Reversible Cerebral Vasoconstriction Syndrome Research Articles

Factors Associated with Poor Outcomes in Reversible Cerebral Vasoconstriction Syndrome: A Seven-year Study at a Comprehensive Stroke Center (P11-4.005)

Factors Associated with Poor Outcomes in Reversible Cerebral Vasoconstriction Syndrome: A Seven-year Study at a Comprehensive Stroke Center (P11-4.005)

Reversible Cerebral Vasoconstriction Syndrome Presenting as Micturition Headaches in a Pediatric Patient (P3-5.029)

Reversible Cerebral Vasoconstriction Syndrome Presenting as Micturition Headaches in a Pediatric Patient (P3-5.029)

Concurrent spontaneous coronary dissection and reversible cerebral vasoconstriction syndrome during postnatal care.

Pregnancy-associated spontaneous coronary artery dissection (SCAD) and reversible cerebral vasoconstriction syndrome (RCVS) are rare conditions that may occur during pregnancy and the postpartum period. The coexistence of both diseases may pose a risk to patients, potentially resulting in a variety of complications and clinical manifestations. This is considered the first case of a patient who successfully recovered from a critical condition in the postpartum period, with contemporaneous SCAD and RCVS. A 33-year-old female with no known medical history was referred to the emergency department after experiencing cardiac arrest, which occurred 1 week after giving birth to her third child. She complained of sudden anterior squeezing chest pain, accompanied by a headache, and eventually collapsed due to ventricular fibrillation with seizure. She was successfully resuscitated after receiving basic life support. She showed an alert mentality and did not experience any further seizure events or additional neurological symptoms. Although vital sign remained stable, the level of highly sensitive troponin I was significantly elevated. Electrocardiography revealed sinus rhythm with T-wave inversion at V1-4, while chest computed tomography (CT) demonstrated severe aspiration pneumonia. The patient was admitted to the intensive care unit due to a high requirement of O2 supply. A consultation with the neurologic department and a brain magnetic resonance angiography (MRA) were conducted for the thunderclap headache. The brain MRA demonstrated stenosis in the basilar artery, the right M2 segment, and bilateral A1 segments, along with sulcal hyperintensity on post-contrast fluid-attenuated inversion recovery (FLAIR) suggesting blood-brain barrier breakdown due to vasoconstriction. Formal echocardiography showed regional wall motion abnormality in the left anterior descending artery (LAD) territory. After the improvement of pneumonia, a coronary angiography was performed, revealing diffuse luminal narrowing from the mid to distal LAD due to a long segmental, extensive dissection. We decided to maintain the medical therapy. A follow-up coronary CT angiography performed 6months later revealed complete remission of the dissected coronary vessel, and a brain MRA checked 3months later showed resolved vasoconstriction of the relevant cerebral vessels. The physicians must be aware of pregnancy-associated complications in certain patients. Clear diagnoses and proper treatments are required in pregnant patients who may be exposed to multiple acute conditions, in order to reduce complications and achieve favorable outcomes.

Stroke without cerebral arteriopathy in sickle cell disease children: causes and treatment.

Cerebral arteriopathy (CA) in children with sickle cell disease (SCD) is classically described as chronic stenosis of arteries in the anterior brain circulation, leading to ischemic stroke. Some studies have however reported strokes in children with SCD but without CA. In order to better understand the etiology and risk factors of these strokes, we retrospectively analyzed ischemic strokes occurring in a large cohort of children over a 13 year-period. Between 2007 and 2020, 25/1500 children with SCD had an ischemic stroke in our center. Among them, 13 (52%) had CA, described as anatomical arterial stenosis, while 12 (48%) did not. Patients with stroke without CA were older than patients with stroke attributed to SCD-CA (9.0 years old vs 3.6 years old, p=0.008), and had more frequently a SC genotype (25% vs 0% respectively). Their stroke involved posterior circulation more frequently, with cerebellar involvement in 42%. Retained stroke etiologies in patients without typical SCD-related CA were reversible cerebral vasoconstriction syndrome, cerebral fat embolism, arterial thrombosis or thromboembolism, hyperviscosity, vasculitis in a context of infectious meningoencephalitis, and severe hemodynamic failure. No recurrence was observed in the 24 months following stroke, even though 67% of the patients were no longer receiving exchange transfusions in this group. In conclusion, in a cohort of pediatric SCD patients with efficient stroke screening strategy, half of occurring ischemic strokes were related to causes other than CA. They affected a different population of SCD children and systematic long-term transfusion programs may not be necessary in these cases.

