A novel approach to diagnose reversible cerebral vasoconstrictive syndrome: a case report

SESSION TITLE: Critical Care Case Report Posters 29 SESSION TYPE: Case Report Posters PRESENTED ON: 10/09/2023 02:10 pm - 02:55 pm INTRODUCTION: Reversible Cerebral Vasoconstriction Syndrome (RCVS) (Call-Fleming syndrome) is a serious neurovascular disease. Although symptoms of this disease may be reversible, complications such as seizures, cerebral edema, and stroke can occur leading to permanent disability and death. RCVS is believed to be caused by autonomic dysfunction leading to both cerebral artery and arteriole constriction and dilation. Potential triggers include pregnancy, stress, trauma, and drugs including serotonin & dopaminergic agonists among others. Diagnosis is often delayed given the lack of specific diagnostic criteria and the clinical similarities it shares with other neurovascular conditions. There are, however, tools currently available to assist clinicians in differentiating RCVS and supporting the diagnosis such as the RCVS2 score and the temporal response to intra-arterial (IA) verapamil. CASE PRESENTATION: We present a case of a woman who was diagnosed and treated for suspected RCVS after using escitalopram and sumatriptan for depression and headaches. She presented with an acute "thunderclap" headache accompanied by vision loss. After a thorough medical work up the diagnosis of RCVS was made based on her medical history, clinical presentation, diagnostic imaging, RCVS2 score, and response to IA verapamil during four vessel cerebral angiography. She was taken off escitalopram and sumatriptan, and was treated with calcium channel blockers resulting in near resolution of cerebral artery vasospasms and a partial clinical recovery. The patient remained stable and continued to improve neurologically at the three-month mark. DISCUSSION: Due to her clinical improvement she declined the repeat cerebral angiogram to confirm resolution of the spasms. Despite this, we believe the temporal response to the IA verapamil together with the RCVS2 score is sufficient in diagnosing RCVS without a confirmatory three-month angiogram. CONCLUSIONS: Though diagnostic imaging and scoring systems help to evaluate RCVS, there is a need for expanded research on the topic in order to improve the accuracy and methods of diagnosing RCVS as well as the efficacy of treatment options. REFERENCE #1: 1. Togha, Mansoureh, et al. "Reversible Cerebral Vasoconstriction Syndrome (RCVS): An Interesting Case Report - The Journal of Headache and Pain." BioMed Central, Springer Milan, 6 Apr. 2021, https://thejournalofheadacheandpain.biomedcentral.com/articles/10.1186/s10194-021-01225-7. REFERENCE #2: 2. Sattar, Ahsan, et al. "Systematic Review of Reversible Cerebral Vasoconstriction Syndrome." Expert Review of Cardiovascular Therapy, U.S. National Library of Medicine, Oct. 2010, https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3020907/. REFERENCE #3: 3. Ba, Fang, et al. "A Reversible Cerebral Vasoconstriction Syndrome." BMJ Case Reports, U.S. National Library of Medicine, 11 July 2012, https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3417010/. DISCLOSURES: No relevant relationships by Sami Borno No disclosure on file for Mohamad Fayad No relevant relationships by yema jalal No relevant relationships by Yi Mcwhorter Consultant relationship with Ceribell Inc Please note: 01/07/2021 Added 03/31/2023 by Robert Riggio, source=Web Response, value=Consulting fee