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Edlow JA, Baggett M, Singhal A. Reversible Cerebral Vasoconstriction Syndrome for the Internist-A Narrative Review. Am J Med 2025; 138:396-405. [PMID: 39522671 DOI: 10.1016/j.amjmed.2024.10.034] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/14/2024] [Revised: 10/21/2024] [Accepted: 10/21/2024] [Indexed: 11/16/2024]
Abstract
Reversible cerebral vasoconstriction syndrome is a common, increasingly recognized cause of thunderclap headache. Most patients have some type of trigger that precedes the onset (e.g., orgasm, physical exertion, Valsalva maneuvers, exposure to vasoconstrictive medications) followed by multiple short-duration thunderclap headaches that occur over days to weeks. Physical examination is often without focal neurological deficits. Brain computed tomography may be normal, or show a convexal subarachnoid hemorrhage. Angiography shows multifocal areas of cerebral arterial vasoconstriction, although can be normal early in the course. The vasoconstriction is reversible and repeat angiography in three months will show normalization. The clinical outcomes are usually good despite some patients having hemorrhagic or ischemic strokes. Treatment is primarily analgesics and avoidance of triggers. Triptans, steroids and immunosuppressive agents, which are sometimes used if migraine or central nervous system angiitis is suspected, should be avoided. Improved recognition of RCVS will likely lead to earlier diagnosis and minimize potentially harmful empiric treatment strategies.
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Affiliation(s)
- Jonathan A Edlow
- Department of Emergency Medicine, Beth Israel Deaconess Medical Center, Boston, Mass.
| | - Meridale Baggett
- Department of Medicine, Massachusetts General Hospital, Boston, Mass
| | - Aneesh Singhal
- Department of Neurology, Massachusetts General Hospital, Boston, Mass
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Singhal AB. Reversible cerebral vasoconstriction syndrome: A review of pathogenesis, clinical presentation, and treatment. Int J Stroke 2023; 18:1151-1160. [PMID: 37246916 DOI: 10.1177/17474930231181250] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/30/2023]
Abstract
Reversible segmental narrowing of the intracranial arteries has been described since several decades in numerous clinical settings, using variable nosology. Twenty-one years ago, we tentatively proposed the unifying concept that these entities, based on similar clinical-imaging features, represented a single cerebrovascular syndrome. This "reversible cerebral vasoconstriction syndrome" or RCVS has now come of age. A new International Classification of Diseases code, (ICD-10, I67.841) has been established, enabling larger-scale studies. The RCVS2 scoring system provides high accuracy in confirming RCVS diagnosis and excluding mimics such as primary angiitis of the central nervous system. Several groups have characterized its clinical-imaging features. RCVS predominantly affects women. Recurrent worst-ever (thunderclap) headaches are typical at onset. While initial brain imaging is often normal, approximately one-third to half develop complications such as convexity subarachnoid hemorrhages, lobar hemorrhages, ischemic strokes located in arterial "watershed" territories and reversible edema, alone or in combination. Vasoconstriction evolves over hours to days, first affecting distal and then the more proximal arteries. An overlap between RCVS and primary thunderclap headache, posterior reversible encephalopathy syndrome, Takotsubo cardiomyopathy, transient global amnesia, and other conditions has been recognized. The pathophysiology remains largely unknown. Management is mostly symptomatic: headache relief with analgesics and oral calcium-channel blockers, removal of vasoconstrictive factors, and avoidance of glucocorticoids that can significantly worsen outcome. Intra-arterial vasodilator infusions provide variable success. Overall, 90-95% of admitted patients achieve complete or major resolution of symptoms and clinical deficits within days to weeks. Recurrence is exceptional, although 5% can later develop isolated thunderclap headaches with or without mild cerebral vasoconstriction.
