Case Presentation: Ms. T.J. is a 47-year-old female with a past medical history consisting of migraines and tobacco use who presented with headache. 6 weeks prior to admission, the patient had a sudden onset of severe headaches. The headaches would differ in severity. She described having a constant headache with a dull ache located at the base of her skull. The worst headaches were sudden in onset and felt like a “vice grip” around her head. They were so debilitating it would cause nausea, vomiting, and photosensitivity. There were no warning signs before the onset of her severe headaches. She had multiple ED and PCP visits with trials of different medications, which included: zolmitriptan, prednisone, estradiol, diazepam and exedrin migraine, none of which provided relief. A LP was attempted at an ED visit which was aborted secondary to pain. Her PCP ordered an MRI, which was normal.Later, she reported feeling like her depth perception was off when she was trying to pick up items with her left hand. She also noticed double vision while trying to read. She experienced missing a step with her left leg while walking up a set of stairs. A repeat brain MRI demonstrated restricted diffusion in the right frontal, parietal and occipital lobes, concerning for acute/subacute ischemic infarction. The multiple vascular distributions raised the question of either an embolic process or vasculitis. There was also mildly prominent leptomeningeal enhancement, concerning for possible inflammatory process versus meningitis.
Upon admission, her neurological exam was normal with no deficits. The patient did report subjective weakness in her left lower extremity. Work up revealed unremarkable echo, spinal fluid analysis, MRI head, neck and CTA head except for narrowed right MCA vessels and small aneurysm. Hypercoaguable and autoimmune labs were negative. A cerebral angiogram demonstrated vascular irregularities with dilation and constriction, consistent with reversible cerebral vasoconstriction syndrome (RCVS). She sent home on verapamil, magnesium oxide, aspirin and atorvastatin.
Discussion: RCVS is an under diagnosed syndrome. This is an important syndrome to recognize in hospitalized patients presenting with severe thunderclap headache because there is available treatment. Recognition of symptoms is key in helping with diagnosis. Symptoms include thunderclap headache with or without neurologic signs or symptoms. Diagnosis requires demonstration of cerebral artery vasoconstriction on angiography, CTA, or MRA, no evidence of aneurysmal SAH and normal CSF analysis. The syndrome usually resolves with treatment. Treatment includes calcium channel blocker and magnesium.
Conclusions: Thunderclap headache has a broad differential, including RCVS. Recognition, diagnosis, and treatment of this condition can bring relief to patients experiencing debilitating headaches associated with RCVS.
To cite this abstract:Olson, KM; Rearigh, L; Frankova, D. When Thunder Strikes. Abstract published at Hospital Medicine 2018; April 8-11; Orlando, Fla. Abstract 767. https://www.shmabstracts.com/abstract/when-thunder-strikes/. Accessed February 25, 2020.