CLINICAL IMAGE
A 31-year-old with idiopathic reversible cerebral vasoconstriction syndrome Ihtesham A. Qureshi1
, Mohtashim A. Qureshi1, Obiajulu Kanu2
& Salvador Cruz-Flores1
1
Neurology Department, Texas Tech University Health Sciences Center, 4800 Alberta Avenue, El Paso, Texas 79905 Internal Medicine Department, Texas Tech University Health Sciences Center, 4800 Alberta Avenue, El Paso, Texas 79905
2
Correspondence Ihtesham A. Qureshi, Neurology Department, Texas Tech University Health Sciences Center, 4800 Alberta Avenue, El Paso 79905, TX. Tel: 915-215-5911; Fax: 915-545-6705; E-mail: [email protected]
Funding Information No sources of funding were declared for this study Received: 4 May 2017; Revised: 6 June 2017; Accepted: 19 June 2017
Key Clinical Message In our patient with reversible cerebral vasoconstriction syndrome (RCVS) syndrome, presenting with thunderclap-like headache, there is a possibility to be readily confused with migraine. Initiating treatment with selective serotonin reuptake inhibitors (SSRIs) and triptans can further aggravate the condition. Therefore, it is essential to understand the nature and type of headache and correlate the clinical findings with imaging studies. Keywords Cerebral angiogram, migraine, reversible cerebral vasoconstriction syndrome, thunderclap headache.
Clinical Case Reports 2017; 5(9): 1544–1545 doi: 10.1002/ccr3.1090
A 31-year-old female presented with severe headache that started a week ago not relieved on pain medications, comes to the hospital with severe headache, intermittent, pulsatile, throbbing type, located over the frontal region bilaterally radiating to the back of the head associated with three episodes of non-bloody, non-bilious vomiting. Computed tomography (CT) of head without contrast,
Figure 1. Computed tomography (CT) head and brain without contrast is negative for acute intracranial pathology.
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lumbar puncture, and CT angiogram head were negative (Figs 1 and 2). Secondary causes for reversible cerebral vasoconstriction syndrome (RCVS) like subarachnoid hemorrhage (SAH) were ruled out from negative computed tomography head (CT) and lumbar puncture (LP), while vasculitis was excluded from the laboratory findings
Figure 2. Computed tomography (CT) angiogram with IV contrast was negative for acute intracranial abnormalities, intra-cranial arterial flow limiting stenosis, aneurysms, dissections, occlusion, or vascular malformations.
ª 2017 The Authors. Clinical Case Reports published by John Wiley & Sons Ltd. This is an open access article under the terms of the Creative Commons Attribution License, which permits use, distribution and reproduction in any medium, provided the original work is properly cited.
I. A. Qureshi et al.
Reversible cerebral vasoconstriction syndrome
(A)
that showed normal erythrocyte sedimentation rate (ESR), anti-nuclear antibody (ANA), anti-neutrophil cytoplasmic antibody (ANCA) P&C, cryoglobulin, complement, rheumatoid factor (RF), anti SS-A and SS-B levels along with unremarkable cerebrospinal fluid analysis (CSF). The patient was started on sertraline and sumatriptan with no relief. Neurology was consulted to evaluate the headache. They recommended to stop both medications and initiate with magnesium, solumedrol, and verapamil [1, 2]. Cerebral angiogram was performed and demonstrated the imaging stigmata of RCVS (Fig. 3A and B). Patient’s headache improved and was discharged on verapamil with follow up within 4–6 weeks.
(B)
Conflict of Interest None declared.
Authorship IAQ: involved in manuscript writing; MAQ: involved in critical revision of the manuscript; OK and SCF: involved in patient care. References
Figure 3. (A) Cerebral angiogram shows multiple areas of arterial constriction in the anterior and posterior circulations findings consistent with reversible cerebral vasoconstriction syndrome. (B) Cerebral angiogram shows multiple areas of arterial constriction in the anterior and posterior circulations findings consistent with reversible cerebral vasoconstriction syndrome.
ª 2017 The Authors. Clinical Case Reports published by John Wiley & Sons Ltd.
1. Kato, Y., T. Hayashi, S. Mizuno, Y. Horiuchi, M. Ohira, N. Tanahashi, et al. 2016. Triptan-induced Reversible Cerebral Vasoconstriction Syndrome: two case reports with a literature review. Intern. Med. 55:3525–3528. 2. Theeler, B. J., M. V. Krasnokutsky, and B. R. Scott. 2010. Exertional reversible cerebral vasoconstriction responsive to verapamil. Neurol. Sci. 31:773–775.
