NeuroSpeak: reversible cerebral vasoconstriction syndrome and fingolimod

Another possible vascular complication of fingolimod; reversible cerebral vasoconstriction syndrome #NeuroSpeak #MSBlog

Reversible cerebral vasoconstriction syndrome (RCVS) is a relatively new condition. I have my first patient admitted under me a few months ago with this condition. She presented with a thunderclap headache whilst running on a treadmill and was admitted with a subarachnoid haemorrhage. An angiogram showed diffuse cerebral vasoconstriction and no aneurysm.  We managed her with nimodipine and she made a good recovery from the acute crisis. A repeat angiogram after discharge was normal. Unfortunately, when I reviewed her in clinic a few weeks ago she has developed migraine headaches and has persistent fatigue, both relatively common complications of a subarachnoid haemorrhage. Her only risk factor for RCVS was borderline hypertension. RVCS has been strongly associated with stimulants (cocaine and amphetamines), serotonin reuptake inhibitors, triptans, tacrolimus and pregnancy states. I was therefore fascinated to read that an MSer on fingolimod had RVCS 3 months post-partum. I can only assume that fingolimod is a risk factor for RVCS. Fingolimod is vasoactive and has been linked to several vascular complications, i.e. macular oedema, hypertension and posterior reversible encephalopathy syndrome  or PRES. I would be interested to see if there have been any more reports of RCVS in MSers on fingolimod?”

“Please note that NeuroSpeak posts are a new feature on this blog and are targeted at neurologists reading this blog. However, if you are an MSer on fingolimod you need to be aware of the vascular complications of fingolimod. Based on this case study and others I would recommend you try and avoid vasoactive stimulants (cocaine, amphetamines, ephedrine, pseudoephedrine, etc.). Please note that pseudoephedrine is the active ingredient in many nasal decongestants and is widely used as an appetite suppressant.”

Kraemer et al. Reversible cerebral vasoconstriction syndrome associated with fingolimod treatment in relapsing-remitting multiple sclerosis three months after childbirth. Mult Scler. 2015 Aug . pii: 1352458515600249.

Reversible cerebral vasoconstriction syndrome (RCVS) is characterized by acute thunderclap headache, evidence of vasoconstriction in conventional angiography or magnetic resonance angiography and reversibility of these phenomena within 12 weeks. Some triggering factors, for example drugs such as selective serotonin reuptake inhibitors, sumatriptan, tacrolimus, cyclophosphamide and cocaine, or states such as pregnancy, puerperium or migraine have been described. We describe the case of a 29-year-old woman with RCVS associated with fingolimod three months after childbirth. This case represents the first report of RCVS in fingolimod treatment.

One thought on “NeuroSpeak: reversible cerebral vasoconstriction syndrome and fingolimod”

  1. I had a patient with this only two weeks back (unrelated to fingolimod), we tried the watch and wait policy without much luck, then responded well to nimodipine.

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