0:00

So, Reversible Cerebral Vasoconstriction

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Syndrome, or RCVS, is characterized

0:08

by vasospasm for 6 to 12 weeks.

0:11

The patients typically have

0:13

recurrent thunderclap headaches.

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They tend to be women who

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are young or middle-aged.

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Two-thirds are seen in association with

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vasoactive drugs, such as SSRIs, but you can

0:25

also see them with cocaine, among others.

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Imaging, you'll have multifocal

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angiographic beading.

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Up to 45 percent have subarachnoid

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or intraparenchymal hemorrhage.

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Sometimes they can also have

0:37

pressure because there's an overlap.

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Usually, the patients recover, and I'm

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going to show you some vessel wall

0:44

imaging later, but there's usually

0:46

thickening with little enhancement.

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So these are images of a 55-year-old

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female who was on an SSRI with recurrent

0:53

thunderclap headaches and presented

0:56

with left-right and right hemiparesis.

0:58

And on her angiographic imaging, you can

1:01

see multifocal beading of the proximal

1:03

MCAs, proximal PCAs, and proximal ACAs.

1:07

And on the sagittal image, you can

1:08

see multifocal beading of the anterior

1:11

cerebral arteries, their border zone

1:13

infarcts in the cerebellum, as well as

1:16

in the right occipital lobe and the right

1:19

greater than left parietal lobes, or

1:20

some in the left occipital lobe as well.

1:23

So that's a classic case of RCVS.

1:26

Now let's review another case.

1:29

This is a case of RCVS, and these

1:33

are images of a 56-year-old female

1:35

who had headaches for three weeks.

1:37

They were multiple recurrent headaches.

1:39

thunderclap headaches, and she

1:42

had a right homonymous hemianopsia

1:45

and presented to our hospital.

1:47

This is the noncontrast CT, and what

1:50

we see is a hemorrhage in the left

1:52

posterior temporal and occipital lobes.

1:54

There's surrounding edema.

1:55

There's a little bit of mass effect on

1:57

the atrium of the lateral ventricle,

1:59

and I don't see any definite ischemia.

2:01

You can see there's some effacement

2:04

of sulci up over the vertex.

2:06

Just show this coronal images.

2:12

And really I just see again that hematoma

2:14

was surrounding edema and some mass effect.

2:19

So we went ahead and got a CTA of the head, and

2:23

we're going to just look at the MIP images of

2:26

the head, maximum intensity projection images.

2:30

We'll start at the bottom.

2:31

Vertebral arteries look okay.

2:34

Basilar artery looks okay.

2:36

But you can see multifocal stenosis in

2:38

the bilateral posterior cerebral arteries,

2:42

the left middle cerebral artery, there

2:43

are multifocal areas of narrowing,

2:45

the right middle cerebral artery,

2:51

the proximal anterior cerebral artery.

2:53

I'll show you that on different images.

2:54

You can see continued multifocal

2:56

stenosis throughout the MCAs as

2:59

we go up through the vessels.

3:02

On the sagittal images, you can see multifocal

3:04

stenosis in the bilateral anterior cerebral

3:07

arteries and the posterior cerebral arteries.

3:12

Basilar artery looks pretty normal.

3:15

Let's look at the coronal images.

3:18

And again, multifocal stenosis throughout

3:22

the middle cerebral arteries, and the

3:25

proximal posterior cerebral arteries,

3:28

and the anterior cerebral arteries.

3:30

So this was a classic case of RCVS, and

3:37

the patient seemed to be getting better,

3:40

but then she developed visual changes

3:43

on the left side, and she got another

3:46

diffusion-weighted image five days

3:48

later, and this is what it looked like.

3:50

And I'll start at the bottom here.

3:52

You can see this dark area with

3:55

susceptibility is the old hemorrhage.

3:57

There's a little ischemia around it, but

3:58

she's got new ischemic regions in the right

4:00

occipital lobe, the right posterior temporal

4:02

lobe, and the right parietal lobe and the

4:07

left posterior frontal and parietal lobes.

4:09

So this is a patient who eventually

4:13

recovered but had a prolonged course with

4:17

continued vasospasm and new infarctions.

4:20

It's very variable.

4:22

Some patients recover within 24 to 48

4:25

hours and some patients take longer.