Reversible cerebral vasoconstriction syndrome (RCVS) caused by over-the-counter calcium supplement ingestion

Abstract

A 59-year-old woman was found unresponsive at home. Initial neurologic examination revealed aphasia and right-sided weakness. Laboratory results demonstrated a serum calcium level of 17.3 mg/dL (corrected serum calcium for albumin concentration was 16.8 mg/dL). Extensive workup for intrinsic aetiology of hypercalcemia was unrevealing. Further discussion with family members and investigation of the patient's home for over-the-counter medications and herbal supplements revealed chronic ingestion of calcium carbonate tablets. CT angiogram of the brain revealed multifocal intracranial vascular segmental narrowing, which resolved on a follow-up cerebral angiogram done 2 days later. These findings were consistent with reversible cerebral vasoconstriction syndrome.Appropriate blood pressure control with parenteral agents, calcium channel blockade with nimodipine and supportive care therapies resulted in significant improvement in neurologic status. By discharge, patient had near-complete resolution of neurologic symptoms.

Keywords: adult intensive care; drugs and medicines; drugs: CNS (not psychiatric); neurological injury; stroke.

Figure 1

MRI brain with hyperintensity (white arrows) seen on diffusion-weighted image (DWI) (A and B), with apparent diffusion coefficient (ADC) maps (C and D) showing corresponding hypointensity (white arrows), indicating acute infarctions of the left occipital cortex, posterior thalamus, hippocampus, anterior temporal cortex, insula and posterior parietal cortex. Corresponding fluid-attenuated inversion recovery (FLAIR) image (E and F) showing expected T2 signal hyperintensity (white arrows) in areas of acute infarction, but absence of vasogenic oedema in white matter regions.

Figure 2

Multifocal irregularities and narrowing of bilateral intracranial arteries (red arrows) (A and B), as seen on CT angiography (CTA) at the base of the brain. Cerebral angiography images acquired 48 hours after CTA showing resolution of the focal narrowing of the same vessels (red arrows) (C and D).