He was initially investigated appropriately for SAH; receiving an unenhanced head CT and lumbar puncture, which were both unremarkable. In the week leading up to the visit described in this case, the patient had presented to the ED three times with a chief complaint of a severe and sudden onset headache. In this case, the time from first symptoms to diagnosis was consistent with previous literature suggesting an average time of nine days to receive a diagnosis [7-8]. Fatal course was linked also to initial focal signs on neurological examination, rapid clinical decline, or initial abnormal imaging suggestive of stroke . Neurology was consulted to assist in patient management. While a rarely made diagnosis in emergency medicine practice, RCVS may be as common as subarachnoid hemorrhage (SAH). doi:10.7759/cureus.8374. Although this may be true, it also remains unclear how multifocal vasospasm could cause usually rather focal subarachnoid hemorrhage. The label RCVS is an attempt to unify these various descriptions of a distinct clinico-radiological pattern. The results of the angiogram confirmed the absence of dissection, stenosis, intracranial aneurysm, or occlusion. Because of this we are asking our users located in the EU to opt in to the data we collect in order to bring a better web experience. Roberts A, Sowers N (May 31, 2020) A Case of Reversible Cerebral Vasoconstriction Syndrome in a Healthy Adult Male. On exam, the patient was in no apparent distress with stable vital signs. Published via the Dalhousie Emergency Medicine Channel. Triggers include elevated catecholamine syndromes, serotonergic medications, illicit drugs and Valsalva-events. His Glasgow Coma Scale (GCS) score was 15/15. Over the nine-day period of headaches, the pain became progressively worse. 1-800-AHA-USA-1 The present case highlights the importance of considering RCVS in all demographics in cases where other risk factors such as vasoactive substance use or a significant family history have been documented. An unenhanced head CT was performed approximately 24 hours after symptom onset, which revealed no significant findings. Customer Service Reversible cerebral vasoconstriction syndrome (RCVS) is characterised by severe headaches, with or without other acute neurological symptoms, and diff use seg mental con- striction of cerebral arteries that resolves spontaneously within 3 months.1,2Manifestations are attributed to a transient disturbance of the regulation of cerebral arterial tone. Cureus 12(5): e8374. Research Article vs Review Article . Power and sensation were normal and equal bilaterally in the upper and lower extremities. Table 1 illustrates the sequence of presentation and investigations the patient received. This case demonstrates an earlier age of presentation than is typically seen in RCVS. Other reports emphasize the value of supportive care and careful observation.13 We will only know whether any treatments are helpful by conducting randomized controlled trials, which will require clearer diagnostic criteria to allow appropriate patient selection. This link will take you to a third party website that is not affiliated with Cureus, Inc. Following this initial workup, he was assessed on several other occasions, treated symptomatically as a migraine, and discharged home. Reversible cerebral vasoconstriction syndrome at the emergency department, Reversible cerebral vasoconstriction syndrome - a narrative revision of the literature, Effect of nimodipine treatment on the clinical course of reversible cerebral vasoconstriction syndrome, Reversible cerebral vasoconstriction syndrome: recognition and treatment, Triptan-induced reversible cerebral vasoconstriction syndrome: two case reports with a literature review, Second unenhanced CT, CT angiogram, pain management. © Copyright 2020Roberts et al. His neurological exam was unremarkable, with no apparent cranial nerve abnormalities. Patients therefore cannot be reassured that RCVS is always benign and will wish to be offered effective treatment. A lumbar puncture performed on his third presentation the following day (seven days since symptom onset) was unremarkable. 1-800-242-8721 Contact Us, Correspondence to Dr David Werring, UCL Institute of Neurology, National Hospital for Neurology and Neurosurgery, Box 6, Queen Square, London WC1N 3BG, UK. A similar syndrome has attracted many different names, depending on whether patients present to specialists in headache, obstetrics, or neurology. RCVS, reversible cerebral vasoconstriction syndrome. The American Heart Association is qualified 501(c)(3) tax-exempt It may well be that therapy needs to be tailored to the underlying causes or mechanisms, although current approaches focus on the shared common factor of vasospasm, which logically might reduce the main complications of infarction and hemorrhage. Indeed, it is the only thing that ever has.". Learn more here. On May 25, 2018, the GDPR (General Data Protection Regulation) went into effect and changed how organizations deal with personal data of customers located in the EU. RCVS can be complicated by stroke, subarachnoidal haemorrhage, or intracerebral haemorrhage which are reported in 39%, 34% and 20% of cases, respectively.116 In PRES, brain MRI may show vasogenic oedema in the parieto-occipital region (70%), often with a symmetrical bihemispheric distribution which is contrasting with PML (figure 4, table 1).117 RCVS and PRES show very similar … The authors argue that the pattern of subarachnoid blood in their cohort (unilateral or bilateral focal cortical) is unlikely to cause multifocal vasospasm. On this occasion, he received metoclopramide, ketorolac, and acetaminophen with codeine for pain management. As such, a CT angiogram (CTA) was conducted, which confirmed a diagnosis of RCVS. On his second presentation with a recurring headache five days later, the patient received similar treatment for pain and was discharged with a diagnosis of migraine. He described a paternal history of a SAH leading to a generalized seizure several years ago. Cureus 12(5): e8374. What causes the high rate of hemorrhagic complications in RCVS? Therefore, the true value of RCVS as a diagnostic entity in the clinic remains uncertain, because it cannot yet reliably guide treatment or prognosis. A similar syndrome has attracted many different names, depending on whether patients present to … High ratings should be reserved for work that is truly groundbreaking in its respective field. The CT scan showed no intracranial hemorrhage, edema, mass, or signs of herniation. In the setting of a firm diagnosis of RCVS, some advocate treatment with a calcium channel blocker either alone or combined with a faster tapering course of prednisone than would be used in PACNS. A Case of Reversible Cerebral Vasoconstriction Syndrome in a Healthy Adult Male. He had no signs of meningeal irritation. Reversible cerebral vasoconstriction syndrome (RCVS) represents a potentially under-recognized cause of thunderclap headache in patients presenting to the ED. and The features of what is now called RCVS have been repeatedly recognized, especially since an influential early report by Drs Call and Fleming et al1 published in 1988. Anything above 5 should be considered above average. The patient denied fever, chills, and any neurological deficits. E-mail. Another important feature that has not been documented in the literature is the patient's family history of a parental thunderclap headache and suspected SAH. How often is thunderclap headache caused by the reversible cerebral vasoconstriction syndrome? However, before treatment for RCVS can be confidently recommended, trials targeting those at highest risk for poor outcome with rational therapeutic approaches are needed; however, such studies must await a clearer understanding of the underlying mechanisms and prognostic indicators. The present study has clearly shown that the prognosis is often not benign because cerebral hemorrhage and infarction may occur, with a significant minority unable to work because of persistent deficits at 6 months. organization. No acute infarct was evident. Share this article with your colleagues. Scholarly Impact Quotient™ (SIQ™) is our unique post-publication peer review rating process. Reviewing with Cureus is easy, fast and hassle-free! Although RCVS generally resolves without significant sequelae, a rare and possibly underrecognized hemorrhagic presentation has a worse potential … His pupils were equal and reactive to light.


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