Extracranial Four-Vessel Dissection with Reversible Cerebral Vasoconstriction Syndrome in a Habitual Cocaine User Presenting with Thunderclap Headache

Abstract

A four-vessel dissection involving both extracranial carotid and vertebral arteries is an uncommon occurrence
more so when it is likely a consequence of cocaine
abuse [1]. Reversible cerebral vasoconstriction syndrome (RCVS) is well documented with cocaine use [2],
but its association with a four-vessel dissection has not
been described.
This is a clinical picture of 36-year-old right-handed
woman presenting with second episode within a week of
a new onset thunderclap headache. Her CSF was normal
except for three RBCs. Contrast-enhanced neck MRA
showed a focal left extra-cranial internal carotid artery
dissection [Figure 1(A)], which was suspected to be the
cause of her thunderclap headache along with diffuse
narrowing of the distal small vessels on non-contrast
head MRA. A diagnosis of RCVS was made, and treatment with verapamil and heparin anticoagulation was
started for the dissection.
Her symptoms progressed to pulsatile tinnitus and worsening headache despite the treatment. Following this
contrast enhanced MRA on Day 10 showed new focal
right extra-cranial internal carotid artery (Figure 1B). On
Day 14 and 20, we performed a four-vessel angiogram
which showed new focal left vertebral and finally right
vertebral artery dissection, respectively, along with the
previous dissections remaining stable [Figure 1(C) and
(D)]. By the end of the hospital stay, the patient conceded being a habitual cocaine user with the last use couple of weeks before the admission. The patient had
incomplete recovery of headache and persistent neurological deficits on discharge.