Fulminant Reversible Cerebral Vasoconstriction Syndrome in Breakthrough COVID 19 Infection

Abstract

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RCVS: by clinicians for clinicians—a narrative review

“…A limited number of case reports and one small case series of RCVS related to COVID-19, including mild respiratory infection, have been published [52,[80][81][82]. In 30% of COVID-19 patients with RCVS, none of the previously known precipitants could be detected [80].…”

“…RCVS can occur spontaneously/idiopathically, without a precipitating factor; in other patients, it occurs secondarily (approximately 40-60% of cases) [1,46]. The precipitating factors and triggers of RCVS and TCH, respectively, are manifold (Table 4), which illustrates why the exact pathophysiology is not yet fully understood [11,12,17,[47][48][49][50][51][52][53][54][55][56][57][58][59][60][61]. Trigger factors for the most severe headache in a patient's life can include coughing, bathing, physical exertion, Valsalva maneuvers, and sexual activity [55,[62][63][64][65].…”

“…In 30% of COVID-19 patients with RCVS, none of the previously known precipitants could be detected [80]. Enhanced activation of the classical renin-angiotensin system (RAS) axis with sympathetic overactivation, which may lead to vasoconstriction of cerebral vessels, was postulated to occur via downregulation of the angiotensin-converting enzyme 2 (ACE2) receptor directly by SARS-CoV-2 [52,81,83]. This mechanism, as well as a coagulopathic/proinflammatory state in the context of critical illness, is also known to lead to ischemia in the context of COVID-19 [84].…”

Pathophysiology of reversible cerebral vasoconstriction syndrome

“…Patients may be left with permanent neurological deficits [ 14 , 16 , 17 , 32 ]. Death has also been reported in a few cases [ 17 , 33 , 34 ]. Calcium channel blockers, particular nimodipine, may be helpful for aborting headaches [ 2 , 14 , 35 ].…”

Reversible cerebral vasoconstriction syndrome: literature review

“…The largest studies suggest that 50–80% of patients will have a secondary cause for RCVS [ 1 , 10 , 19 , 35 , 41 , 44 ]. The main precipitating factors described are: postpartum state [ 7 , 10 , 13 , 14 , 16 , 25 , 31 , 35 , 39 , 45 – 47 ], drugs with vasoactive properties [ 10 , 12 – 14 , 36 , 39 , 47 , 48 ], such as cocaine, marijuana, and heroin [ 33 , 39 ], catecholamine-secreting tumors [ 35 , 49 – 51 ], autoimmune disorders, such as systemic vasculitis, systemic lupus erythematous, antiphospholipid syndrome [ 13 ], blood transfusions, ginseng [ 5 , 6 ], sexual intercourse, temperature differences (baths too hot or too cold), air travel [ 39 , 48 ], Corona Virus Disease 2019 (COVID-19) infection [ 36 , 52 – 54 ] and medications [ 6 , 29 , 39 , 48 ].…”