Intra‐Arterial Milrinone for Reversible Cerebral Vasoconstriction Syndrome

Department of Neurological Sciences, CHA (Enfant-Jésus), Faculty of Medicine, Laval University, Quebec City, QC, Canada.
Headache The Journal of Head and Face Pain (Impact Factor: 2.71). 01/2009; 49(1):142-5. DOI: 10.1111/j.1526-4610.2008.01211.x
Source: PubMed


Reversible cerebral vasoconstriction syndrome (RCVS) usually presents with recurrent thunderclap headaches and is characterized by multifocal and reversible vasoconstriction of cerebral arteries that can sometimes evolve to severe cerebral ischemia and stroke. We describe the case of a patient who presented with a clinically typical RCVS and developed focal neurological symptoms and signs despite oral treatment with calcium channel blockers. Within hours of neurological deterioration, she was treated with intra-arterial milrinone, a phosphodiesterase inhibitor, which resulted in a rapid and sustained neurological improvement.

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Available from: Nicolas Dupré, Nov 05, 2014
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    • "It has been hypothesized that either the episodes of systemic hypertension lead to hyperperfusion, or cerebral vasoconstriction and therefore hypoperfusion result in vasogenic edema observed in PRES [52]. Mainstay of treatment remains calcium-channel blockers including intravenous nimodipine [49••], intravenous prostacyclin [53] and intra-arterial delivery of milrinone [54], nimodipine [55], verapamil [56] that have been reported to be beneficial. "
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    ABSTRACT: Cranial or cervical vascular disease is commonly associated with headaches. The descriptions may range from a thunderclap onset of a subarachnoid hemorrhage to a phenotype similar to tension type headache. Occasionally, this may be the sole manifestation of a potentially serious underlying disorder like vasculitis. A high index of clinical suspicion is necessary to diagnose the disorder. Prompt recognition and treatment is usually needed for many conditions to avoid permanent sequelae that result in disability. Treatments for many conditions remain challenging and are frequently controversial due to paucity of well controlled studies. This is a review of the recent advances that have been made in the diagnosis or management of these secondary headaches.
    Preview · Article · May 2013 · Current Pain and Headache Reports
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    • "Other systemic treatments that have been used include intravenous and oral nicardipine [13], intravenous and oral verapamil [30], and intravenous magnesium sulphate (in the treatment of postpartum angiopathy) [31]. These reports all have the inherent limitations of case studies. "
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    ABSTRACT: Reversible cerebral vasoconstriction syndrome (RCVS) is an increasingly recognized and important cause of acute headache. The majority of these patients develop potentially serious neurological complications. Rigorous investigation is required to exclude other significant differential diagnoses. Differentiating RCVS from subarachnoid haemorrhage (SAH) and primary angiitis of the central nervous system (PACNS) may be difficult but has important therapeutic implications. This paper describes what is currently known about the epidemiology, pathophysiology, clinical, and diagnostic features of the syndrome, an approach to investigation, a summary of treatments, and what is known of prognosis.
    Full-text · Article · Jul 2012
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    • "In patients with refractory vasoconstrictions, intra-arterial therapy might be considered. Calcium channel blockers such as nimodipine [Elstner et al. 2009; Klein et al. 2009] or the phosphodiesterase inhibitor milrinone [Bouchard et al. 2009] have been employed in some cases and led to satisfactory outcomes. However, more studies are required. "
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    ABSTRACT: Reversible cerebral vasoconstriction syndrome (RCVS) is characterized by recurrent thunderclap headaches and reversible cerebral vasoconstrictions. RCVS is more common than previously thought and should be differentiated from aneurismal subarachnoid hemorrhage. RCVS can be spontaneous or evoked by pregnancy or exposure to vasoactive substances. Patients tend to be middle-aged women but pediatric patients have been seen. Up to 80% of sufferers have identifiable triggers. Thunderclap headaches tend to recur daily and last for a period of around 2 weeks, while the vasoconstrictions may last for months. About one-third of patients have blood pressure surges accompanying headache attacks. The potential complications of RCVS include posterior reversible encephalopathy syndrome, ischemic strokes over watershed zones, cortical subarachnoid hemorrhage and intracerebral hemorrhage. Magnetic resonance images including angiography and venography and lumbar punctures are the studies of choice, whereas catheter angiography should not be implemented routinely. Patients with a mean flow velocity of the middle cerebral artery greater than 120 cm/s shown by transcranial color-coded sonography have a greater risk of ischemic complications than those without. The pathophysiology of RCVS remains unknown; sympathetic hyperactivity may play a role. Open-label trials showed calcium channel blockers, such as nimodipine may be an effective treatment in prevention of thunderclap headache attacks. In severe cases, intra-arterial therapy may be considered. Most patients with RCVS recover without sequelae; however, relapse has been reported in a small proportion of patients.
    Full-text · Article · May 2010 · Therapeutic Advances in Neurological Disorders
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