Intra‐Arterial Milrinone for Reversible Cerebral Vasoconstriction Syndrome

Bouchard, Manon; Verreault, Steve; Gariépy, Jean-Luc; Dupré, Nicolas

doi:10.1111/j.1526-4610.2008.01211.x

Cited by 73 publications

(42 citation statements)

References 14 publications

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“…In the event of definite clinical or radiologic progression, glucocorticoids should be withheld but intra-arterial vasodilator treatment may still be considered on the basis of anecdotal case reports. 17,[27][28][29] Substantial clinical experience and judgment is required to determine the appropriate threshold for intervention.…”

Section: Resultsmentioning

confidence: 99%

Glucocorticoid-associated worsening in reversible cerebral vasoconstriction syndrome

2017

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Objective: Factors predicting poor outcome in patients with the reversible cerebral vasoconstriction syndrome (RCVS) have not been identified. Methods:In this single-center retrospective study, we analyzed the clinical, brain imaging, and angiography data in 162 patients with RCVS. Univariable and multivariable regression analysis were performed to identify predictors of persistent (nontransient) clinical worsening, radiologic worsening, early angiographic progression, and poor discharge outcome (modified Rankin Scale score 4-6).Results: The mean age was 44 6 13 years; 78% of patients were women. Persistent clinical worsening occurred in 14% at 6.6 6 4.1 days after symptom onset, radiologic worsening in 27% (mainly new infarcts), and angiographic progression in 15%. Clinical worsening correlated with angiographic progression and new nonhemorrhagic lesions. Age and sex did not independently predict any type of worsening. Infarction on baseline imaging predicted poor outcome. Prior serotonergic antidepressant use predicted clinical and angiographic worsening but not poor outcome. Intra-arterial vasodilator therapy independently predicted clinical worsening and poor discharge outcome but was offered to more severe cases. Glucocorticoid treatment proved to be an independent predictor of clinical, imaging, and angiographic worsening and poor outcome. Of the 23 patients with clinical worsening, 17 received glucocorticoids (15 within the preceding 2 days). There were no significant differences in baseline brain lesions and angiographic abnormalities between glucocorticoid-treated and untreated patients. Conclusion:Patients with RCVS at risk for worsening can be identified on basis of baseline features. Iatrogenic factors such as glucocorticoid exposure may contribute to worsening. Over the last decade, the clinical and imaging features of reversible cerebral vasoconstriction syndrome (RCVS) have been extensively characterized 1-7 and distinguished from its historic mimic, primary angiitis of the CNS (PACNS). [7][8][9] Patients with RCVS invariably present with recurrent severe thunderclap headaches. One-third to half develop ischemic and hemorrhagic brain lesions, either alone or in combination. Despite the dramatic onset and frequently ominous cerebral angiographic appearance, over 90% have excellent clinical outcome. 2,6 Yet studies that included a high proportion of inpatients have reported poor outcome (discharge modified Rankin Scale [mRS] score .3, including death) in 5%-14% of patients. 6,10 Factors predicting clinical outcome in RCVS have not been adequately identified. 10,11 We have reported an association between poor clinical outcome (mRS . 3) and glucocorticoid treatment, 6,7 which if confirmed has major clinical implications since glucocorticoids are frequently offered due to consideration of PACNS, a condition that warrants prompt initiation of long-term

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Section: Resultsmentioning

confidence: 99%

Glucocorticoid-associated worsening in reversible cerebral vasoconstriction syndrome

2017

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“…1,6,16,17 Other vasodilators, such as phosphodiesterase inhibitors, have also been used with anecdotal success in case reports. 73 However, vasodilators, including calcium channel blockers, must be used with caution because drops in systolic blood pressure may impair cerebral perfusion in patients with RCVS with severe cerebral vasoconstriction. 2,44 Intraarterial administration of vasodilators and balloon angioplasty have been performed in cases of severe RCVS-related vasoconstriction, though the indications and efficacy of these treatments remain unclear (Fig 3).…”

Section: Treatmentmentioning

confidence: 99%

Reversible Cerebral Vasoconstriction Syndrome, Part 1: Epidemiology, Pathogenesis, and Clinical Course