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Affiliation(s)
- Aneesh B Singhal
- Neurology Department, Massachusetts General Hospital, Boston, MA, USA
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Tentolouris-Piperas V, Lymperopoulos L, Tountopoulou A, Vassilopoulou S, Mitsikostas DD. Headache Attributed to Reversible Cerebral Vasoconstriction Syndrome (RCVS). Diagnostics (Basel) 2023; 13:2730. [PMID: 37685270 PMCID: PMC10487016 DOI: 10.3390/diagnostics13172730] [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: 07/10/2023] [Revised: 08/10/2023] [Accepted: 08/18/2023] [Indexed: 09/10/2023] Open
Abstract
Reversible cerebral vasoconstriction syndrome (RCVS) is a condition with variable outcomes presenting a new onset thunderclap headache accompanied by focal neurological symptoms or seizures. It can be idiopathic or arise secondarily to a variety of trigger factors. The condition is increasingly recognized in clinical practice, but many facets remain poorly understood. This article aims to clarify the headache characteristics in RCVS, the temporal association of angiographic findings, the potential association of the condition with SARS-CoV-2 infection, and the clinical presentation of RCVS in children and is based on a systematic PRISMA search for published analytical or large descriptive observational studies. Data from 60 studies that fulfilled specific criteria were reviewed. Most people with RCVS exhibit a typical thunderclap, explosive, or pulsatile/throbbing headache, or a similar acute and severe headache that takes longer than 1 min to peak. Atypical presentations or absence of headaches are also reported and may be an underrecognized phenotype. In many cases, headaches may persist after resolution of RCVS. Focal deficits or seizures are attributed to associated complications including transient ischemic attacks, posterior reversible encephalopathy syndrome, ischemic stroke, cerebral edema, and intracranial hemorrhage. The peak of vasoconstriction occurs usually within two weeks after clinical onset, possibly following a pattern of centripetal propagation, and tends to resolve completely within 3 months, well after symptoms have subsided. There are a few reports of RCVS occurring in relation to SARS-CoV-2 infection, but potential underlying pathophysiologic mechanisms and etiological associations have not been confirmed. RCVS occurs in children most often in the context of an underlying disease. Overall, the available data in the literature are scattered, and large-scale prospective studies and international collaborations are needed to further characterize the clinical presentation of RCVS.
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Affiliation(s)
| | | | | | | | - Dimos D. Mitsikostas
- 1st Department of Neurology, Eginition Hospital, School of Medicine, National and Kapodistrian University of Athens, 11528 Athens, Greece; (V.T.-P.); (L.L.); (A.T.); (S.V.)
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Osteraas ND, Dafer RM. Advances in Management of the Stroke Etiology One-Percenters. Curr Neurol Neurosci Rep 2023; 23:301-325. [PMID: 37247169 PMCID: PMC10225785 DOI: 10.1007/s11910-023-01269-z] [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] [Accepted: 04/13/2023] [Indexed: 05/30/2023]
Abstract
PURPOSE OF REVIEW Uncommon causes of stroke merit specific attention; when clinicians have less common etiologies of stoke in mind, the diagnosis may come more easily. This is key, as optimal management will in many cases differs significantly from "standard" care. RECENT FINDINGS Randomized controlled trials (RCT) on the best medical therapy in the treatment of cervical artery dissection (CeAD) have demonstrated low rates of ischemia with both antiplatelet and vitamin K antagonism. RCT evidence supports the use of anticoagulation with vitamin K antagonism in "high-risk" patients with antiphospholipid antibody syndrome (APLAS), and there is new evidence supporting the utilization of direct oral anticoagulation in malignancy-associated thrombosis. Migraine with aura has been more conclusively linked not only with increased risk of ischemic and hemorrhagic stroke, but also with cardiovascular mortality. Recent literature has surprisingly not provided support the utilization of L-arginine in the treatment of patients with mitochondrial encephalopathy, lactic acidosis, and stroke-like episodes (MELAS); however, there is evidence at this time that support use of enzyme replacement in patients with Fabry disease. Additional triggers for reversible cerebral vasoconstriction syndrome (RCVS) have been identified, such as capsaicin. Imaging of cerebral blood vessel walls utilizing contrast-enhanced MRA is an emerging modality that may ultimately prove to be very useful in the evaluation of patients with uncommon causes of stroke. A plethora of associations between cerebrovascular disease and COVID-19 have been described. Where pertinent, authors provide additional tips and guidance. Less commonly encountered conditions with updates in diagnosis, and management along with clinical tips are reviewed.
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Affiliation(s)
| | - Rima M Dafer
- Rush University Medical Center, Chicago, IL, USA.
- Department of Neurological Sciences, Rush University Medical Center, 1725 W. Harrison St., Suite 1118, Chicago, IL, 60612, USA.