Frequency of ischaemic stroke and intracranial haemorrhage in patients with reversible cerebral vasoconstriction syndrome (RCVS) and posterior reversible encephalopathy syndrome (PRES) - A systematic review.

Posterior reversible encephalopathy syndrome (PRES) and reversible cerebral vasoconstriction syndrome (RCVS) may cause ischaemic stroke and intracranial haemorrhage. The aim of our study was to assess the frequency of the afore-mentioned outcomes. We performed a PROSPERO-registered (CRD42022355704) systematic review and meta-analysis accessing PubMed until 7 November 2022. The inclusion criteria were: (1) original publication, (2) adult patients (≥18 years), (3) enrolling patients with PRES and/or RCVS, (4) English language and (5) outcome information. Outcomes were frequency of (1) ischaemic stroke and (2) intracranial haemorrhage, divided into subarachnoid haemorrhage (SAH) and intraparenchymal haemorrhage (IPH). The Cochrane Risk of Bias tool was used. We identified 848 studies and included 48 relevant studies after reviewing titles, abstracts and full text. We found 11 studies on RCVS (unselected patients), reporting on 2746 patients. Among the patients analysed, 15.9% (95% CI 9.6%-23.4%) had ischaemic stroke and 22.1% (95% CI 10%-39.6%) had intracranial haemorrhage. A further 20.3% (95% CI 11.2%-31.2%) had SAH and 6.7% (95% CI 3.6%-10.7%) had IPH. Furthermore, we found 28 studies on PRES (unselected patients), reporting on 1385 patients. Among the patients analysed, 11.2% (95% CI 7.9%-15%) had ischaemic stroke and 16.1% (95% CI 12.3%-20.3%) had intracranial haemorrhage. Further, 7% (95% CI 4.7%-9.9%) had SAH and 9.7% (95% CI 5.4%-15%) had IPH. Intracranial haemorrhage and ischaemic stroke are common outcomes in PRES and RCVS. The frequency reported in the individual studies varied considerably.

The prevalence of non-contrast CT imaging abnormalities in reversible cerebral vasoconstriction syndrome: A systematic review and meta-analysis.

Reversible cerebral vasoconstriction syndrome (RCVS) is a syndrome of recurrent thunderclap headaches and reversible vasoconstriction of the cerebral arteries on neuroimaging within 3 months of onset. Initial non-contrast computed tomography (CT) can reveal abnormalities such as ischemic stroke, intracerebral hemorrhage, and subarachnoid hemorrhage (SAH) can be present in patients with RCVS and may delay diagnosis. We conducted a systematic review and meta-analysis in accordance with the PRISMA guidelines. We aimed to estimate the prevalence of imaging abnormalities on initial non-contrast CT head in adult patients with RCVS. We searched electronic databases including MEDLINE, EMBASE, and the Cochrane Register of Clinical Trials from inception to August 2, 2022. Eligible studies included articles reporting the prevalence of non-contrast CT abnormalities on initial neuroimaging in patients with RCVS, aged 18 and older. Case series, observational studies and clinical trials were included. Data was extracted directly from included papers using a standardized data charting form. The search yielded 722 titles with duplicates removed. Twenty studies that included 379 patients with RCVS met inclusion criteria. We classified non-contrast CT abnormalities as either ischemic stroke, ICH, or SAH. We pooled prevalence data using a random effects model with the inverse-variance weighted method. The most common imaging finding was SAH with a pooled prevalence of 24% (95% CI:17%-33%), followed by ICH at 14% (95% CI:8%-22%), and ischemic stroke at 10% (95% CI:7%-14%). The pooled prevalence of any of these imaging abnormalities on initial non-contrast CT was 31% (95% CI:23%-40%). Risk of bias was moderate to very-high-risk for case-series and low-risk for observational studies. Our review demonstrates that one-third of patients with RCVS will have an abnormality on initial non-contrast CT head, including either an ischemic stroke, ICH, or SAH. These findings highlight the diagnostic challenges of RCVS imaging and contribute to our understanding of this disease.

Predictors of angiographic resolution in patients with presumed reversible cerebral vasoconstriction syndrome.

