J Stroke Cerebrovasc Dis

. 2021 Sep 17;30(12):106118.
doi: 10.1016/j.jstrokecerebrovasdis.2021.106118. Online ahead of print.
Reversible Cerebral Vasoconstriction Syndrome in Patients with Coronavirus Disease: A Multicenter Case Series

Kristine Arandela 1 , Shilpa Samudrala 1 , Mohamad Abdalkader 2 , Pria Anand 1 , Ali Daneshmand 3 , Hormuzdiyar Dasenbrock 3 , Thanh Nguyen 4 , Charlene Ong 3 , Courtney Takahashi 3 , Julie Shulman 1 , Marc Alain Babi 5 , Sanjeev Sivakumar 6 , Neel Shah 6 , Sandip Jain 6 , Samyuktha Anand 7 , Christa O'Hana S Nobleza 8 , Shashank Shekhar 8 , Chitra Venkatasubramanian 9 , Hisham Salahuddin 10 , Muhammad A Taqi 11 , Hassan Aboul Nour 12 , Justin B Nofar 12 , Anna M Cervantes-Arslanian 13



Background and objectives: RCVS (Reversible Cerebral Vasoconstrictive Syndrome) is a condition associated with vasoactive agents that alter endothelial function. There is growing evidence that endothelial inflammation contributes to cerebrovascular disease in patients with coronavirus disease 2019 (COVID-19). In our study, we describe the clinical features, risk factors, and outcomes of RCVS in a multicenter case series of patients with COVID-19.
Materials and methods: Multicenter retrospective case series. We collected clinical characteristics, imaging, and outcomes of patients with RCVS and COVID-19 identified at each participating site.
Results: Ten patients were identified, 7 women, ages 21 - 62 years. Risk factors included use of vasoconstrictive agents in 7 and history of migraine in 2. Presenting symptoms included thunderclap headache in 5 patients with recurrent headaches in 4. Eight were hypertensive on arrival to the hospital. Symptoms of COVID-19 included fever in 2, respiratory symptoms in 8, and gastrointestinal symptoms in 1. One patient did not have systemic COVID-19 symptoms. MRI showed subarachnoid hemorrhage in 3 cases, intraparenchymal hemorrhage in 2, acute ischemic stroke in 4, FLAIR hyperintensities in 2, and no abnormalities in 1 case. Neurovascular imaging showed focal segment irregularity and narrowing concerning for vasospasm of the left MCA in 4 cases and diffuse, multifocal narrowing of the intracranial vasculature in 6 cases. Outcomes varied, with 2 deaths, 2 remaining in the ICU, and 6 surviving to discharge with modified Rankin scale (mRS) scores of 0 (n=3), 2 (n=2), and 3 (n=1).
Conclusions: Our series suggests that patients with COVID-19 may be at risk for RCVS, particularly in the setting of additional risk factors such as exposure to vasoactive agents. There was variability in the symptoms and severity of COVID-19, clinical characteristics, abnormalities on imaging, and mRS scores. However, a larger study is needed to validate a causal relationship between RCVS and COVID-19.

Keywords: COVID-19; RCVS; SARS-CoV-2; Stroke.