A Case Report of Thunderclap Headache with Sub-arachnoid Hemorrhage and Negative Angiography: A Review of Call-Fleming Syndrome and the use of Transcranial Dopplers in Predicting Morbidity

Abstract

Introduction: We present a case report in a patient with severe, recurrent, thunderclap with computed tomography (CT) evidence of
subarachnoid blood and negative work-up for aneurysm. This case is an example of
Call-Fleming syndromewith subarachnoid hemorrhage inwhich transcranialDoppler
(TCD) was used for monitoring of cerebral vasoconstriction when angiography did
not evidence vasoconstriction. We will review Call-Fleming syndrome and the utility
of transcranial doppler imaging to assess cerebral vasoconstriction.
Methods: A review of the current literature regarding diagnostics, treatment, and
morbidity in Call-Fleming (reversible cerebral vasoconstriction syndrome) as well
as a review of the data using transcranial color-coded sonography and transcranial
doppler imaging to assess vasospasm in these cases.
Results: The patient underwent computed tomography angiography (CTA) and
venography (CTV), catheter angiography, lumbar puncture, and vasculitis work-up
which were all negative. His magnetic resonance imaging (MRI)showed T2 weighted
and fluid attenuation inversion recovery (FLAIR) hyper-intensities in the posterior
frontal lobes as well as subarachnoid blood along bilateral occipital convexities.
TCDs were obtained which showed elevated mean velocities.
Conclusion: The use of bedside transcranial doppler imaging is a non-invasive means of assessing vasospasm in Call-Fleming syndrome;
even in cases where angiography is negative. Determining the degree of vasospasm based on the data in subarachnoid hemorrhage,
we are able to predict a patient’s risk of complications related to vasospasm including reversible posterior leukoencephalopathy and
ischemic events.