Reversible cerebral vasoconstriction syndrome is a complex neurovascular syndrome that presents with varying neurological deficits as well as segmental vasoconstriction of the small and medium cerebral arteries. There is limited literature on pathologies that mimic reversible cerebral vasoconstriction syndrome, so this study aims to understand what factors may impact the angiographic confirmation of reversible cerebral vasoconstriction syndrome on follow-up and play a role in establishing the diagnosis. The Clinical Research Data Warehouse at this institution was employed to search the medical records for patients with diagnosis and treatment of reversible cerebral vasoconstriction syndrome between January 2010 and May 2021. After screening, 32 patients met the inclusion criteria for a presumed diagnosis of reversible cerebral vasoconstriction syndrome with both angiography on presentation and at three-month follow-up after treatment. Patients were divided into two categories: those with complete angiographic resolution, versus partial or no improvement on follow-up. Clinical and radiographic data were analyzed. Patients who had partial or no resolution were more likely to have a history of hypertension (p = 0.001), higher systolic blood pressure on admission (p = 0.047), and present with a recurrent thunderclap headache (p = 0.038). Binary logistic regression selected for hypertension (odds ratio [OR] 18.35 [95% CI, 1.37-245.1]) as predictive of not having reversible cerebral vasoconstriction syndrome, as can be seen by partial or no resolution on follow-up angiography (p = 0.028). Complete resolution on follow-up angiography is a distinguishing factor of reversible cerebral vasoconstriction syndrome. Our analysis revealed that a history of hypertension is the most significant predictor of confirming that a patient may not have reversible cerebral vasoconstriction syndrome. This is due, in part, to increased atherosclerotic or hypertensive cerebral arterial changes, which can mimic reversible cerebral vasoconstriction syndrome and present as partial or no resolution on angiography.

Spontaneous intracerebral hemorrhage to reversible cerebral vasoconstriction syndrome: Case report

Spontaneous intracerebral hemorrhage (sICH) is a common cause of morbidity and mortality in many countries. Hemorrhagic stroke occurs due to the internal hemorrhage inside the brain as a result of blood vessel rupture. Reversible cerebral vasoconstriction syndrome (RCVS) is multifocal arterial constriction and dilation in the cerebral vasculature and can cause subarachnoid hemorrhage and intracerebral hemorrhage (ICH). We present a case of diagnostic studies of sICH to RCVS in a patient with alcohol chronic consumption history.

Reversible cerebral vasoconstriction syndrome and posterior reversible encephalopathy syndrome following vaccination: analysis of the VAERS database and systematic review.

This study aimed to analyze the Vaccine Adverse Event Reporting System (VAERS) database and systematically review the literature to provide a comprehensive analysis of reversible cerebral vasoconstriction syndrome (RCVS) and posterior reversible encephalopathy syndrome (PRES) secondary to vaccination. The authors analyzed the VAERS database and conducted a systematic review following PRISMA guidelines. The inclusion criteria for VAERS data were a score of ≥3 on the RCVS2 score and/or radiographic findings consistent with the diagnosis of RCVS or PRES. The systematic review was registered with PROSPERO. Our combined data set included 29 cases (9 RCVS and 20 PRES). Most cases were women (72.4%) with a mean age of 50.7 years (SD 19.4 years). Most cases were associated with COVID-19 mRNA vaccines (58.6% Moderna, 20.7% Pfizer). Hypertension (37.9%), hyperlipidemia (13.7%), chronic kidney disease (CKD) (10.3%), and end-stage renal disease (6.8%) were common comorbidities. Furthermore, 20.6% (6/29) of cases were on immunosuppression therapy for various reasons. The mean time to symptom onset was 10.49 days after vaccination (SD 18.60), and the mean duration of hospitalization was 7.42 days (SD 5.94). The symptoms reported the most frequently were headache (41.3%), elevated blood pressure (31.0%), and emesis (17.2%). Typical radiographic findings included T2/FLAIR hyperintensities affecting the parieto-occipital lobes, indicative of vasogenic and/or cytotoxic edema. This study provides a comprehensive analysis of postvaccine RCVS and PRES. Both disease states were seen most often in those with pre-existing risk factors such as female sex, age over 50, hypertension, renal disease, and immunosuppression. Vaccines and their associated immune response may cause endothelial dysfunction leading to cerebral vasospasm and loss of cerebral autoregulation. However, further research is required to understand the underlying pathophysiological mechanisms. Despite the associations found, the absolute risk of these syndromes remains extremely low compared to the immense benefits of vaccination.

