Reply to “Reversible Cerebral Vasoconstriction Syndrome Responsive to Intravenous Milrinone”

NCJ_cover.jpgBy Ankur Khandelwal, Niraj Kumar

First Online: 20 December 2019


We read with interest the case report by Hawkes et al. [1] wherein the authors successfully managed a case of postpartum Reversible Cerebral Vasoconstriction Syndrome (RCVS) and highlighted the role of intravenous milrinone in reversing the arterial vasospasm refractory to oral nimodipine. However, the article brings forth certain queries which need to be addressed. Firstly, how did the authors diagnose aphasia on admission when the patient’s trachea was already intubated? Secondly, the authors have mentioned both hyperemia and vasospasm as the cause of increased mean blood flow velocities (MBFV) in left middle cerebral artery (MCA) (post-operative day [POD] 1 to POD 6) and right MCA (POD 3 to POD 6) even though Lindegaard (and not Lindegaard as stated by authors) ratio is clearly suggestive of vasospasm and not hyperemia [2]. Thirdly, in the discussion section, the authors have mentioned that arterial vasospasm progressed for 5 days after hemicraniectomy; however, the MBFV were clearly high even on POD 6 in bilateral MCA with Lindegaard ratio > 3 indicating vasospasm. Fourthly, the authors should have explained as to how pulsatility index increased in left MCA from < 1 (POD1 to POD 6) to 1.4 (suggestive of intracranial hypertension) on POD 7 despite reduction in vasospasm. Lastly, we believe that intravenous milrinone could have been initiated right from POD 1 as Table 1 clearly shows increased MBFV in left MCA from POD 1. Despite these above points, we appreciate authors for their efforts in successfully treating RCVS.

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