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“Thunderclap” headache in a patient with depression: Answer
Journal of Clinical Neuroscience xxx (2016) xxx–xxx
Contents lists available at ScienceDirect
Journal of Clinical Neuroscience journal homepage: www.elsevier.com/locate/jocn
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‘‘Thunderclap” headache in a patient with depression: Answer Junwei Zhang a,⇑, Gopinathan Anil a,b a
Department of Diagnostic Imaging, National University Hospital, Level 2 Main Building, 5 Lower Kent Ridge Road, Singapore 119074, Singapore Department of Diagnostic Radiology, Yong Loo Lin School of Medicine, National University of Singapore, NUHS Tower Block, Level 11, 1E Kent Ridge Road, Singapore 119228, Singapore b
1. Answer C. Reversible cerebral vasoconstriction syndrome (RCVS). 2. Discussion Non-contrast CT scan (Fig. 1A of Images in Neuroscience: Question) showed a small left frontal convexity subarachnoid haemorrhage (cSAH). CT angiography was unremarkable (not shown). MRI (Fig. 1B of Images in Neuroscience: Question) revealed bilateral parieto-occipital T2/FLAIR hyperintensities, which were consistent with posterior reversible encephalopathy syndrome (PRES) [1]. Cerebral angiogram showed multifocal short segments of narrowing, predominantly in the distal cortical branches of the left anterior and middle cerebral arteries (Fig. 1C of Images in Neuroscience: Question) as well as proximal left superior cerebellar artery and multiple other vascular territories (Fig. 1). There was no aneurysm or vascular malformation. The diagnosis was RCVS complicated by cSAH, probably triggered by selective serotonin-reuptake inhibitor (SSRI) usage. Our patient was managed conservatively with cessation of SSRI, blood pressure control and seizure prophylaxis. Symptoms resolved during admission and MRI findings resolved at one-month follow-up. RCVS (also known as Call-Fleming syndrome) typically affects young to middle-aged females. It may be spontaneous or secondary to exogenous triggers (in 25–60% of cases), which include vasoactive drugs e.g. SSRIs, migraine medications, sympathomimetic nasal decongestants, pregnancy and the postpartum state, and a history of migraine [2–4]. The underlying pathophysiology is uncertain, although dysregulation of cerebral vascular tone likely plays a role [2]. RCVS is characterised by presentation with ‘‘thunderclap” headache and evidence of cerebral vasoconstriction on imaging studies [3]. Other diagnostic criteria include a uniphasic disease course, no evidence for aneurysmal SAH, reversibility of angiographic findings and unremarkable cerebrospinal fluid (CSF) analysis [5]. RCVS can be complicated by non-aneurysmal cSAH (30–34%) and associated with PRES-like cerebral oedema (9–38%) [3], both of which were present in our patient. DOI of question: http://dx.doi.org/10.1016/j.jocn.2016.09.007
⇑ Corresponding author. Fax: +65 6779 5678.
E-mail addresses: [email protected] (J. Zhang), [email protected] (G. Anil).
Fig. 1. (A) Right internal carotid artery and (B) right vertebral artery cerebral angiograms show multifocal segmental vasoconstriction (arrows) in multiple vascular territories.
Primary angiitis of the central nervous system (PACNS) can cause a similar angiographic appearance [6]. However, the older male patient profile, pleocytosis and elevated protein on CSF usually allow confident distinction from RCVS [6,7]. cSAH and PRES are also much less common in PACNS [6,7]. Increased recognition of RCVS and its association with nonaneurysmal cSAH and PRES would allow prompt diagnosis and appropriate prognostication of this relatively benign entity, avoiding repeated angiograms searching for the cause of SAH. Financial disclosures and conflicts of interest None. References [1] Bartynski WS. Posterior reversible encephalopathy syndrome, part 1: fundamental imaging and clinical features. AJNR Am J Neuroradiol 2008;29:1036–42. [2] Miller TR, Shivashankar R, Mossa-Basha M, et al. Reversible cerebral vasoconstriction syndrome, part 1: epidemiology, pathogenesis, and clinical course. AJNR Am J Neuroradiol 2015;36:1392–9. [3] Ducros A. Reversible cerebral vasoconstriction syndrome. Lancet Neurol 2012;11:906–17. [4] Chen SP, Fuh JL, Wang SJ. Reversible cerebral vasoconstriction syndrome: current and future perspectives. Expert Rev Neurother 2011;11:1265–76. [5] Calabrese LH, Dodick DW, Schwedt TJ, et al. Narrative review: reversible cerebral vasoconstriction syndromes. Ann Intern Med 2007;146:34–44. [6] Miller TR, Shivashankar R, Mossa-Basha M, et al. Reversible cerebral vasoconstriction syndrome, part 2: diagnostic work-up, imaging evaluation, and differential diagnosis. AJNR Am J Neuroradiol 2015;36:1580–8. [7] Hajj-Ali RA, Singhal AB, Benseler S, et al. Primary angiitis of the CNS. Lancet Neurol 2011;10:561–72.
http://dx.doi.org/10.1016/j.jocn.2016.09.009 0967-5868/Ó 2016 Elsevier Ltd. All rights reserved.