Reversible Cerebral Vasoconstriction Syndrome With Typical and Atypical Symptoms: A Case Series.

Introduction Reversible cerebral vasoconstriction syndrome (RCVS) is most commonly characterized by focal or diffuse severe thunderclap headache with or without focal neurological deficits and associated transient focal vasoconstriction of the intracerebral arteries lasting up to three months. We present six patients diagnosed as RCVS, with three patients presenting with focal neurological deficits without headache and the remaining three with severe headache alone. Neuroimaging revealed focal subarachnoid bleed with or without segmental intracerebral vasospasm, which resolved over three months. Despite thunderclap headache being the most prevalent symptom associated with RCVS, the absence of this symptom should not preclude the diagnosis, especially in the presence of cortical subarachnoid hemorrhage (SAH) or focal segmental intracerebral arterial narrowing. Methods This case series is a retrospective analysis of all patients diagnosed with RCVS between 2018 and 2022, focusing on clinical symptoms, imaging findings, and management. Results Six patients (three males and three females) were diagnosed with RCVS between 2018 and 2022. Three patients presented with typical symptoms, while the remaining three presented with atypical symptoms. Neuroimaging findings ranged from normal to focal SAH with or without arterial narrowing. Conclusion This case series underscores the diverse clinical presentations of RCVS, emphasizing that while thunderclap headache is the predominant symptom, its absence should not exclude the possibility of RCVS, especially when accompanied by focal neurological deficits or cortical SAH. Neuroimaging played a crucial role in identifying the spectrum of findings. These findings highlight the importance of comprehensive evaluation and consideration of RCVS in patients presenting with neurological symptoms, even in the absence of typical headache features.

Clinical relevance of reversible cerebral vasoconstriction syndrome in pregnant women with posterior reversible encephalopathy syndrome: review of case reports in Japan.

We systematically reviewed case reports of posterior reversible encephalopathy syndrome (PRES), and investigated the characteristics of PRES in pregnant Japanese women and the clinical relevance of reversible cerebral vasoconstriction syndrome (RCVS) in pregnant women with PRES. Articles were collected using the PubMed/Medline and Ichushi-Web databases. This review was ultimately conducted on 121 articles (162 patients). The clinical characteristics of PRES, individual sites of PRES lesions, edema types, and clinical characteristics of RCVS in PRES cases were examined. The most common individual site of PRES lesion was the occipital lobe (83.3%), followed by the basal ganglia, parietal lobe, frontal lobe, brain stem, cerebellum, temporal lobe, thalamus, and splenium corpus callosum (47.5, 42.6, 24.7, 16.1, 9.3, 5.6, 4.3, and 0.0%, respectively). Edema types in 79 cases with PRES were mainly the vasogenic edema type (91.1%), with very few cases of the cytotoxic edema type (3.8%) and mixed type (5.1%). Among 25 PRES cases with RCVS, RCVS was not strongly suspected in 17 (68.0%) before magnetic resonance angiography. RCVS was observed at the same time as PRES in 13 cases (approximately 50%), and between days 1 and 14 after the onset of PRES in the other 12. These results suggest that the basal ganglia is a frequent site of PRES lesions in pregnant women. RCVS may occur at or after the onset of PRES, even if there are no symptoms to suggest RCVS.

Primary Headache Associated with Sexual Activity: A Review of the Literature.

This review summarizes the evolution in diagnosis, evaluation, and treatment of primary headache associated with sexual activity (PHASA). Despite increased access to patient information and advances in imaging, the pathophysiology of PHASA remains not fully understood. There are many secondary headaches that may present with headache during sexual activity, and a thorough workup is indicated to rule out potentially life-threatening etiologies. Many recent case series discuss the efficacy of known treatments of PHASA, as well as suggest other potential therapies for this condition including the newer CGRP-targeted therapies. Headaches during sexual activity can be worrisome events which necessitate urgent evaluation, particularly when presenting with sudden-onset and severe "thunderclap" headaches. A thorough workup including imaging should be conducted to rule out etiologies such as subarachnoid hemorrhage, reversible cerebral vasoconstrictive syndrome (RCVS),vasospasm, and dissection. PHASA is commonly comorbid with migraine, tension-type headache, exertional headache, and hypertension. PHASA can present as a dull headache that progresses with sexual excitement, or an explosive headache at or around orgasm. Pain is primarily occipital, diffuse, and bilateral. The headaches are discrete, recurrent events with bouts that typically self-resolve, but may also relapse and remit or continue chronically in some patients. PHASA can be treated preemptively with indomethacin and triptans administered prior to sexual activity, or treated prophylactically with beta-blockers, topiramate, and calcium channel blockers. CGRP-targeted therapies may provide relief in PHASA based on a few case reports, but there are no randomized controlled trials looking at specific efficacy for these therapies.

