Reversible Cerebral Vasoconstriction Syndrome Secondary to Loperamide Ingestion: A Case Report
Momina Qureshi1, Ammar Jum'ah1, Abdalla Albanna1, Shaneela Malik1
1Henry Ford Hospital
Objective:
To describe a unique case of RCVS secondary to the antidiarrheal agent loperamide.
Background:
Reversible cerebral vasoconstriction syndrome (RCVS) is a cerebrovascular disorder characterized by diffuse, multifocal vasoconstriction of the cerebral circulation. While RCVS may be idiopathic, the leading cause is exposure to certain drugs. RCVS is self-limiting and almost always reversible. The main mechanism underlying the pathophysiology of vasoconstriction is cerebrovascular dysregulation of vascular tone.
Design/Methods:
A 73-year-old woman presented with severe vertigo of 3 days duration. CT angiography of the head and neck showed focal stenoses at the bilateral posterior cerebral arteries, the left superior cerebellar artery, and the right inferior cerebellar artery. Symptoms resolved after fluid administration. Two weeks later, magnetic resonance (MR) imaging of the brain, head and neck with contrast showed resolution of intracranial stenoses and absence of intracranial insults and vascular enhancement. Patient had been experiencing vomiting and diarrhea for one week before her ED presentation and had been using the antidiarrheal agent loperamide in 2 mg doses four times daily for 6 days, which resolved the diarrhea.
Results:
Our patient’s RCVS with diffuse vasoconstriction was most likely caused by excessive use of the over-the-counter antidiarrheal agent loperamide, which is an opioid receptor antagonist that works in the gut, halting peristaltic movements and water secretion. Although loperamide’s vasoconstrictive effects have been reported as possibly inducing myocardial ischemia, to our knowledge, loperamide associated with cerebral vasoconstriction and RCVS has not been reported.
Conclusions:
RCVS is a syndrome which classically presents with headache, but presentation can be varied. Therefore it is important to keep in mind the image findings of multi-focal stenosis which later resolves. We propose that Loperamide, an anti-diarrheal agent, is a causative agent for RCVS, as seen in our patient. Reviewing current medications for suspected RCVS is extremely important, and immediately eliminating the causative agent is imperative.