Anesthetic Management of Reversible Cerebral Vasoconstriction Syndrome: A Case Report

Reversible cerebral vasoconstriction syndrome (RCVS) is a group of disorders characterized by prolonged reversible cerebral vasoconstriction, associated with acute-onset, severe, episodic "thunderclap" headaches with or without other neurologic clinical features. We describe the first reported case, to our knowledge, of a patient with RCVS who was managed under general anesthesia in the field of oral and maxillofacial surgery. A 67-year-old woman with a diagnosis of RCVS made 2 months earlier was scheduled to undergo surgical extraction of the mandibular right third molar. Standard monitoring included noninvasive blood pressure measurement, pulse oximetry, and electrocardiography; a bispectral index (BIS) monitor sensor was placed on her forehead. General anesthesia was induced by target-controlled infusion of propofol to an effect site concentration of 5.0 μg · mL^-1, with remifentanil, 0.50 μg · kg^-1 per minute, and rocuronium, 40 mg. After tracheal intubation, anesthesia was maintained uneventfully with remifentanil, 0.15 to 0.2 μg · kg^-1 per minute, and propofol, 2.0 to 3.0 μg · mL^-1, in oxygen and air. The end-tidal carbon dioxide concentration was maintained at 38 to 42 mm Hg. The BIS reading was 40 to 60. Fentanyl, 0.1 mg, and acetaminophen, 750 mg, were administered before the end of surgery for postoperative analgesia. The postoperative course was uneventful, with no headaches or hypertensive complications. We successfully achieved anesthetic management with no appreciable clinical signs of cerebral ischemia or recurrence in a patient with RCVS. We used propofol as the anesthetic agent with BIS monitoring to detect cerebral ischemia. However, there is no definitive evidence of the utility of these measures for the prevention or diagnosis of RCVS, and further study is needed.