Reversible cerebral vasoconstriction syndrome successfully treated by intrathecal nicardipine

Zeitouni, Daniel; Parish, Jonathan; Smith, Mitchell T.; Stetler, William R.; Bernard, J

doi:10.1016/j.clineuro.2021.106705

Cited by 5 publications

(6 citation statements)

References 4 publications

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“…According to two of the four main studies, the most frequent precipitating factors, accounting for 31% of cases overall, are vasoactive medications (especially serotonergic drugs) and the postpartum period [6,67]. Vasoactive substances mainly include serotonergic drugs, such as selective serotonin reuptake inhibitors (SSRIs); serotonin-noradrenaline reuptake inhibitors (SNRIs); 3,4-methylenedioxymethamphetamine (ecstasy); and triptans and sympathomimetics with serotonergic effects, such as over-the-counter drugs for upper respiratory tract infections (e.g., pseudoephedrine), amphetamines, cocaine, and ergot derivatives [13,14,49,50,[68][69][70]. The use of these substances in combination with each other or with cannabis or opioids (which also have known SSRI effects) has already led to fatal cases of RCVS [46,53,[71][72][73].…”

Section: Risk Factors and Triggersmentioning

confidence: 99%

RCVS: by clinicians for clinicians—a narrative review

2022

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Background/Objective Reversible cerebral vasoconstriction syndrome may be underdiagnosed. It can be accompanied by various complications, mainly intracerebral hemorrhage and ischemic stroke. The clinical presentation of this condition varies according to its localization. The aims of this review are to raise awareness of the disease, especially in the presence of corresponding risk factors; to connect its precipitating factors, pathophysiology, and complications; and to compare various differential diagnoses of vasoconstriction. Methods A review of the literature in PubMed/MEDLINE and Google Scholar was conducted from May 1997 until May 2022. Results Reversible cerebral vasoconstriction syndrome, which is a clinical–radiological syndrome, is mainly characterized by the occurrence of thunderclap headache and widespread vasoconstriction. The most common precipitating factors are the use of vasoactive substances and postpartum status. The pathophysiology is currently assumed to include two mechanisms: sympathetic overactivity and endothelial dysfunction. From these mechanisms, it is possible to derive potential complications as well as the most important differential diagnoses: posterior reversible encephalopathy syndrome, convexity subarachnoid hemorrhage, ischemic and hemorrhagic stroke, and primary angiitis of the central nervous system. Conclusion In general, the outcome of reversible cerebral vasoconstriction syndrome is very good. Vasospasm as well as thunderclap headache attacks can be fully reversible, and > 90% of patients are functionally independent at discharge.

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Section: Risk Factors and Triggersmentioning

confidence: 99%

RCVS: by clinicians for clinicians—a narrative review

2022

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“…In this approach, the patient was discharged in a stable condition when it was verified that his weakness improved significantly [ 46 ]. In another report, a 36-year-old woman with headache, paresis, positive neurological examination for ataxia of the upper limb, and decreased sensitivity to touch, temperature, and vibration on the left side, while receiving treatment with intrathecal nicardipine, she obtained an improvement of the arterial vasospasm evidenced on angiography [ 77 ].…”

Section: Discussionmentioning

confidence: 99%

Reversible cerebral vasoconstriction syndrome: literature review

Ribas

Paticcié

Medeiros³

et al. 2023

Egypt J Neurol Psychiatry Neurosurg

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Reversible Cerebral Vasoconstriction Syndrome (RCVS) is a neurovascular condition characterized by a severe sudden-onset headache that may be associated with focal neurological deficits. On imaging, the suggestive finding corresponds to multifocal vasoconstriction of the cerebral arteries, with a spontaneous resolution of approximately 12 weeks. The identification of precipitating factors and diagnosis must be carried out early, so that adequate management is established and the patient has a good prognosis, given the risk of secondary complications and residual neurological deficits. This study consists of a literature review based on the analysis of articles published between 2017 and 2022 in PubMed, SciELO, and ScienceDirect on RCVS, intending to understand the clinical and radiological characteristics, diagnosis, treatment, and prognosis of patients with RCVS. The pathophysiology, drug management, and prognosis still lack solid evidence; therefore, further studies on RCVS are needed to expand medical knowledge and avoid underdiagnosis and inadequate treatment of this important condition.

