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Abstract Details

A case of cerebral vasculitis mimicking RCVS
P9 - Poster Session 9 (5:30 PM-6:30 PM)
Thunderclap headache (TCH) constitutes a red-flag in emergency department and is most frequently associated with significant vascular intracranial disorders, primarly subarachnoid hemorrhage (SAH) and reverse vasocostriction syndrome (RCVS).
To showcase a cerebral vasculitis mimicking RCVS.
A 47 years-old woman referred for episodes of frontal headache suggestive for TCH, associated with nausea and vomiting. She also complained mild left laterocervical pain two days earlier. Her personal medical and pharmacological histories were unremarkable, without previous headache episodes, but she reported a case of autoimmune glomerulonephritis in her family history. 

Urgent CT showed bilateral mild cortical SAH however angioCT did not disclose aneurysms, revealing a left inner carotid artery (ICA) stenosis interpreted as dissection. Brain MRI confirmed cortical SAH without evidence of ischemic lesions or other microbleedings and angiography showed widespread thinning of the pericallosal and callosomarginal arteries, suggestive for vasospasm. She was diagnosed with RCVS and put on nimodipine, however patient continued to complain about headache and a second MRI showed an asymptomatic ischemic lesion. Thrombophilic and immunological screening were negative and cerebrospinal fluid isoElettroFocusing revealed oligoclonal bands. Whole-body FDG-PET confirmed circumscribed inflammation involving left ICA walls and excluded other vessels’ involvement. She was treated with high-dose steroids with headache remission and then put on immunosuppressant treatment with also radiological improvement and vascular abnormalities resolution.

Although TCHs rarely characterizes headache in cerebral vasculitis and often addresses towards other etiologies, this case emphasizes the need of a comprehensive differential diagnosis of all possible underlying causes, in order to not miss potentially treatable conditions.
Valentina Poretto, MD (Department of Emergency, Neurology Unit)
Dr. Poretto has nothing to disclose.
No disclosure on file
Bruno Giometto, MD (Azienda Provinciale Er I Servizi Sanitari) Dr. Giometto has nothing to disclose.
Sabrina Marangoni (Ospedale Santa Chiara) No disclosure on file