Managing Psychiatric Disorders in Reversible Cerebral Vasoconstriction Syndrome (RCVS) Triggered by Citalopram in the Inpatient Rehab Setting

Case Diagnosis: Managing Psychiatric Disorders in Reversible Cerebral Vasoconstriction Syndrome (RCVS) Triggered by Citalopram in the Inpatient Rehab Setting

Case Description or Program Description: We present a 45F admitted to acute care with severe headache. Work up revealed right basal ganglia hemorrhage and intraventricular bleed along with right middle and anterior cerebral infarcts. There were vascular irregularities suggestive of a diagnosis of RCVS. Believed to trigger RCVS, citalopram was discontinued. Psychiatry was consulted for management of depression and elected to hold treatment in acute setting. Early in acute inpatient rehabilitation course, the patient presented with a compulsive behavior: sequential counting. She endorsed counting when anxious, in pain, or otherwise uncomfortable. Therapy with neuropsychology continued throughout admission with weekly sessions. She demonstrated decreased mood and engagement as admission progressed. Rehabilitation course was complicated with left spastic hemiplegia, which caused physical and mental distress. Pain was managed with botulinum toxin injection, oral antispasmodics, and multimodal pain regimen that included gabapentin, which provided an anxiolytic effect. Trial of bupropion was initiated after discussions with psychiatry, neurosurgery, and family. It was discontinued after the patient developed emotional lability and paranoias.

Setting: In-patient rehabilitation hospital

Assessment/Results: Patient began taking citalopram for postpartum depression and continued for treatment of anxiety and depression. Although effective prior to the hospitalization, discontinuation and avoidance of serotonergic selective serotonin reuptake inhibitors (SSRIs) created a challenging environment to manage depression and anxiety during rehabilitation. Bupropion was chosen because it is an atypical antidepressant with no serotonergic activity, limiting RCVS risk. Unfortunately, a tolerated medication was not found thus far during inpatient rehabilitation.

Discussion (relevance): Few articles in the literature describe psychiatric treatment after RCVS and none on management in in-patient rehabilitation.

Conclusions: When RCVS is triggered by an SSRI, a multidisciplinary approach is necessary, with careful consideration of risks and benefits in collaboration with psychiatry, to optimize treatment and minimize complications.