Your browser does not support JavaScript!



[2019/05/15] New MRI Imaging Techniques—Thunderclap Headaches No Longer a Nightmare

The Ministry of Science and Technology held a press conference on April 10thto introduce important research findings


The Taipei Veterans General Hospital-National Yang-Ming University (TVGH-NYMU) headache research team, which includes Associate Professor Chen, Researcher Chuo, and Director Wang, have discovered a specific change in brain imaging that is associated with “reversible cerebral vasoconstriction syndrome”, otherwise called “thunderclap headaches”, through the use of advanced neuroimaging techniques. This investigation has brought about a better understanding of the syndrome's underlying pathophysiological mechanisms. The paper was published on September 1st, 2018 in the world renowned journal “JAMA Neurology” (IF=11.43, 5/197).


Reversible cerebral vasoconstriction syndrome (RCVS) is the most severe and most dangerous of headaches and has, as its clinical manifestation, repeated attacks of explosion-like severe headaches (thunderclap headaches) that are linked to vasoconstriction. The headaches are usually induced by daily activities that involve significant bodily activity, such as using the toilet, showering, sexual activity or emotional events. These sudden and explosive headaches leave patients severely disabled, and bring them repeatedly back to the ER, even making them scared of engaging in their normal daily routines. Additionally, the syndrome causes other complications, such as ischemic stroke and cerebral hemorrhage, which can result in a considerable burden on both patients and Taiwan's medical system.


RCVS has only been officially accepted as a disease for the past decade, and the majority of doctors, particularly those who do not specialize in neurology, and the public in general are unfamiliar with this disease. Academically, our understanding of the pathophysiological mechanism(s) of the disease is also very limited. The TVGH-NYMU headache team has been the leader in researching RCVS/thunderclap headaches and has recruited and treated many patients. Not only has the team contributed to an understanding of these patients’ clinical manifestations, they have also explored the pathophysiological mechanism(s) behind the disease and how to treat the disease. Furthermore, they have published a series of important papers in heavyweight neurology journals, such as “Annals of Neurology”, “Neurology” and “Cephalalgia”, etc. Importantly, their most recent publication on white matter lesions of the brains of RCVS patients is a major breakthrough in the field.


Specific spatial distribution and dynamic changes in the disease


Large scale studies in the past have shown that a small number of white spots (white matter hyperintensities), which are also present in normal human brain MRIs, seems to be related to an increased risk of stroke, dementia and death. In RCVS patients, the white spots are more common and are of great concern to patients and doctors. However, until recently, there have been no studies targeting these white matter lesions that have explored their spatial distribution, dynamic changes and clinical significance, all of which have until now been completely unexplored by medicine.


The TVGH-NYMU headache team used the latest MRI imaging techniques to confirm the fact that RCVS patients have a tenfold higher frequency of white matter spots than control individuals. These tiny white spots have a specific spatial distribution in the patients, undergo dynamic changes and are completely different to other white matter lesions that are associated with aging, hypertension, diabetes, renal diseases, and migraine. These white matter lesions are specific to the patients suffering from RCVS syndrome and their volume is related to the severity of the disease. Thus the number of lesions can be used as an indicator of the severity of the patient's disease.


The latest MRI imaging technique


In the past, the approaches that have been used to determine the severity of the RCVS are invasive, specifically the use of angiography. Furthermore, the interpretation of each angiogram is based on the personnel experience of the doctor and this can result in differences in interpretation between practitioners. The new technique used in this study by TVGH-NYMU has overcome these difficulties and is easier for doctors to interpret. During long-term follow-up, the research team found that these white mater lesions would partially disappear as blood vessels recover to normal. This is important information for doctors and patients. Furthermore, haemodynamic findings by the team have suggested that there is a clear pathophysiological mechanism related to excessive cerebral blood flow that causes these white matter lesions, and subsequent brain ischemia and autonomic dysfunction; these findings will be helpful when developing a specific treatment for the disease.


The team is now focusing on in-depth research into the disease, and has published their latest high-resolution angiogram findings on this disease in “The Journal of Headache and Pain“, confirming that weather, including temperature, pressure, and rainfall, can affect the incidence of this disease by 10%. This has been published in “Headache”. The group is now involved in investigations targeting blood, urine, and cerebrospinal fluid analysis, as well as genome-related research in the hope of discovering a biomarker that will be able to help pinpoint the pathophysiological mechanism(s) of this disease. Their goal is to discover new treatments and prevention measures that will benefit RCVS patients in the future.