(PO-174) (PO-174) Management of major depression following vasoconstrictive stroke due to serotonergic medications

Background: Reversible cerebral vasoconstriction syndrome (RCVS) is an uncommon form of stroke caused by temporary dysregulation of cerebrovascular tone. Symptoms include severe, recurrent headaches, with or without focal neurological findings. Radiography reveals diffuse segmental vasospasm of cerebral arteries that peaks 2-3 weeks after symptom onset and resolves spontaneously within 3 months. Serotonergic and adrenergic medications are among the most common causes of RCVS (Ducros, 2012).

Methods/Case: We present a 53-year-old female with history of major depressive disorder (MDD), generalized anxiety disorder (GAD), and alcohol use disorder who developed left parietal and right frontal subarachnoid hemorrhages months after her serous ovarian cancer diagnosis. Neurological workup revealed RCVS as the cause of her strokes, with suspected causes including serotonergic medications duloxetine and bupropion and medical marijuana use. After duloxetine and bupropion were stopped on the recommendation of her neurologists to reduce the risk of recurrent RCVS, her anxious and depressive symptoms worsened. Treatment options were limited given that serotonergic and noradrenergic medication were relatively contraindicated. After incomplete symptom resolution on trials of mirtazapine and aripiprazole augmentation, she ultimately showed clinically significant improvement following addition of liothyronine.



Results: This case presentation and literature review includes discussion of pathophysiology of RCVS, as well as common symptoms and presentation. Potential offending agents are explored, as well as treatment approaches to RCVS and also comorbid psychiatric disorders.

Discussion: RCVS is a rare but serious side effect of serotonergic and noradrenergic medications, both of which are routinely prescribed by psychiatrists. Management of mood disorders following RCVS poses a significant clinical challenge given the dearth of non-serotonergic and -noradrenergic medications available to treat such conditions. We present successful treatment of MDD and GAD despite the clinical limitations posed by RCVS as a guide for CL psychiatrists facing similar management challenges. We additionally emphasize the importance of integrating within the medical community, as coordination with both oncology and neurology was imperative for optimal case management.

Implications: Attendees will advance their knowledge of the role of psychotropic medications in RCVS and potential management options of mood and anxiety disorders following this form of stroke.





Reference

1.Ducros, A. (2012). Reversible cerebral vasoconstriction syndrome. The Lancet Neurology, 11(10), 906-917.