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Images in Neurology
February 2016

Reversible Cerebral Vasoconstriction Syndrome

Author Affiliations
  • 1Pulmonary, Critical Care, and Respiratory Services, MedStar Washington Hospital Center, Washington, DC
JAMA Neurol. 2016;73(2):232-233. doi:10.1001/jamaneurol.2015.3472

A woman in her 30s presented by private car to the emergency department after a generalized tonic-clonic seizure lasting 3 minutes. She had a Glasgow Coma Scale score of 9, moved all her extremities, appeared to be in pain, was afebrile, and had stable vital signs. Her glucose level was 133 mg/dL (to convert to millimoles per liter, multiply by 0.0555). The patient's friend reported she used synthetic cannabis just before the seizure. She had no seizure disorder but had a left cerebral ischemic stroke and myocardial infarction 4 months ago with use of synthetic cannabis with resolution of symptoms and neurologic deficits. The patient developed another tonic-clonic seizure, which aborts with lorazepam followed by levetiracetam. The patient was subsequently intubated for airway protection before computed tomography and magnetic resonance imaging. Magnetic resonance imaging (Figure) revealed edema in cortical and subcortical white matter bilaterally. The results of the following laboratory tests were normal: complete blood cell count, chemistry panel, aspirin level, acetaminophen level, alcohol level, and liver function tests. The urine drug screen result was positive for cannabinoids, and cerebrospinal fluid was not obtained. The patient was admitted to the intensive care unit with gradual improvement in neurologic examination findings. The patient was weaned from mechanical ventilation within 24 hours. She returned to normal mentation without neurologic deficits and was discharged from the hospital to home after 7 days. Lack of health insurance coverage resulted in the patient not being followed up at the neurology clinic, and no additional brain imaging was performed. The patient was followed up by telephone at 90 days and revealed 2 recurrent self-limited seizures despite reported use of levetiracetam. The patient denied any additional use of illicit drugs. She noted complete mobility and independent activities of daily living but inability to stand for more than 20 minutes because of fatigue. In addition, she was unable to return to work because of persistent memory problems and difficulty focusing during tasks.

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