Intro-Reversible Cerebral Vasoconstriction Syndrome (RCVS): An ultra-short case report

Mirza Alamdar Ali1, Abbas1, M.M. Harish1, K. Yadav2, T. Rao2, Sridhar G1, Goura L1, Gururaj G1, Ahwoni1, Shivashankar B1

1Department of Critical Care Medicine, Kauvery Hospital, Bangalore

2Department of Neurosurgery, Kauvery Hospital, Bangalore

Background

Intro-Reversible Cerebral Vasoconstriction Syndrome (RCVS) encompasses various conditions characterized by temporary narrowing of multiple cerebral arteries, often leading to symptoms such as sudden, severe headaches, and occasionally accompanied by neurological issues such as stroke or seizures. While the typical outcome is favourable, severe strokes can lead to significant disability or even death in a small percentage of cases. Although no randomized controlled trials exist for the treatment of reversible cerebral vasoconstriction syndrome, empiric treatment has been proposed based on expert opinion and reported case series.

Objectives

To present a case of Cabergoline-induced reversible cerebral vasoconstriction syndrome leading to posterior cerebral artery (PCA) stroke and discuss the clinical presentation, management, and outcome.

Methods

A 29-year-aged female, with no comorbidities, and a history of irregular menses, was diagnosed with hyperprolactinemia and started on tablet cabergoline 0.5mg once a week (2 doses taken). She presented to the Critical Care Unit with a severe thunderclap headache, blurred vision, and dizziness. Clinical examination and imaging studies were performed, including MRI with Angiogram, to evaluate the extent of cerebral vasospasm and possible infarction.. Treatment involved intra-arterial administration of Alteplase and Nimodipine, along with antiplatelet therapy and supportive measures. The patient’s clinical course and outcome were monitored, and she was discharged without any focal neurological deficits.

Impression

C – Acute ischemic infarct involving right thalamus, right medial temporal and occipital lobes corresponding to right PCA territory

MR Angiogram shoes non-visualization of P3 and P4 segments of right PCA – likely dues to high – grade stenosis/complete occlusion

D – Right transverse sinus distal segment stenosis (mild)

Conclusion

This case emphasizes on the importance of adopting a high index of suspicion for RCVS in patients who present with unusual stroke, with risk factors for RCVS, and diagnose it. Cabergoline is one of the drugs which is prone to cause RCVS.

Just one case report has been published till date. Understanding diagnosis as well as therapeutic options available to treat helps in improving overall outcome in RCVS.

Dr. Harish Mallapura Maheshwarappa
Director – Institute of Critical Care Medicine

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