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“…Nicardipine, another type of L-type calcium channel blocker, may prove effective in RCVS treatment because of its ability to penetrate the blood-brain barrier. However, to date, few case reports have discussed the use of intrathecal (IT) or continuous IA administration of nicardipine for the treatment of severe RCVS [1,[5][6][7][8]. In this paper, we present the case of a 58-year-old female who presented with refractory RCVS, non-responsive to oral calcium channel blocker, ultimately requiring concomitant IT and continuous IA nicardipine for treatment.…”

Section: Introductionmentioning

confidence: 99%

“…Reversible cerebral vasoconstriction syndrome (RCVS) is an increasingly recognized entity characterized by the development of segmental cerebral artery narrowing and dilation that commonly resolves spontaneously in three months. RCVS often presents as a severe “thunderclap” headache with or without focal neurological symptoms [ 1 ]. The course of RCVS is often benign, with an estimated 4% of patients left with severe disabilities [ 2 ].…”

Section: Introductionmentioning

confidence: 99%

“…Treatment modalities for RCVS have not been fully established, as there is sparse literature. Currently, oral and intraarterial (IA) calcium channel blockers, balloon angioplasty, and milrinone have been used [ 1 ]. The often-used calcium channel blocker nimodipine has no proven effect on the time course of cerebral vasoconstriction or hemorrhagic and ischemic complications [ 4 ].…”

Section: Introductionmentioning

confidence: 99%

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Intrathecal Nicardipine for Severe Intractable Reversible Cerebral Vasoconstriction Syndrome: A Novel Case Report

Wakefield¹,

Ngo²,

Naydin³

et al. 2023

Cureus

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Reversible cerebral vasoconstriction syndrome (RCVS) is a poorly understood but increasingly recognized entity, likely multifactorial in nature and characterized by diffuse cerebral vasospasm that presents as sudden, intense, and fluctuating headaches. Due to insufficient evidence, there is currently no consensus on RCVS treatment guidelines. However, nicardipine, an L-type calcium channel blocker, may prove effective in RCVS treatment because of its ability to penetrate the blood-brain barrier. We report the concomitant use of intrathecal (IT) nicardipine and continuous intraarterial (IA) nicardipine infusion via microcatheter placed in the intracranial circulation for the treatment of a 58-year-old female with severe refractory RCVS. On presentation, this patient was noted to have a non-traumatic non-aneurysmal subarachnoid hemorrhage secondary to RCVS. Initially managed with oral verapamil, she later developed refractory symptomatic vasoconstriction requiring multiple angiograms for spasmolysis via balloon angioplasty and IA nicardipine. Due to the refractory nature of her spasm despite the IA therapy, we decided to attempt intrathecal nicardipine, starting at 4 mg q12 h via an external ventricular drain. This dose was escalated to 4 mg q6 h. The patient stabilized for 24 h but again decompensated, requiring continuous IA spasmolysis via a microcatheter placed in the left middle cerebral artery and left for continuous IA nicardipine infusion (5 mg/h). The patient showed slow incremental improvement clinically and a decrease in vasospasms on imaging, ultimately suffering minimal stroke burden. This patient's hospital course demonstrates that nicardipine, administered intrathecally or intraarterially, could be beneficial in select patients with refractory RCVS as a means of minimizing repeat angiography/angioplasty. Further studies are needed to better define a treatment paradigm for these patients.

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Reversible cerebral vasoconstriction syndrome successfully treated by intrathecal nicardipine

Cited by 5 publications

References 4 publications

RCVS: by clinicians for clinicians—a narrative review

RCVS: by clinicians for clinicians—a narrative review

Reversible cerebral vasoconstriction syndrome: literature review

Intrathecal Nicardipine for Severe Intractable Reversible Cerebral Vasoconstriction Syndrome: A Novel Case Report

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