Interactive Transcript
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Although we took a little side trip on the signal
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intensity characteristics of
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interparenchymal hematomas, we're still in scenario three,
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which is the worst headache of one's life.
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One of the other entities that may cause a
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thunderclap, acute, abrupt headache is reversible
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cerebral vasoconstriction syndrome, or RCVS.
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Patients with RCVS develop a severe headache.
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It may be associated with vasoactive drugs
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that they may be taking for hypertension,
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for example, or in the postpartum setting with
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women who may have elevation of blood pressure.
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Risk factors include migraineurs or patients
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who may have dissection of the vessels,
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or cannabis use—actually, marijuana use.
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Normally, we would evaluate these
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patients with a non-contrast CT scan.
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The vast majority of these patients
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do not show subarachnoid hemorrhage.
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Rarely, you will see a little bit of blood products,
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but the vast majority do not show subarachnoid hemorrhage.
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And yet, because of that thunderclap nature
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of the headache, they will often get a CTA.
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Certainly, you may also evaluate
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the patient with MRI or MRA.
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And in these instances,
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what you see is vasoconstriction.
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What do we mean by vasoconstriction?
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We're talking about something that looks like vasospasm.
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Here is an MRA of a patient who presented with
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a thunderclap headache, had a negative CT scan, a negative
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lumbar puncture, did the MRA, and what you see are
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these areas in which the blood vessels are missing.
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This is severe vasospasm in the left
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middle cerebral artery distribution.
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Also found in the posterior cerebral
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artery distribution in this individual.
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So this vasospasm, in and of itself,
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can cause the severe headache.
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Here is an example that has an
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arteriogram from the literature.
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This is from one of my former clinical
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neuroradiology fellows and a colleague at the University
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of Maryland, Dheeraj Gandhi and Mossa-Basha.
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And what you see is a high signal intensity
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in the posterior white matter of the brain.
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This is the pattern that you would normally
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think—well, could this be posterior
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reversible encephalopathy syndrome?
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PRESS.
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And this is RCVS simulating PRESS
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can have the same sort of
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issues related to blood pressure.
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On follow-up examination, it goes away.
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But at the time of the patient's symptomatology,
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you see that the patient had an arteriogram showing
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areas of high-grade stenosis in peripheral vessels,
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indicative of RCVS—Reversible
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Cerebral Vasoconstriction Syndrome.
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The criteria for making this diagnosis are: severe,
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acute headache; usually a uniphasic disease;
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no subarachnoid hemorrhage from an aneurysm; CSF
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normal; but multifocal, segmental cerebral artery
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vasoconstriction or vasospasm demonstrated on catheter
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angiography or via the CTA or MRA, which reverses—
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so it is the "R" (reversible) within 12 weeks of onset.
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