PRES must be aware of the clinical spectrum of the associated conditions, the diagnostic modalities, and the correct treatment.

Biography: history of developments in imaging techniques: Egas Moniz and angiography

Angiography, the primary imaging technique used for visualizing the brain's blood vessels and any accompanying abnormalities, also is used for imaging aneurysms and other lesions having an infectious cause. A Nobel laureate who later was recognized for his radical treatment for mental illness, Antonio Caetano de Abreu Freire Egas Moniz, has been credited with discovering angiography. However, despite the tremendous impact it has had on the field of medicine, angiography did not receive the recognition that the researcher's later work in psychosurgery did. For many years, the reason for this seeming oversight remained a mystery, especially considering that leucotomy subsequently was superseded by psychopharmaceutical drugs and other management modalities, whereas angiography continues to play a vital role in medicine. This article looks at the various achievements of Egas Moniz, who excelled in many disciplines, as well as at the circumstances surrounding his being denied the Nobel Prize for the discovery of angiography.