Clinical significance of centripetal propagation of vasoconstriction in patients with reversible cerebral vasoconstriction syndrome: A retrospective case-control study

Abstract

Introduction We previously reported centripetal propagation of vasoconstriction at the time of thunderclap headache remission in patients with reversible cerebral vasoconstriction syndrome. Here we examine the clinical significance of centripetal propagation of vasoconstriction. Methods Participants comprised 48 patients who underwent magnetic resonance angiography within 72 h of reversible cerebral vasoconstriction syndrome onset and within 48 h of thunderclap headache remission. Results In 24 of the 48 patients (50%), centripetal propagation of vasoconstriction occurred on magnetic resonance angiography at the time of thunderclap headache remission. The interval from first to last thunderclap headache in patients with centripetal propagation of vasoconstriction (14 ± 10 days) was significantly longer than that of patients without centripetal propagation of vasoconstriction (4 ± 2 days). In the patients with centripetal propagation of vasoconstriction at the time of thunderclap headache remission, the incidence of another cerebral lesion (38%, 9 of 24 cases) was significantly higher than in patients without centripetal propagation of vasoconstriction (0%). From findings of sequential magnetic resonance angiography before and after thunderclap headache remission, we observed tendencies in which centripetal propagation of vasoconstriction gradually progressed after the onset of reversible cerebral vasoconstriction syndrome and peaked at the time of thunderclap headache remission. The progress of centripetal propagation of vasoconstriction concluded with thunderclap headache remission. Conclusions Centripetal propagation of vasoconstriction has clinical significance as an indicator of the severity of reversible cerebral vasoconstriction syndrome. The presence of centripetal propagation of vasoconstriction is associated with an increased risk of brain lesions and a longer interval from first to last thunderclap headache. Moreover, repeat magnetic resonance angiography to assess centripetal propagation of vasoconstriction during the time from onset to thunderclap headache remission can help diagnose reversible cerebral vasoconstriction syndrome.

Keywords: Headache remission; magnetic resonance angiography; neuroradiological diagnosis; thunderclap headache.

Figure 1.

Images from a 28-year-old woman with puerperium-related reversible cerebral vasoconstriction syndrome. The patient was admitted to the hospital 2 h after onset. (a) The initial magnetic resonance angiography (MRA) obtained 3 h after the onset of thunderclap headache (TCH) shows vasoconstriction in the right M2-3 portions (circle) and terminal of the M1 portion of the middle cerebral artery (white arrowhead). (b) MRA obtained 6 days after onset shows centripetal propagation of vasoconstriction (CPV) in the bilateral M1 portions (white arrowheads) and A1 portions of the anterior cerebral arteries (white arrows). Vasoconstriction of the right M2-3 portion remains (circle). (c) MRA obtained at the time of TCH remission (12 days after onset of TCH) shows progress of CPV in the bilateral P1 portions of the posterior cerebral artery (open arrows). Vasoconstriction of the right M2-3 portion remains (circle). (d) MRA obtained 16 days after onset shows conclusion of CPV. Vasoconstriction of the bilateral A1 (white arrows), M1 (white arrowheads), and P1 (open arrow) portions tends to improve. Vasoconstriction of the right M2-3 portion remains (circle). (e) MRA obtained 31 days after onset shows only mild vasoconstriction of the right M1 portion (white arrow). Vasoconstriction of the right M2-3 portion tends to improve (circle).

Figure 2.

Images from a 50-year-old woman with reversible cerebral vasoconstriction syndrome. The patient was admitted to the hospital 6 h after onset. (a) The initial magnetic resonance angiography (MRA) obtained 7 h after the onset of thunderclap headache (TCH) shows vasoconstriction in the bilateral M2-3 portions of the middle cerebral artery (circles) and the P2-3 portion of the posterior cerebral artery (dotted circle). (b) MRA obtained at the time of TCH remission (5 days after onset of TCH) shows no findings of centripetal propagation of vasoconstriction (CPV) in the major cerebral arteries. Vasoconstriction of the bilateral M2-3 (circles) and P2-3 portion (dotted circle) remains. (c) MRA obtained 12 days after onset (5 days after TCH remission) also shows no findings of CPV in the major cerebral arteries. Vasoconstriction of the bilateral M2-3 (circles) and P2-3 portion (dotted circle) tends to improve.