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| 50th Annual Meeting of the American Headache Society |
Boston, Massachusetts June 26-29, 2008 |
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The Year's Top Clinical Advances |
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BY MAURY M. BREECHER
Contributing Writer |
BOSTON — The highlight in headache research in
the past year was a “spectacular” paper presented by
French investigators A. Ducros and colleagues at the
2008 conference of American Academy of Neurology,
reported Dr. Stephen D. Silberstein on June 28 at the
50th Annual Meeting of the American Headache Society.
Dr. Silberstein of Thomas Jefferson University in
Philadelphia said the title of the paper was “Clinical
and Radiological Spectrum of Reversible Cerebral
Vasoconstriction Syndrome.”
Reversible cerebral vasoconstriction syndrome (RCVS) is
a clinical radiological syndrome in which patients
experience severe headache, progressive “brutal onset”
or thunderclap headaches with or without focal defects
and or seizures. On angiography, the image that presents
has a typical string and beads appearance.
Ducros and his colleagues did a prospective study of 67
such patients over three years between 2004 and 2007.
The objective of the study was to describe the clinical
and radiologic features of RCVS.
Dr. Silberstein said he was surprised to read that
almost twice as many women as men experienced this type
of headache. There were 47 female and 24 male
participants. Twelve percent of the females experienced
the headaches postpartum. The mean age was 42 years and
most participants (63%) had secondary forms of the
headache.
The preponderance of participants had headaches they
described as “thunderclap,” and 94% of the participants
reported that the headaches were recurrent. Sixty
percent of the patients used vasoactive substances such
as cannabis, SSRI, or decongestants. The headaches were
often triggered by sexual activity, strenuous effort, or
emotion. Only 3% had seizures, yet 21% had focal
deficits, and 28% had abnormal MRIs.
“Diagnosis of this condition may be difficult because of
incomplete sensitivity of noninvasive technique,” warned
Dr. Silberstein. “If you do not continue to aggressively
follow and re-examine these patients, you’ll miss the
diagnosis.”
Repeated investigations are important, Dr. Silberstein
continued. Twenty-one percent of the patients had normal
first MRAs and the transcranial Doppler (TCD) was normal
in 31% of the cases. Or, to put it another way,
vasoconstriction was not revealed by MRA in six cases on
day 5, but was visible at day 13. The TCD showed
increased velocities in more than twice as many patients
(N=44) as was revealed in day 6 (N=20).
The French researchers emphasized in their paper that
RCVS is an underdiagnosed type of headache and should be
considered whenever patients present with thunderclap
headache, cortical SAH, or cryptogenic stroke.
“It’s extremely important to realize that you need to
repeat the noninvasive studies,” continued Dr.
Silberstein. “The French researchers not only
demonstrated the presence of vasoconstriction but also
showed reversibility over a period of time.”
Sixty-one of the patients were treated with nimodipine.
Within 1–3 months there was 100% reversal of
vasoconstriction, yet persistent neurological deficits
remained in 6% of the patients. Three patients could not
resume work and two patients developed epilepsy. The
French researchers warned that the efficacy of
nimodipine was “uncertain” since by definition RCVS is
reversible.
Although reversible, it is not benign, stated Dr.
Silberstein. Cortical subarachnoid hemorrhage,
infarctions and reversible encephalalogy syndrome can
occur in a significant percentage of those patients.
The French researchers emphasized that screening for
vasoactive substances (eg, Cannabis, SSRI, or
decongestants) was recommended and if discovered, the
patients should be encouraged to stop taking those
substances. |
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