Gender and hormonal influences in reversible cerebral vasoconstriction syndrome

Abstract

Introduction: The reversible cerebral vasoconstriction syndromes, including postpartum angiopathy, have been characterized over the last decade. Women are predominantly affected. Some studies suggest that postpartum angiopathy carries a worse prognosis. Patients and methods: We compared the clinical, neuroimaging, and angiographic features of 36 men, 110 nonpregnant women and 16 postpartum women included in our single-center cohort of patients with reversible cerebral vasoconstriction syndromes encountered from 1998 to 2016. Results: As compared to men, non-pregnant women were older (48 AE 11 vs. 34 AE 13 years, p < 0.001), had more underlying migraine (49% vs. 19%, p ¼ 0.002), depression (53% vs. 14%, p < 0.001) and serotonergic antidepressant use (45% vs. 11%, p < 0.001), developed more clinical worsening (18% vs. 3%, p ¼ 0.022), more infarcts (39% vs. 20%, p ¼ 0.031) and worse angiographic severity scores (23 AE 14 vs. 10.9 AE 10.3, p < 0.001), but had similar discharge outcomes (modified Rankin scale scores 0-3, 90% vs. 91%, p ¼ 0.768). Sexual activity was an important trigger in men (22% vs. 4%, p ¼ 0.002). As compared to non-pregnant women, postpartum angiopathy patients were younger (33 AE 6 years, p < 0.001) and had less vasoconstrictive drug exposure (25% vs. 67%, p ¼ 0.002) but showed similar clinical, radiological and angiographic findings and similar discharge outcomes (modified Rankin scale scores 0-3 in 94%, p ¼ 0.633). There were no significant differences between pre-and post-menopausal women, or those with and without hysterectomy. Discussion/Conclusion: The observed gender differences in reversible cerebral vasoconstriction syndromes may result from hormonal or non-hormonal factors. Hormonal imbalances may trigger reversible cerebral vasoconstriction syndromes. Given the absence of significant differences in the female subgroups, hormonal factors do not appear to significantly affect the course or outcome of reversible cerebral vasoconstriction syndromes.

Cerebrovascular disease in women

“…This postpartum angiopathy usually occurs within 2 weeks post-delivery. 152,154,156 OCs and HT may also increase risk. Furthermore, women are shown to have a more severe clinical syndrome than men, with more severe focal deficits, higher frequency of clinical and radiological worsening, more widespread vasoconstriction, and a longer hospitalization.…”

“…154 Female hormones have been postulated to play a role in triggering this disease; however, there are no discernible differences in the clinical course and outcomes between various female subgroups regardless of pregnancy, menopause, or hysterectomy status. 154 The combined case fatality is reported to be less than 1%. 152 Long-term outcomes are usually favorable; however, some patients may have residual deficits from stroke.…”

Cerebral Arteriopathies, Venous Thrombosis, and Migraine

“…56 Up to one-third of patients do not have any identifiable trigger; however, the majority has been associated with exposure to vasoconstrictive medications, illicit drugs, over-the-counter agents, sexual activity, high altitude, and hormonal influences. [57][58][59] Most patients have normal early brain parenchymal imaging findings despite the presence of significant angiographic abnormalities. Over the ensuing 1 to 2 weeks, approximately one-third to two-thirds develop ischemic stroke, convexity (nonaneurysmal) subarachnoid hemorrhage, parenchymal hemorrhage, and reversible brain edema, either alone or in combination.…”

Grief-induced reversible cerebral vasoconstriction syndrome (RCVS)

“…The pathophysiology of RCVS remains unclear. Female predominance may suggest hormonal influences, particularly given the increased risk during pregnancy and the postpartum period 1. Increased sympathomimetic activity triggered by sexual activity, ingestion of sympathomimetic drugs and the increased incidence of RCVS in patients with a prior history of serotonergic antidepressant use could alternatively suggest biochemical triggers 2 3.…”