Reversible Cerebral Vasoconstriction Syndrome and Female Sex: A Narrative Review.

Reversible cerebral vasoconstriction syndrome (RCVS) refers to segmental, multifocal constriction of intracranial arteries along with acute headache and resolves within weeks. It occurs more commonly in women, and 1 well-known manifestation of RCVS is postpartum angiopathy. Furthermore, the female sex is included in scoring systems designed to assist with diagnosing RCVS. Nonetheless, the literature is mixed regarding the true role of female and pregnancy-related factors in the pathophysiology of RCVS, and it is similarly unclear whether management of this disorder differs by sex. Given the association of RCVS with female sex and the importance of highlighting, recognizing, and managing stroke etiologies in women, herein, the author reviews what is currently known and unknown about the topic of RCVS in women.

DIAGNOSTIC CHALLENGE IN MIDDLE-AGED WOMAN WITH RECURRENT ISCHEMIC STROKES: A CASE OF PRIMARY CENTRAL NERVOUS SYSTEM VASCULITIS AND LITERATURE REVIEW

Primary vasculitides of the central nervous system are rare vascular disorders whose pathophysiology involves inflammatory infiltration exclusively in the vessels of the central nervous system. Its spectrum extends from primary angiitis of the central nervous system to cerebral amyloid angiopathy. This case portrays a 46-year-old woman with a history of multiple strokes. History of multiple comorbidities such as systemic arterial hypertension, prediabetes, and smoking. During follow-up after the second ischemic event, a patent foramen ovale was detected with positive microbubbles stand. Therefore, she was using oral anticoagulants. Transthoracic echocardiogram and magnetic resonance angiography without relevant changes. However, she resorted to the neurological deficit three more times. Cerebrospinal fluid (CSF) analysis was done twice; both were normal. Cerebral angiography was performed at the time of the last stroke and revealed suggestive signs of vasculitis. Discrimination of angiitis and reversible cerebral vasoconstriction syndrome was challenging and based on the demographic and clinical features of the patient. The characteristics of this case that corroborate the hypothesis of angiitis are the patient's age, which is in the median age range (40-60 years), chronic headache, and focal symptoms not temporally associated with the headache. Intravenous methylprednisolone pulse therapy (one gram/day) was performed for five days. Evolved with progressive improvement of the motor deficit. On hospital discharge, it was prescribed prednisone, and after ten days, Azathioprine 2.5mg/Kg/day was started. Diagnosis of primary central nervous system vasculitis requires high clinical suspicion due to the low specificity of the clinical features. This report reinforces the importance of investigating CNS vasculitis in young patients with a history of recurrent stroke.

Dynamic changes in glymphatic function in reversible cerebral vasoconstriction syndrome.

The pathophysiology of the reversible cerebral vasoconstriction syndrome (RCVS) remains enigmatic and the role of glymphatics in RCVS pathophysiology has not been evaluated. We aimed to investigate RCVS glymphatic dynamics and its clinical correlates. We prospectively evaluated the glymphatic function in RCVS patients, with RCVS subjects and healthy controls (HCs) recruited between August 2020 and November 2023, by calculating diffusion-tensor imaging along the perivascular space (DTI-ALPS) index under a 3-T MRI. Clinical and vascular (transcranial color-coded duplex sonography) investigations were conducted in RCVS subjects. RCVS participants were separated into acute (≤ 30days) and remission (≥ 90days) groups by disease onset to MRI interval. The time-trend, acute stage and longitudinal analyses of the DTI-ALPS index were conducted. Correlations between DTI-ALPS index and vascular and clinical parameters were performed. Bonferroni correction was applied to vascular investigations (q = 0.05/11). A total of 138 RCVS patients (mean age, 46.8years ± 11.8; 128 women) and 42 HCs (mean age, 46.0years ± 4.5; 35 women) were evaluated. Acute RCVS demonstrated lower DTI-ALPS index than HCs (p < 0.001) and remission RCVS (p < 0.001). A continuously increasing DTI-ALPS trend after disease onset was demonstrated. The DTI-ALPS was lower when the internal carotid arteries resistance index and six-item Headache Impact test scores were higher. In contrast, during 50-100days after disease onset, the DTI-ALPS index was higher when the middle cerebral artery flow velocity was higher. Glymphatic function in patients with RCVS exhibited a unique dynamic evolution that was temporally coupled to different vascular indices and headache-related disabilities along the disease course. These findings may provide novel insights into the complex interactions between glymphatic transport, vasomotor control and pain modulation.

