Article Text
Abstract
Introduction Reversible cerebral vasoconstriction syndrome (RCVS) typically presents with varying neurological deficits and segmental vasoconstriction of the small and medium cerebral arteries. Patients with RCVS commonly present with ischemia, hemorrhage, or both, but there is limited understanding as to what predisposes a patient to a particular presentation. This study aims to compare the differences in patients with RCVS with hemorrhagic versus ischemic presentations.
Methods The Clinical Research Data Warehouse at this institution was employed to search the medical records for patients with a diagnosis of RCVS between January 2010 and May 2021. After screening, 88 patients met the inclusion criteria for a presumed diagnosis of RCVS. A presumed diagnosis of RCVS was determined both by radiographic findings and clinical presentation by both the primary service and neurointerventionist. Patients were initially divided into 2 categories: any hemorrhagic presentation (n=60) versus ischemic/other presentation (n=28). Subgroup analyses were conducted on those with hemorrhage, comparing the presence of subarachnoid (SAH) (n=27) versus parenchymal hemorrhage (IPH) (n=23) only. Clinical and radiographic data were analyzed.
Results In the main analysis, a history of migraines (p=0.019) and tumors (p=0.003) were seen more frequently in patients in the ischemic/headache presentation group. Opiate use was noted in patients with hemorrhage (p=0.006), specifically with SAH (p≤0.001) in the subgroup analysis. Nausea/vomiting (p=0.016) and a higher C-reactive protein (CRP) (p=0.002) were seen in the main hemorrhage group. In the hemorrhage subgroup analysis, cocaine use was more common in patients with IPH (p=0.01). Headache on presentation was more common in SAH (p≤0.001), while hemiparesis (p≤0.001) and altered mental status (p=0.044) were more common in IPH. RCVS2 scores were also higher in the SAH (p≤0.001) subgroup compared to IPH. Regarding outcome, there was no significant difference between hemorrhagic and ischemic/headache presentation. However, within the sub-group analysis, patients with IPH were more likely to have a worse discharge disposition (p≤0.001) and worse modified Rankin Scale (mRS) on discharge (p≤0.001) and follow-up (p≤0.001), when compared to SAH.
Conclusion Our analysis revealed that RCVS patients with a history of migraines or tumors are predisposed to ischemic manifestations. In contrast, a history of exposure to vasoactive substances may predispose a patient to IPH. Our data suggests that the presence of IPH is a negative predictor of clinical outcomes in patients with RCVS, as patients with IPH on admission presented with a worse physical exam and tended to have worsened clinical outcomes when compared to SAH. IPH seems to be a relatively common variant of RCVS, as seen by half of our confirmed RCVS hemorrhage patients presenting with IPH, yet it is not a criterion in the RCVS2 score. This needs to be verified in a larger dataset, and if our data is reproducible, the RCVS2 score may need to be modified to include IPH as a criterion for diagnosis.
Disclosures A. Madapoosi: None. L. Stone McGuire: None. A. Fuentes: None. M. Tshibangu: None. P. Theiss: None. T. Abou Mrad: None. S. Amin-Hanjani: None. A. Alaraj: None.