Miller

Shivashankar

Mossa‐Basha

et al. 2015

AJNR Am J Neuroradiol

208

194

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SUMMARY:Reversible cerebral vasoconstriction syndrome is a clinical and radiologic syndrome that represents a common presentation of a diverse group of disorders. The syndrome is characterized by thunderclap headache and reversible vasoconstriction of cerebral arteries, which can either be spontaneous or related to an exogenous trigger. The pathophysiology of reversible cerebral vasoconstriction syndrome is unknown, though alterations in cerebral vascular tone are thought to be a key underlying mechanism. The syndrome typically follows a benign course; however, reversible cerebral vasoconstriction syndrome may result in permanent disability or death in a small minority of patients secondary to complications such as ischemic stroke or intracranial hemorrhage.ABBREVIATIONS: RCVS ϭ reversible cerebral vasoconstriction syndrome; PRES ϭ posterior reversible encephalopathy syndrome

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“…7 Short-term treatment with calcium channel antagonists is often used as supplemental therapy, 3,[21][22][23] though a recent retrospective analysis did not find calcium channel blockers to have a significant effect on outcome. 9 Others have reported intra-arterial therapy with milrinone, 24 verapamil, 25 or balloon angioplasty. 25 Overall, RCVS has a better prognosis than PACNS, particularly when recognized early.…”

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confidence: 99%

Multimodal Imaging of Reversible Cerebral Vasoconstriction Syndrome: A Series of 6 Cases

Marder¹,

Donohue

Weinstein

et al. 2012

AJNR Am J Neuroradiol

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SUMMARY: RCVS is a clinical condition of recurrent severe headaches that may be associated with ischemic or hemorrhagic stroke and that is defined by the presence of segmental vasoconstriction in multiple cerebral arteries. The angiographic appearance resembles vasculitis, except that the abnormalities resolve during the course of several months. Because the treatment of RCVS differs from that for vasculitis, radiologists must understand the clinical and radiologic features so as to better guide imaging algorithms and facilitate diagnosis. We present a series of 6 cases of RCVS that highlight the imaging features across multiple modalities.ABBREVIATIONS: IPH ϭ intraparenchymal hemorrhage; MIP ϭ maximum intensity projection; NSAID ϭ nonsteroidal anti-inflammatory drug; PACNS ϭ primary angiitis of the CNS; PRES ϭ posterior reversible encephalopathy syndrome; RCVS ϭ reversible cerebral vasoconstriction syndrome; SDH ϭ subdural hematoma; TCD ϭ transcranial Doppler R CVS is an under-recognized clinical-radiologic entity characterized by a history of sudden severe headaches, sometimes associated with ischemic or hemorrhagic stroke, focal neurologic deficits, or seizures. First described by Call et al in 19881 , RCVS encompasses a wide variety of entities previously described by other names, including postpartum angiopathy, migrainous vasospasm, migrainous stroke, druginduced angiopathy, and benign angiopathy of the CNS. 2,3The condition is defined by reversible segmental cerebral vasoconstriction on angiography.1-3 The angiographic findings are similar to those of other vasculopathies, including PACNS.4 Unlike PACNS, the vascular abnormalities of RCVS resolve within several months. 1,2,5,6 RCVS typically occurs following exposure to a trigger, commonly sympathomimetic or vasoactive agents, including amphetamines, phenylpropanolamine, pseudoephedrine, serotonergic antidepressants, nicotine, caffeine, cannabis, and triptan-or ergot-containing medications.2,7-9 Other triggers include the peripartum period, 10 eclampsia, strenuous physical activity, bathing or showering, sexual activity, and binge alcohol drinking.2 Most patients with RCVS are young and middle-aged women. 3Patients with RCVS exhibit a range of parenchymal abnormalities, including convexal SAH, IPH, ischemic infarcts, and PRES.2,9,11-13 Alternatively, imaging findings may be normal.2,9 Findings of CSF analysis are usually normal or nearnormal.3 Because of the overlap with other causes of headache and stroke in adults and because the vascular abnormalities early in the course of the disease may be subtle or absent, the diagnosis of RCVS is easily missed. Early recognition of RCVS allows appropriate clinical management aimed at reducing the frequency, duration, and severity of vascular complications, primarily through identification and removal of triggers. Because management and outcome of RCVS differ from those of other vasculopathies, it is critical that radiologists recognize its typical imaging appearance, time course, and clinical features. Case Series...

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Intra‐Arterial Milrinone for Reversible Cerebral Vasoconstriction Syndrome

Cited by 73 publications

References 14 publications

Glucocorticoid-associated worsening in reversible cerebral vasoconstriction syndrome

Glucocorticoid-associated worsening in reversible cerebral vasoconstriction syndrome

Reversible Cerebral Vasoconstriction Syndrome, Part 1: Epidemiology, Pathogenesis, and Clinical Course

Multimodal Imaging of Reversible Cerebral Vasoconstriction Syndrome: A Series of 6 Cases

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