Abstract WP271: Marijuana Use and Stroke: A Systematic Review and Meta-Analysis

Introduction: The prevalence of stroke among young adults has been on the rise, along with a similar rising trend in marijuana use. Ischemic strokes, intracerebral hemorrhage (ICH), reversible cerebral vasoconstriction syndrome (RCVS), and subarachnoid hemorrhage (SAH) are among the commonly reported neurovascular events associated with marijuana use. We attempted to systematically review the literature and find an association between marijuana use and stroke. Methods: We searched data from PubMed/Medline, SCOPUS and studies that met the inclusion criteria were selected and Review Manager 5.4.1 was used for statistical analysis of data. Twenty six studies with a total of 13,550 patients were selected of which 11 were included in the meta analysis. Results: The pooled odds of cannabis use in ischemic stroke patients was statistically significant at 1.16 (95% CI: 1.07-1.25). Among patients with undefined stroke, pooled odds of cannabis use were 0.86 (0.43, 1.72). Meta-analysis for the SAH subgroup could not be done due to varying outcome measures. Overall, upon combining all the subgroups, the odds of cannabis use among stroke patients was not significant (OR: 0.96; 0.77,1.20, I2-100%). High heterogeneity might be the pooling of studies with different stroke types and individual study variations. Conclusions: Cannabis use was significantly associated with ischemic stroke although this significance was not maintained among other stroke subgroups and with overall analysis. Further research should be done to assess the association of dose, chronicity and frequency of cannabis on stroke to further delineate the true association.

Abstract WP121: Cerebral Hemodynamics in the First Week Postpartum in Healthy Women and Women With Preeclampsia

Objective: Standard adult normative data for transcranial Doppler (TCD)-based cerebral hemodynamic measures, such as mean and peak cerebral blood flow velocity (mCBFV, pCBFV), are used to identify pathological conditions such as postpartum angiopathy. However, little is known about cerebral hemodynamics during the early postpartum period, particularly in patients with preeclampsia (PEC). We characterized cerebral hemodynamics using TCD in the first week postpartum in patients with and without PEC. Methods: We prospectively recruited women with PEC and normotensive pregnant women delivering at an urban academic medical center. We measured CBFV in the bilateral middle cerebral arteries with TCD and calculated systolic mCBFV and pCBFV as well as pulsatility index (PI) and PI-derived noninvasive intracranial pressure (nICP). We compared systolic mCBFV and pCBFV between postpartum women with and without PEC, and historical data from non-pregnant young adult female controls. Results: Subjects were 51 women with PEC, 19 normotensive postpartum women, and 28 non-pregnant historical controls. In the PEC group, median mCBFV was 75.0 cm/s (IQR 65.2-99.1) and median pCBFV was 106.9 cm/s (IQR 92.7-130.8). In the normotensive postpartum group, median mCBFV was 77.1 cm/s (IQR 66.0-92.3) and median pCBFV was 107.9 cm/s (IQR 96.6-127.4). In the non-pregnant female control group, median mCBFV was 62.0 cm/s (IQR 48.5-67.9) and median pCBFV was 83.6 cm/s (IQR 69.3-95.2) (p&lt;0.0001 for mean and peak 3-way comparisons; see Figure). PI and nICP were within normal range in both postpartum groups and did not differ significantly between groups. Conclusion: Postpartum women with and without PEC had mCBFV and pCBFV significantly higher than non-pregnant controls, and many fell outside the standard normal range for healthy adults, but PI and nICP were within normal range. Standard ranges of CBFV for healthy adults may not apply in the postpartum period.

