Cyproheptadine in the treatment of reversible cerebral vasoconstriction syndrome
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LETTER TO THE EDITOR
Cyproheptadine in the treatment of reversible cerebral vasoconstriction syndrome Jennifer Chima1 · Naresh Mullaguri1 · Tracey Fan1 · Pravin George1 · Christopher R. Newey1,2 Received: 13 May 2020 / Accepted: 26 August 2020 © Belgian Neurological Society 2020
Keywords Reversible cerebral vasoconstriction syndrome · Cyproheptadine · Sumatriptan · Dexamphetamine · Ischemic stroke · Serotonin
Introduction Reversible cerebral vasoconstriction syndrome (RCVS) is a transient vasculopathy of the cerebral blood vessels often characterized by thunderclap headache and transient cerebral vasoconstriction with ischemic and/or hemorrhagic stroke [1]. Various risk factors have been described to predispose or trigger RCVS including usage of serotonergic antidepressants, migraine medications, and nasal decongestants [1, 2]. Apart from removing the precipitating agents, medical management is limited to supportive care, calcium channel blockers, and blood pressure optimization to prevent worsening of vasoconstriction and ischemic complications [3]. Serotonin plays a major role in vascular tone as both a vasoconstrictor and vasodilator [2, 4]. These vasoactive effects of serotonergic medications can worsen or trigger vasospasm in patients with RCVS [2, 3]. A few cases have described reversal of vasoconstriction in coronary arteries with the use of the serotonin receptor antagonist * Jennifer Chima [email protected] Naresh Mullaguri [email protected] Tracey Fan [email protected] Pravin George [email protected] Christopher R. Newey [email protected] 1
Cerebrovascular Center, Neurological Institute, Cleveland Clinic Foundation, 9500 Euclid Avenue, Cleveland, OH 44195, USA
Epilepsy Center, Neurological Institute, Cleveland Clinic Foundation, Cleveland, OH, USA
2
cyproheptadine, but the effect of cyproheptadine on serotonin-induced cerebral artery vasoconstriction is largely unknown [4, 5]. We report a case of a patient with sumatriptan-induced cerebral vasoconstriction successfully treated with cyproheptadine.
Method/case presentation A 44-year-old female with a past medical history of marijuana use, opioid dependence on methadone, hypertension, and attention deficit hyperactivity disorder on dexamphetamine presented to the emergency department (ED) with a 2-week history of intermittent severe headaches with associated nausea/vomiting and photophobia. The patient was noted to be a poor historian and had difficulty characterizing the onset of her headaches. Computerized tomography of the head (CT) and angiography (CTA) were normal. She was diagnosed with migraine and prescribed sumatriptan which provided some headache relief. She presented to ED two more times (day 3 and day 8 after initial ED visit) with a similar headache and both times was noted to be extremely agitated and difficult to interview. Both times she was discharged from the ED without further imaging. She presented to the ED for a fourth time 16 days after her initial visit, now with constant severe headache and inability to lift her right arm
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