Confirmation of an adequate angiographic response to treatment was defined as a 10%–30% improvement in the most severely constricted vessel caliber. We do not capture any email address. Thank you for your interest in spreading the word on American Journal of Neuroradiology. MR imaging studies after 4 days showed right frontal hemorrhage, which was unchanged, and an MRA showed right ICA/MCA occlusion. In light of the growing evidence, we suggest a low threshold when considering IA verapamil injection not only as a therapeutic option but also as an early diagnostic tool for patients with oral treatment–refractory presumed RCVS. One patient required balloon angioplasty in addition to intra-arterial verapamil for severe ICA stenosis (patient 3). Four patients received and were unresponsive to steroids before the diagnosis of RCVS was considered. Angiogram on hospital day 2 shows severe distal basilar occlusion (C). to verify inclusion. Herein we describe a case of medically refractory RCVS that required treatment with intra-arterial (IA) verapamil and subsequent nimodipine, resulting in both angiographic and clinical improvement after failing to respond to hemodynamic augmentation. * *Money was paid to the individual. Patients were monitored clinically and with daily transcranial Doppler sonography. Reversible cerebral vasoconstriction syndrome (RCVS) describes a constellation of clinical and angiographic findings that includes severe headache and reversible segmental vasoconstriction of the cerebral arteries, with or without neurologic deficits. RCVS remains a challenging diagnosis, and its severity can be underestimated. The only residual symptom was a mild left neglect. Nevertheless, IA treatment with calcium channel blockers has not only been recognized as an important treatment adjunct for severe refractory RCVS but has also been proposed as a differential diagnostic tool.8,9,27,33⇓⇓-36 At our institutions, there is an increased awareness of the entity in general and a lower threshold for intervention. Except for 1 groin pseudoaneurysm successfully treated with thrombin injection, there were no complications reported from the angiographic procedures. One patient who developed heparin-induced thrombocytopenia required the use of argatroban, a direct thrombin inhibitor, during her procedures (patient 4). A 43-year-old woman presented at an outside hospital with headache and altered mental status; hypernatremia was found on laboratory work-up. At 5-year follow-up, a slight weakness of the lower extremities and left lower quadrantanopia was still present. This question is for testing whether or not you are a human visitor and to prevent automated spam submissions. Additionally, 10 mg in the right ICA and, again, 10 mg in the basilar artery were administered; overall, 40 mg of verapamil was administered. Multifocal vasoconstriction was seen in the left anterior circulation and was most severe in the bilateral posterior circulation (Fig 1). Oral nimodipine was discontinued on hospital day 12 due to resolution of symptoms. Policy, Get useful, helpful and relevant health + wellness information. Oral verapamil was started and titrated to 240 mg daily. Narrative review: reversible cerebral vasoconstriction syndromes, Transcranial color Doppler study for reversible cerebral vasoconstriction syndromes, Reversible cerebral vasoconstriction syndromes and primary angiitis of the central nervous system: clinical, imaging, and angiographic comparison, Reversible cerebral vasoconstriction syndromes: analysis of 139 cases, Reversible cerebral vasoconstriction syndrome: a complicated clinical course treated with intra-arterial application of nimodipine, Chemical angioplasty for medically refractory reversible cerebral vasoconstriction syndrome, Endovascular treatment of medically refractory cerebral vasospasm following aneurysmal subarachnoid hemorrhage, High-dose intraarterial verapamil in the treatment of cerebral vasospasm after aneurysmal subarachnoid hemorrhage, Improvement in angiographic cerebral vasospasm after intra-arterial verapamil administration, Reversible cerebral vasoconstriction syndromes presenting with subarachnoid hemorrhage: a case series, Hemorrhagic manifestations of reversible cerebral vasoconstriction syndrome: frequency, features, and risk factors, Systematic review of reversible cerebral vasoconstriction syndrome, Reversible cerebral vasoconstriction syndrome presenting as subarachnoid hemorrhage, reversible posterior leukoencephalopathy, and cerebral infarction. This clinical report adds evidence for the effectiveness of IA verapamil as a treatment escalation in RCVS and confirms its favorable safety profile. To date, only case reports and 1 small series have discussed the utility of intra-arterial vasodilators for the treatment of reversible cerebral vasoconstriction syndrome.

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