Reversible cerebral vasoconstriction syndrome: treatment with combined intra-arterial verapamil infusion and intracranial angioplasty

Abstract

We report a case of severe RCVS treated with a combination of selective intra-arterial verapamil infusions and intracranial angioplasty, resulting in angiographic and clinical improvement. Endovascular techniques more commonly used in the treatment of SAH-induced vasospasm are potentially important adjuncts to systemic drug therapy in the management of severe RCVS.

Fig 1.

A, On day 9 of illness, MRA of the circle of Willis demonstrates normal caliber of the ICAs, MCAs, ACAs, and vertebrobasilar system. B−D, At the same time, FLAIR shows bilateral parieto-occipital white matter edema, leading to an initial diagnosis of PRES. E−H, FLAIR MR imaging on illness day 19 shows progressive edema involving the occipital, parietal, and paramedian posterior frontal lobes. I−P, Diffusion-weighted imaging (I−L) and concomitant apparent diffusion coefficient maps (M−P) on illness day 19 confirm extensive infarction in the occipital, parietal, and paramedian posterior frontal lobes, corresponding to almost the entire extent of FLAIR abnormality.

Fig 2.

A, Before endovascular treatment, digital subtraction angiography on illness day 19 demonstrates marked narrowing of the basilar artery (measuring 1.1 mm in diameter) and proximal PCAs, with beaded irregular areas of narrowing and dilation in the distal PCAs. B, Following intra-arterial verapamil infusion, marked improvement is noted in the caliber of the basilar artery (2.2 mm) as well as the proximal PCAs. C, After PTA of the basilar artery, basilar artery caliber is further improved (3.1 mm). D, Repeat digital subtraction angiography on illness day 32 demonstrates stable basilar caliber (3.0 mm), though subsequent to further intra-arterial verapamil administration, further basilar artery dilation was observed (to 3.7 mm, not shown).