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Nehme A, Lanthier S, Boulanger M, Aouba A, Cacoub P, Jayne D, Makhzoum JP, Pagnoux C, Rhéaume M, Terrier B, Touzé E, de Boysson H. Diagnosis and management of adult primary angiitis of the central nervous system: an international survey on current practices. J Neurol 2023; 270:1989-1998. [PMID: 36538155 DOI: 10.1007/s00415-022-11528-7] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/10/2022] [Revised: 12/09/2022] [Accepted: 12/10/2022] [Indexed: 12/25/2022]
Abstract
BACKGROUND Primary angiitis of the central nervous system (PACNS) is a rare disease, for which no validated guidelines exist. We report the findings of a survey on the clinical practice of physicians who manage adults with PACNS. METHODS An online survey was distributed through neurology, internal medicine, and rheumatology societies in Canada and Europe. Participants who were directly involved as treating physicians for at least two adult patients with PACNS were eligible for the survey. RESULTS Ninety-six physicians completed the survey. Most participants were neurologists (n = 38, 40%), internists (n = 34, 35%) or rheumatologists (n = 22, 23%). Participants obtained a CNS biopsy in a median of 25% (IQR: 5-50%) of suspected PACNS cases. When determining the degree to which eight scenarios justified a CNS biopsy, participants achieved fair inter-rater agreement (Gwet's AC2 0.30, 95% CI 0.23-0.41). For induction therapy, 81 (84%) participants reported using glucocorticoids and cyclophosphamide in > 50% of patients. After obtaining remission, 85 (89%) participants systematically introduced or maintained immunosuppressive therapy. Glucocorticoids were prescribed for a median of 12 months. Maintenance therapy with another immunosuppressant was continued for a median of 24 months. In patients who achieved remission, we explored how eight scenarios with different imaging and CSF results supported an increase in treatment. Inter-rater agreement was substantial if the patient was symptomatic (0.66, 95% CI 0.58-0.80) and moderate (0.50, 95% CI 0.45-0.60) if asymptomatic. CONCLUSION This survey illustrates current real-world management of PACNS and emphasizes several areas for which physicians still lack study-based evidence and/or clinical practice guidelines.
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Affiliation(s)
- Ahmad Nehme
- Caen Normandie University, Caen, France.
- Department of Neurology, Centre Hospitalier Universitaire de Caen-Normandie, Avenue de la Côte de Nacre, 14000, Caen, France.
- INSERM UMR-S U1237 PhIND/BB@C, Caen, France.
| | - Sylvain Lanthier
- Department of Neurology, Hôpital du Sacré-cœur de Montréal, Université de Montréal, Montréal, Canada
| | - Marion Boulanger
- Caen Normandie University, Caen, France
- Department of Neurology, Centre Hospitalier Universitaire de Caen-Normandie, Avenue de la Côte de Nacre, 14000, Caen, France
- INSERM UMR-S U1237 PhIND/BB@C, Caen, France
| | - Achille Aouba
- Caen Normandie University, Caen, France
- Department of Internal Medicine, Caen University Hospital, Caen, France
| | - Patrice Cacoub
- Department of Internal Medicine and Clinical Immunology, AP-HP, Groupe Hospitalier Pitié-Salpêtrière, 75013, Paris, France
- Sorbonne Universités, UPMC Univ Paris 06, UMR 6211, Paris, France
- Inflammation-Immunopathology-Biotherapy Department (DHU i2B), 75005, Paris, France
| | - David Jayne
- Department of Medicine, University of Cambridge, Cambridge, UK
| | - Jean-Paul Makhzoum
- Department of Internal Medicine, Hôpital du Sacré-cœur de Montréal, Université de Montréal, Montréal, Canada
| | - Christian Pagnoux
- Division of Rheumatology, Vasculitis Clinic, Mount Sinai Hospital, University of Toronto, Toronto, Canada
| | - Maxime Rhéaume
- Department of Internal Medicine and Clinical Immunology, Dijon University Hospital, Dijon, France
| | - Benjamin Terrier
- Department of Internal Medicine, National Referral Center for Rare Systemic Autoimmune Diseases, Hôpital Cochin, Assistance Publique-Hôpitaux de Paris (AP-HP), Université Paris, Paris, France
| | - Emmanuel Touzé
- Caen Normandie University, Caen, France
- Department of Neurology, Centre Hospitalier Universitaire de Caen-Normandie, Avenue de la Côte de Nacre, 14000, Caen, France
- INSERM UMR-S U1237 PhIND/BB@C, Caen, France
| | - Hubert de Boysson
- Caen Normandie University, Caen, France
- Department of Internal Medicine, Caen University Hospital, Caen, France
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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: 21] [Impact Index Per Article: 10.5] [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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