Please cite this article in press as: Zhang J, Anil G. ‘‘Thunderclap” headache in a patient with depression: Answer. J Clin Neurosci (2016), http://dx.doi.org/ 10.1016/j.jocn.2016.09.009
Contents lists available at ScienceDirect
Journal of Clinical Neuroscience journal homepage: www.elsevier.com/locate/jocn
Images
‘‘Thunderclap” headache in a patient with depression: Answer Junwei Zhang a,⇑, Gopinathan Anil a,b a
Department of Diagnostic Imaging, National University Hospital, Level 2 Main Building, 5 Lower Kent Ridge Road, Singapore 119074, Singapore Department of Diagnostic Radiology, Yong Loo Lin School of Medicine, National University of Singapore, NUHS Tower Block, Level 11, 1E Kent Ridge Road, Singapore 119228, Singapore b
1. Answer C. Reversible cerebral vasoconstriction syndrome (RCVS). 2. Discussion Non-contrast CT scan (Fig. 1A of Images in Neuroscience: Question) showed a small left frontal convexity subarachnoid haemorrhage (cSAH). CT angiography was unremarkable (not shown). MRI (Fig. 1B of Images in Neuroscience: Question) revealed bilateral parieto-occipital T2/FLAIR hyperintensities, which were consistent with posterior reversible encephalopathy syndrome (PRES) [1]. Cerebral angiogram showed multifocal short segments of narrowing, predominantly in the distal cortical branches of the left anterior and middle cerebral arteries (Fig. 1C of Images in Neuroscience: Question) as well as proximal left superior cerebellar artery and multiple other vascular territories (Fig. 1). There was no aneurysm or vascular malformation. The diagnosis was RCVS complicated by cSAH, probably triggered by selective serotonin-reuptake inhibitor (SSRI) usage. Our patient was managed conservatively with cessation of SSRI, blood pressure control and seizure prophylaxis. Symptoms resolved during admission and MRI findings resolved at one-month follow-up. RCVS (also known as Call-Fleming syndrome) typically affects young to middle-aged females. It may be spontaneous or secondary to exogenous triggers (in 25–60% of cases), which include vasoactive drugs e.g. SSRIs, migraine medications, sympathomimetic nasal decongestants, pregnancy and the postpartum state, and a history of migraine [2–4]. The underlying pathophysiology is uncertain, although dysregulation of cerebral vascular tone likely plays a role [2]. RCVS is characterised by presentation with ‘‘thunderclap” headache and evidence of cerebral vasoconstriction on imaging studies [3]. Other diagnostic criteria include a uniphasic disease course, no evidence for aneurysmal SAH, reversibility of angiographic findings and unremarkable cerebrospinal fluid (CSF) analysis [5]. RCVS can be complicated by non-aneurysmal cSAH (30–34%) and associated with PRES-like cerebral oedema (9–38%) [3], both of which were present in our patient. DOI of question: http://dx.doi.org/10.1016/j.jocn.2016.09.007
⇑ Corresponding author. Fax: +65 6779 5678.
E-mail addresses: [email protected] (J. Zhang), [email protected] (G. Anil).
Fig. 1. (A) Right internal carotid artery and (B) right vertebral artery cerebral angiograms show multifocal segmental vasoconstriction (arrows) in multiple vascular territories.
Primary angiitis of the central nervous system (PACNS) can cause a similar angiographic appearance [6]. However, the older male patient profile, pleocytosis and elevated protein on CSF usually allow confident distinction from RCVS [6,7]. cSAH and PRES are also much less common in PACNS [6,7]. Increased recognition of RCVS and its association with nonaneurysmal cSAH and PRES would allow prompt diagnosis and appropriate prognostication of this relatively benign entity, avoiding repeated angiograms searching for the cause of SAH. Financial disclosures and conflicts of interest None. References [1] Bartynski WS. Posterior reversible encephalopathy syndrome, part 1: fundamental imaging and clinical features. AJNR Am J Neuroradiol 2008;29:1036–42. [2] Miller TR, Shivashankar R, Mossa-Basha M, et al. Reversible cerebral vasoconstriction syndrome, part 1: epidemiology, pathogenesis, and clinical course. AJNR Am J Neuroradiol 2015;36:1392–9. [3] Ducros A. Reversible cerebral vasoconstriction syndrome. Lancet Neurol 2012;11:906–17. [4] Chen SP, Fuh JL, Wang SJ. Reversible cerebral vasoconstriction syndrome: current and future perspectives. Expert Rev Neurother 2011;11:1265–76. [5] Calabrese LH, Dodick DW, Schwedt TJ, et al. Narrative review: reversible cerebral vasoconstriction syndromes. Ann Intern Med 2007;146:34–44. [6] Miller TR, Shivashankar R, Mossa-Basha M, et al. Reversible cerebral vasoconstriction syndrome, part 2: diagnostic work-up, imaging evaluation, and differential diagnosis. AJNR Am J Neuroradiol 2015;36:1580–8. [7] Hajj-Ali RA, Singhal AB, Benseler S, et al. Primary angiitis of the CNS. Lancet Neurol 2011;10:561–72.
http://dx.doi.org/10.1016/j.jocn.2016.09.009 0967-5868/Ó 2016 Elsevier Ltd. All rights reserved.
Please cite this article in press as: Zhang J, Anil G. ‘‘Thunderclap” headache in a patient with depression: Answer. J Clin Neurosci (2016), http://dx.doi.org/ 10.1016/j.jocn.2016.09.009