Marijuana-related Reversible Cerebral Vasoconstriction Syndrome

Abstract

The legalization of recreational marijuana in some countries has been accompanied by an increased number of case reports of serious cardiovascular and cerebrovascular complications. However, there have been few studies describing the detailed clinical course of reversible cerebral vasospasm syndrome (RCVS) associated with marijuana use. We herein report a unique case of recurrent bi-fronto-parietal subcortical (watershed) infarction in the setting of chronic daily marijuana use for several years, with evidence of bilateral anterior cerebral artery vasoconstriction. The quick resolution of symptoms with treatment and the normalization of cerebral vasoconstriction on follow-up imaging lend high certainty to the diagnosis of RCVS.

Keywords: RCVS; cannabinoid; marijuana.

Figure.

Clinical and imaging presentation of marijuana-induced RCVS. The patient initially presented hemispatial neglect on clock-drawing test (A), followed by improvement after the initiation of verapamil on hospital day 2 (B, day 3; C, day 5). Brain MRI demonstrated restricted diffusion (D) and increased fluid attenuated inversion recovery signals (E) at the bilateral high convexity subcortical area of the parietal lobes. A magnetic resonance angiogram (F) and CT angiogram (G) were notable for diffuse vasoconstriction of the cerebral arteries, especially in the anterior cerebral arteries (shown with yellow arrowhead). The cerebral angiogram performed on hospital day 6 showed normal cerebral arteries [H, branches of the right internal carotid artery (ICA); I, branches of the left ICA].