Abstract Number ‐ 69: Intrathecal Nicardipine for Severe Intractable Reversible Cerebral Vasoconstriction Syndrome (RCVS): A Novel Case Report

Abstract

Introduction Reversible Cerebral Vasoconstriction Syndrome (RCVS) is a poorly understood but increasingly recognized entity, likely multifactorial in nature and characterized by diffuse cerebral vasospasm that present as sudden, intense, fluctuating headaches. A subset of RCVS patients can present with concomitant TIAs, cerebral infarctions, leukoencephalopathy, subarachnoid hemorrhages (SAH), and seizures. Due to insufficient evidence, there is currently no consensus on RCVS treatment guidelines. Calcium channel blockers such as nimodipine and verapamil have reportedly been employed with varying degrees of efficacy. Nicardipine, an L‐type calcium channel blocker, may prove effective in RCVS treatment because of its ability to penetrate the blood‐brain barrier. However, to date, only 5 case reports have discussed the use of intrathecal (IT) nicardipine for the treatment of severe RCVS, and there has been very limited exploration of continuous intraarterial (IA) administration. This case report examines the use of IT and continuous IA nicardipine in an RCVS patient refractory to traditional management. Methods We present the case of a 58‐year‐old female who was noted to have a non‐traumatic non‐aneurysmal SAH secondary to RCVS. The patient’s only risk factor for RCVS was alcoholic use. 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 q12hours via an external ventricular drain (EVD). This dose was escalated to 4mg q6hours. The patient stabilized for 24 hours but again decompensated, requiring continuous IA spasmolysis via a microcatheter that was placed in the L MCA and left for continuous IA nicardipine infusion (5mg/hr). The patient showed slow incremental improvement clinically and a decrease in vasospasms on imaging, ultimately suffering minimal stroke burden. Results The patient subsequently showed improvement over time in neurological function and a decrease in vasospasms on CTA, MRA, and angiogram imaging, ultimately suffering minimal stroke burden (Fig. 1B). Conclusions Nicardipine, administered intrathecally utilizing an EVD or even intraarterial through a microcatheter, could potentially be beneficial in select patients with refractory RCVS to minimize repeat angiography/angioplasty. We suggest further studies to determine SAH incidence following RCVS and the efficacy of continuous intrathecal administration of the blood‐brain barrier penetrating calcium channel blocker, nicardipine, in RCVS patients.