Bilateral Renal Cortical Necrosis and Reversible Cerebral Vasoconstriction Syndrome in a Case of Severe Postpartum Haemorrhage

Bilateral Renal Cortical Necrosis (BRCN) is a rare but serious condition characterised by the ischaemic necrosis of both kidneys’ cortical tissues. Concurrently, Reversible Cerebral Vasoconstriction Syndrome (RCVS) manifests as a transient constriction of cerebral blood vessels. The fusion of these two rare entities within the context of severe Postpartum Haemorrhage (PPH) poses a unique diagnostic and therapeutic dilemma for healthcare practitioners. This case study documents the intricate and severe complications experienced by a 32-year-old primiparous woman following abruptio placenta with Intrauterine Foetal Death (IUFD). The patient presented with massive vaginal bleeding, leading to an emergency Lower Segment Caesarean Section (LSCS) where bilateral uterine artery ligation and bilateral internal iliac artery ligation were performed to control haemorrhage. Despite initial interventions, the patient’s condition deteriorated, leading to signs of shock, haemoperitoneum, sepsis, Acute Kidney Injury (AKI), and cerebral complications. The medical journey unfolded with an urgent re-laparotomy, draining haemoperitoneum and conducting a subtotal hysterectomy. This case highlights the critical importance of a multidisciplinary approach involving obstetrics, nephrology, and intensive care, in managing such complex postpartum complications. Vigilant monitoring, collaborative decision-making, and meticulous postoperative care played pivotal roles. The successful outcome was attributed to early recognition, aggressive supportive measures, and timely interventions, including haemodialysis. The challenges faced underscore the need for accessible obstetric care, awareness about antenatal complications, and community-focused initiatives. Further research is warranted to unravel the intricate connections between PPH, RCVS, and associated complications, enhancing our understanding and improving patient outcomes in similar critical cases.

Update on the efficiency and safety of orally administered nasal decongestants

Nasal congestion leading to obstruction is one of the main symptoms in acute rhinosinusitis (common cold), other upper respiratory infections and allergic rhinitis. The EPOS 2020 guidelines place oral decongestants as an efficient therapy for the relief of nasal obstruction. In Romania, there are more than 50 available nasal decongestants, so it is very important for practitioners from all medical domains to be aware of recent data regarding their effectiveness and safety profile. Recent concerns raised by both the Food and Drug Administration (FDA) and the European Medicines Agency (EMA) regarding the efficacy and safety of pseudoephedrine (PSE) and phenylephrine (PHE) emphasize the need for informed decision-making in prescribing. Notably, there were concerns raised about the association between PSE, reversible cerebral vasoconstriction syndrome (RCVS) and posterior reversible encephalopathy syndrome (PRES). EMA’s safety committee, Pharmacovigilance Risk Assessment Committee (PRAC), recently recommended measures to minimize risks of serious side effects when using medicines containing PSE. PRAC recommends that medicines containing PSE should not be used in patients with severe or uncontrolled hypertension and severe acute or chronic kidney disease or failure. Additionally, PRAC recommends healthcare professionals to counsel patients to discontinue the use of such medicines promptly and seek medical assistance if they experience symptoms suggesting PRES or RCVS, such as sudden onset of severe headache, confusion, vomiting, visual disturbances or seizures. While effectiveness of oral PSE is confirmed by clinical studies, expert consensus is unfavorable to PHE. Both in vitro and in vivo clinical pharmacology data indicate that neither the recommended doses nor higher doses of oral PHE demonstrate efficacy in alleviating symptoms of nasal congestion.

Atypical Manifestation of Zoster Meningitis Presented with Headache and Multiple Cerebral Vasoconstrictions

Reversible cerebral vasoconstriction syndrome (RCVS) is characterized by headaches and multiple transient cerebral vasoconstrictions. Central nervous system (CNS) infections related to the varicella zoster virus (VZV) can complicate various neurological disorders, including cerebral vasculopathy. We present the case of a patient who complained of a severe headache without any other symptoms or focal neurological signs. Brain magnetic resonance angiography showed multiple focal stenoses, especially in the right middle cerebral artery (MCA), and transcranial Doppler sonography revealed increased velocities in the MCA and right anterior cerebral artery. Initially, the headache was attributed to RCVS, and nimodipine infusion was initiated; however, the headache worsened. A cerebrospinal fluid study showed pleocytosis, increased protein levels, and positive polymerase chain reaction markers for VZV. No skin lesions or fever were observed during treatment. Our case emphasizes considering VZV meningitis as a cause of cerebral vasoconstriction, even in the absence of typical signs of CNS infection.