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Neurological Rehabilitation

(Kiosk 3) Blood on the Brain, Reversible Vasoconstriction Syndrome (RCVS) to Blame: A Case Series

Saturday, November 18, 2023
8:00 AM – 9:15 AM CT

    Primary Author(s)

  • Alicia E. Roldan, DO

    Resident Physician
    Montefiore Medical Center/Albert Einstein College of Medicine PM&R Program
    New Rochelle, New York

    • Co-Author(s)

  • Erika L. Trovato, DO, Other

    Associate Chief Medical Officer, Brain Injury Medicine Physician
    Burke Rehabilitation Hospital PM&R Program
    White Plains, New York

  • JV

    Jennie Valles, MD

    Attending
    Burke Rehabilitation Center Member of Montefiore Health System
    White Plains, New York

Case Diagnosis: Three cases of brain hemorrhage secondary to RCVS

Case Description or Program Description: Between May and June of 2022 three patients were admitted to the same acute rehabilitation hospital with intracranial hemorrhages secondary to RCVS. Patient A was a 32 year-old man that presented to the Emergency Department with acute onset headache, confusion and word finding difficulty. Imaging revealed left frontal intraparenchymal hemorrhage (IPH) and bilateral frontoparietal and left cerebral hemisphere infarcts secondary to RCVS in the setting of marijuana use. Patient B was a 54 year-old woman intermittently taking a caffeinated weight-loss supplement who was found to have a diffuse subarachnoid hemorrhage following a “thunderclap headache” that occurred while the patient was on a group run, exercising for the first time in years. Cerebral angiogram findings were consistent with RCVS likely triggered by vigorous exercise, caffeine supplementation and/or COVID-positive diagnosis. Patient C was a 58 year-old female with depression on escitalopram, who presented to the ED with worsening headache over 24-hours, emesis, altered mental status, right facial droop, aphasia and right hemiplegia. She was diagnosed with left basal ganglia IPH, intraventricular hemorrhage and 5mm midline shift caused by RCVS due to escitalopram use.

Setting: Acute Inpatient Brain Injury Rehabilitation Unit

Assessment/Results: Each patient presented with deficits correlating to the area of their brain injured and required multidisciplinary rehabilitation for cognitive-linguistic impairment and functional impairments limiting activities of daily living.

Discussion (relevance): RCVS is a group of conditions with a wide array of risk factors and triggers that clinically manifest as a “thunderclap headache” caused by reversible multifocal narrowing of cerebral arteries that can lead to brain edema, stroke or seizure. An estimated 3 in one million people are affected by RCVS annually, however the true incidence is unknown.

Conclusions: RCVS is a condition with no defined treatment and potentially devastating consequences requiring multidisciplinary rehabilitation.