When should Computed Tomography Angiography (CTA) be repeated in patients with Reversible Cerebral Vasoconstriction Syndrome (RCVS)?

From the Guidelines

Repeat CTA in patients with RCVS should be performed if there are persistent or evolving symptoms despite medical treatment, or with symptoms suggestive of propagation of thrombus, as recommended by the American Heart Association/American Stroke Association 1. When considering the timing of repeat CTA in RCVS, it is essential to prioritize the clinical presentation and response to treatment.

• In patients with persistent or worsening symptoms, earlier repeat imaging may be necessary to assess for any changes in the cerebral vasculature.
• The American Heart Association/American Stroke Association recommends an early follow-up CTV or MRV in CVT patients with persistent or evolving symptoms despite medical treatment or with symptoms suggestive of propagation of thrombus (Class I; Level of Evidence C) 1.
• Additionally, in patients with previous CVT who present with recurrent symptoms suggestive of CVT, repeat CTV or MRV is recommended (Class I; Level of Evidence C) 1.
• A follow-up CTV or MRV at 3 to 6 months after diagnosis may be reasonable to assess for recanalization of the occluded cortical vein/sinuses in stable patients (Class IIa; Level of Evidence C) 1. The decision to repeat CTA in RCVS should be guided by the individual patient's clinical course and response to treatment, rather than a fixed timeframe.
• The goal of repeat imaging is to confirm resolution of arterial narrowing, distinguish RCVS from other vasculopathies, and assess for any changes in the cerebral vasculature that may impact treatment decisions.
• By prioritizing the clinical presentation and response to treatment, clinicians can optimize the timing of repeat CTA in RCVS and provide personalized care for each patient.

From the Research

Repeating CTA with RCVS

• The decision to repeat CTA with RCVS depends on various factors, including the clinical presentation, initial imaging findings, and response to treatment 2, 3.
• In general, CTA can be repeated to assess the resolution of vasoconstriction and to monitor the patient's response to treatment 2.
• The optimal timing for repeating CTA is not well established, but it is recommended to repeat imaging studies, including CTA, after a few days or weeks to assess the resolution of vasoconstriction 2, 4.
• In some cases, repeat CTA may be necessary to rule out other conditions, such as cerebral vasculitis or moyamoya disease, which can present with similar clinical and imaging features 3, 5.
• The use of CTA as a follow-up imaging modality is supported by its high sensitivity and specificity for detecting reversible cerebral vasoconstriction syndrome (RCVS) 2, 6.

Factors Influencing Repeat CTA

• Clinical presentation, including the presence of thunderclap headaches, neurological deficits, or seizures, may influence the decision to repeat CTA 3, 5.
• Initial imaging findings, including the extent and severity of vasoconstriction, may also guide the decision to repeat CTA 2, 4.
• Response to treatment, including the use of calcium channel blockers, such as nimodipine, may also be a factor in determining the need for repeat CTA 2, 6.

Imaging Modalities

• CTA is a reliable non-invasive diagnostic modality for RCVS, but other imaging modalities, such as magnetic resonance angiography (MRA) or catheter digital subtraction angiography (DSA), may also be used to diagnose and monitor RCVS 3, 4.
• The choice of imaging modality depends on various factors, including availability, patient preference, and clinical presentation 2, 6.