Intra-Arterial Verapamil Treatment in Oral Therapy-Refractory Reversible Cerebral Vasoconstriction Syndrome

Verapamil in the treatment of reversible cerebral vasoconstriction syndrome: A systematic review

INTRODUCTION

Extrapolating from efficacy in subarachnoid haemorrhage (SAH), nimodipine has been used as a treatment for reversible cerebral vasoconstriction syndrome (RCVS). However, 4-hourly dosing is a practical limitation and verapamil has been proposed as an alternative. The potential efficacy, adverse effects, preferred dosing and formulation of verapamil for RCVS have not been systematically reviewed previously.

METHOD

A systematic review was conducted of the databases PubMed, EMBASE, and the Cochrane Library from inception to July 2022 for peer-reviewed articles describing the use of verapamil for RCVS. This systematic review adheres to the PRISMA guidelines and was registered on PROSPERO.

RESULTS

There were 58 articles included in the review, which included 56 patients with RCVS treated with oral verapamil and 15 patients treated with intra-arterial verapamil. The most common oral verapamil dosing regimen was controlled release 120 mg once daily. There were 54/56 patients described to have improvement in headache following oral verapamil and one patient who died from worsening RCVS. Only 2/56 patients noted possible adverse effects with oral verapamil, with none requiring discontinuation. There was one case of hypotension from combined oral and intra-arterial verapamil. Vascular complications including ischaemic and haemorrhagic stroke were recorded in 33/56 patients. RCVS recurrence was described in 9 patients, with 2 cases upon weaning oral verapamil.

CONCLUSIONS

While no randomised studies exist to support the use of verapamil in RCVS, observational data support a possible clinical benefit. Verapamil appears well tolerated in this setting and represents a reasonable treatment option. Randomised controlled trials including comparison with nimodipine are warranted.

Reversible cerebral vasoconstriction syndrome: literature review

Reversible Cerebral Vasoconstriction Syndrome (RCVS) is a neurovascular condition characterized by a severe sudden-onset headache that may be associated with focal neurological deficits. On imaging, the suggestive finding corresponds to multifocal vasoconstriction of the cerebral arteries, with a spontaneous resolution of approximately 12 weeks. The identification of precipitating factors and diagnosis must be carried out early, so that adequate management is established and the patient has a good prognosis, given the risk of secondary complications and residual neurological deficits. This study consists of a literature review based on the analysis of articles published between 2017 and 2022 in PubMed, SciELO, and ScienceDirect on RCVS, intending to understand the clinical and radiological characteristics, diagnosis, treatment, and prognosis of patients with RCVS. The pathophysiology, drug management, and prognosis still lack solid evidence; therefore, further studies on RCVS are needed to expand medical knowledge and avoid underdiagnosis and inadequate treatment of this important condition.

Reversible cerebral vasoconstriction syndrome: review of neuroimaging findings

Reversible cerebral vasoconstriction syndrome (RCVS) is a group of disorders characterized by segmental narrowing and dilatation of medium-to-large cerebral arteries, clinically presenting with recurrent episodes of sudden-onset thunderclap headaches, with or without focal neurological deficits. Cerebral vasoconstriction is typically reversible, with spontaneous resolution within 3 months. Although the syndrome has generally a benign course, patients with neurological deficits may experience worse outcome. The main imaging finding is segmental constriction of intracranial arteries, which can be associated with subarachnoid hemorrhage and/or ischemic foci. Other possible findings are intracranial hemorrhage, subdural bleeding and cerebral edema. The latter may have a pattern which can resemble that of posterior reversible encephalopathy syndrome, a condition that can overlap with RCVS. New imaging techniques, such as vessel wall imaging and arterial spin labeling, are proving useful in RCVS and are giving new insights into the pathophysiology of this condition. In this paper, we aim to review neuroimaging findings of RCVS.

Pediatric Tacrolimus-Induced Reversible Cerebral Vasoconstriction Syndrome after Heart Transplantation

Reversible cerebral vasoconstriction syndrome (RCVS) is a rare post-organ transplantation complication. While uncommon, complications of post-transplant RCVS can be devastating, with sequelae including ischemic or hemorrhagic stroke and potential significant neurological morbidity. There is a paucity of literature on tacrolimus-mediated RCVS, particularly in the pediatric population. To date, only five case reports have been published, with the youngest patient being 15 years of age. We report the youngest case to date of post-heart transplant tacrolimus-induced RCVS in a 6-year-old male. The present case highlights the necessity of urgent imaging in suspected cases of RCVS, the potential diagnostic challenges surrounding the etiology of headache, the benefits of treating underlying cerebral vasospasm, and the importance of rapid discontinuation of the offending agent for the remission of symptoms and prevention of long-term sequelae.

Quantifying Intra-Arterial Verapamil Response as a Diagnostic Tool for Reversible Cerebral Vasoconstriction Syndrome

BACKGROUND AND PURPOSE

There is mounting evidence supporting the benefit of intra-arterial administration of vasodilators in diagnosing reversible cerebral vasoconstriction syndrome. We prospectively quantified the degree of luminal diameter dilation after intra-arterial administration of verapamil and its accuracy in diagnosing reversible cerebral vasoconstriction syndrome.

MATERIALS AND METHODS

Patients suspected of having intracranial arteriopathy on noninvasive imaging and referred for digital subtraction angiography were enrolled in a prospective registry. Intra-arterial verapamil was administered in vascular territories with segmental irregularities. The caliber difference (Caliber_post - Caliber_pre) and the proportion of caliber change ([(Caliber_post - Caliber_pre)/Caliber_pre] × 100%) were used to determine the response to verapamil. The diagnosis of reversible cerebral vasoconstriction syndrome was made on the basis of clinical and imaging features at a follow-up appointment, independent of the reversibility of verapamil. Receiver operating characteristic curve analysis was performed to determine the best threshold.

RESULTS

Twenty-six patients were included, and 9 (34.6%) were diagnosed with reversible cerebral vasoconstriction syndrome. A total of 213 vascular segments were assessed on diagnostic angiography. Every patient with a final diagnosis of reversible cerebral vasoconstriction syndrome responded to intra-arterial verapamil. The maximal proportion of change (P < .001), mean proportion of change (P = .002), maximal caliber difference (P = .004), and mean caliber difference (P = .001) were statistically different between patients with reversible cerebral vasoconstriction syndrome and other vasculopathies. A maximal proportion of change  ≥32% showed a sensitivity of 100% and a specificity of 88.2% to detect reversible cerebral vasoconstriction syndrome (area under the curve = 0.951). The Reversible Cerebral Vasoconstriction Syndrome-2 score of  ≥5 points achieved a lower area under the curve (0.908), with a sensitivity of 77.8% and a specificity of 94.1%.

CONCLUSIONS

Objective measurement of the change in the arterial calibers after intra-arterial verapamil is accurate in distinguishing reversible cerebral vasoconstriction syndrome from other vasculopathies. A proportion of change  ≥32% has the best diagnostic performance.