Reversible Cerebral Vasoconstriction Syndrome Associated With Fluoxetine

Abstract

Background: Reversible cerebral vasoconstriction syndrome (RCVS) is an increasingly recognized neurological syndrome that typically presents with a severe headache. The proposed etiology is transient and segmental constriction of cerebral arteries, which in severe cases can lead to cerebral ischemia. Multiple case reports have been identified associating the use of serotonergic medications with this syndrome.

Objective: A review of the literature describing RCVS in patients taking selective serotonin reuptake inhibitors and other serotonergic medications is summarized. This report also describes the case of a 32-year-old woman with a complicated psychiatric history diagnosed with RCVS who presented with progressive cerebral ischemia despite intensive medical intervention. Ischemic progression did not relent until her home medication fluoxetine was recognized as the likely etiology and discontinued. The psychiatric management of this patient is described after fluoxetine was discontinued. Other potential psychiatric treatments for patients with a history of RCVS are discussed.

Methods: A literature search was performed using PubMed with the following keywords: antidepressant, selective serotonin reuptake inhibitor, serotonin, fluoxetine, reversible cerebral vasoconstriction syndrome, RCVS, and Call-Fleming syndrome.

Results: Fifteen patients were identified to have RCVS with associated use of serotonergic medications from 10 case reports published between 2002 and 2019.

Conclusions: It is important for psychiatrists to recognize the syndrome of RCVS in patients presenting with headache and ischemia due to the possibility of this syndrome being a rare but iatrogenic complication of a common psychiatric medication class. Additionally, identification of safe alternative treatments for patients with psychiatric illness who would otherwise be candidates for serotonergic medications is an important consideration for individuals affected by this disorder.

Keywords: RCVS; SSRI; fluoxetine; headache; ischemia; reversible cerebral vasoconstriction syndrome; serotonin; stroke.