1545
A 31-year-old with idiopathic reversible cerebral vasoconstriction syndrome Ihtesham A. Qureshi1
, Mohtashim A. Qureshi1, Obiajulu Kanu2
& Salvador Cruz-Flores1
1
Neurology Department, Texas Tech University Health Sciences Center, 4800 Alberta Avenue, El Paso, Texas 79905 Internal Medicine Department, Texas Tech University Health Sciences Center, 4800 Alberta Avenue, El Paso, Texas 79905
2
Correspondence Ihtesham A. Qureshi, Neurology Department, Texas Tech University Health Sciences Center, 4800 Alberta Avenue, El Paso 79905, TX. Tel: 915-215-5911; Fax: 915-545-6705; E-mail: [email protected]
Funding Information No sources of funding were declared for this study Received: 4 May 2017; Revised: 6 June 2017; Accepted: 19 June 2017
Key Clinical Message In our patient with reversible cerebral vasoconstriction syndrome (RCVS) syndrome, presenting with thunderclap-like headache, there is a possibility to be readily confused with migraine. Initiating treatment with selective serotonin reuptake inhibitors (SSRIs) and triptans can further aggravate the condition. Therefore, it is essential to understand the nature and type of headache and correlate the clinical findings with imaging studies. Keywords Cerebral angiogram, migraine, reversible cerebral vasoconstriction syndrome, thunderclap headache.
Clinical Case Reports 2017; 5(9): 1544–1545 doi: 10.1002/ccr3.1090
A 31-year-old female presented with severe headache that started a week ago not relieved on pain medications, comes to the hospital with severe headache, intermittent, pulsatile, throbbing type, located over the frontal region bilaterally radiating to the back of the head associated with three episodes of non-bloody, non-bilious vomiting. Computed tomography (CT) of head without contrast,
Figure 1. Computed tomography (CT) head and brain without contrast is negative for acute intracranial pathology.
1544
lumbar puncture, and CT angiogram head were negative (Figs 1 and 2). Secondary causes for reversible cerebral vasoconstriction syndrome (RCVS) like subarachnoid hemorrhage (SAH) were ruled out from negative computed tomography head (CT) and lumbar puncture (LP), while vasculitis was excluded from the laboratory findings
Figure 2. Computed tomography (CT) angiogram with IV contrast was negative for acute intracranial abnormalities, intra-cranial arterial flow limiting stenosis, aneurysms, dissections, occlusion, or vascular malformations.
ª 2017 The Authors. Clinical Case Reports published by John Wiley & Sons Ltd. This is an open access article under the terms of the Creative Commons Attribution License, which permits use, distribution and reproduction in any medium, provided the original work is properly cited.
I. A. Qureshi et al.
Reversible cerebral vasoconstriction syndrome
(A)
that showed normal erythrocyte sedimentation rate (ESR), anti-nuclear antibody (ANA), anti-neutrophil cytoplasmic antibody (ANCA) P&C, cryoglobulin, complement, rheumatoid factor (RF), anti SS-A and SS-B levels along with unremarkable cerebrospinal fluid analysis (CSF). The patient was started on sertraline and sumatriptan with no relief. Neurology was consulted to evaluate the headache. They recommended to stop both medications and initiate with magnesium, solumedrol, and verapamil [1, 2]. Cerebral angiogram was performed and demonstrated the imaging stigmata of RCVS (Fig. 3A and B). Patient’s headache improved and was discharged on verapamil with follow up within 4–6 weeks.
(B)
Conflict of Interest None declared.
Authorship IAQ: involved in manuscript writing; MAQ: involved in critical revision of the manuscript; OK and SCF: involved in patient care. References
Figure 3. (A) Cerebral angiogram shows multiple areas of arterial constriction in the anterior and posterior circulations findings consistent with reversible cerebral vasoconstriction syndrome. (B) Cerebral angiogram shows multiple areas of arterial constriction in the anterior and posterior circulations findings consistent with reversible cerebral vasoconstriction syndrome.
ª 2017 The Authors. Clinical Case Reports published by John Wiley & Sons Ltd.
1. Kato, Y., T. Hayashi, S. Mizuno, Y. Horiuchi, M. Ohira, N. Tanahashi, et al. 2016. Triptan-induced Reversible Cerebral Vasoconstriction Syndrome: two case reports with a literature review. Intern. Med. 55:3525–3528. 2. Theeler, B. J., M. V. Krasnokutsky, and B. R. Scott. 2010. Exertional reversible cerebral vasoconstriction responsive to verapamil. Neurol. Sci. 31:773–775.
1545
