Reversible Cerebral Vasoconstriction Syndrome in Patients with Coronavirus Disease: A Multicenter Case Series

Abstract

Background and objectives: RCVS (Reversible Cerebral Vasoconstrictive Syndrome) is a condition associated with vasoactive agents that alter endothelial function. There is growing evidence that endothelial inflammation contributes to cerebrovascular disease in patients with coronavirus disease 2019 . In our study, we describe the clinical features, risk factors, and outcomes of RCVS in a multicenter case series of patients with COVID-19. Materials and methods: Multicenter retrospective case series. We collected clinical characteristics, imaging, and outcomes of patients with RCVS and COVID-19 identified at each participating site. Results: Ten patients were identified, 7 women, ages 21 À 62 years. Risk factors included use of vasoconstrictive agents in 7 and history of migraine in 2. Presenting symptoms included thunderclap headache in 5 patients with recurrent headaches in 4. Eight were hypertensive on arrival to the hospital. Symptoms of COVID-19 included fever in 2, respiratory symptoms in 8, and gastrointestinal symptoms in 1. One patient did not have systemic COVID-19 symptoms. MRI showed subarachnoid hemorrhage in 3 cases, intraparenchymal hemorrhage in 2, acute ischemic stroke in 4, FLAIR hyperintensities in 2, and no abnormalities in 1 case. Neurovascular imaging showed focal segment irregularity and narrowing concerning for vasospasm of the left MCA in 4 cases and diffuse, multifocal narrowing of the intracranial vasculature in 6 cases. Outcomes varied, with 2 deaths, 2 remaining in the ICU, and 6

COVID-19 Vaccination Might Induce Reversible Cerebral Vasoconstriction Syndrome Attacks: A Case Report

“…Cerebrovascular complications arise in 0.5–5% of acute SARS-CoV-2 infections, including ischemic stroke, intracerebral hemorrhage, and cerebral venous sinus thrombosis [ 4 ]. Several cases of RCVS attacks after SARS-CoV-2 infection have been reported.…”

“…Five patients experienced at least one thunderclap headache with associated neurologic deficits, including encephalopathy, hemiparesis, aphasia, and visual deficits. Three patients did not have a provoking illness or use of vasoactive agents [ 4 ]. Two additional case reports described COVID-19 patients presenting with RCVS attacks confirmed by CT angiography, and one patient was treated with nimodipine and the other with verapamil [ 5 , 6 ].…”

First Reported Case of Reversible Cerebral Vasoconstriction Syndrome After a SARS-CoV-2 Vaccine

“…Whether there was truly a causal relationship between the vaccination and RCVS, however, remains speculative. Arguments in favor of a causal relation are that no alternative explanation for the RCVS could be pleaded, that RCVS has been repeatedly reported as a complication of SARS-CoV-2 infections [6], that RCVS occurred time-linked to the vaccination, and that RCVS has been listed in one case on the Pfizer-BioNTech vaccine analysis print [7]. RCVS has also been reported after administration of IV immunoglobulins [8].…”

“…The most frequent neurological side effects are headache, myositis, monoor polyneuritis cranialis, Guillain-Barré syndrome, venous sinus thrombosis, ischemic stroke, hyperactive encephalopathy, Tolosa-Hunt syndrome, and small fiber neuropathy (SFN) [4,5]. Though reversible cerebral vasoconstriction syndrome (RCVS) has been reported as a complication of SARS-CoV-2 infections [6,7,8], it has not been reported as an adverse reaction of a SARS-CoV-2 vaccination. Here we report the first patient with RCVS after an anti-SARS-CoV-2 vaccination.…”

COVID-19 and the brain

“…The posterior reversible encephalopathy syndrome (PRES), which is most commonly associated with malignant hypertension or chemotherapy agents, has been reported in several cases of COVID, in some, associated with much less dramatic alterations in blood pressure and with immunologic treatment of COVID-19 [ 3 , 21 ]. The reversible cerebral vasoconstriction syndrome (RCVS) is also speculated to be a disorder of endothelial function and has been associated with SARS-CoV-2 infections [ 59 , 60 ]. Cerebrovascular and systemic endotheliitis has been observed, in some cases successfully treated with steroids [48] , as well as vasculitis [61] .…”