Amy Zarrin

Harith Baharith

Journal of Medical Case Reports

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CASE REPORT Open Access
Khat – a new precipitating factor for
reversible cerebral vasoconstriction
syndrome: a case report
Harith Baharith1* and Amy Zarrin2
Abstract
Background: Postpartum reversible cerebral vasoconstriction syndrome is one of the rare reversible cerebral
vasoconstriction syndromes. The clinical presentation is usually characterized by recurrent headache, focal
neurological deficit, and reversible cerebral vasoconstriction seen on cerebral angiography.
Case presentation: We report a case of a 35-year-old Yemeni woman who presented with headache and focal
neurological deficits that occurred 10 days after delivery, with segmental narrowing of cerebral arteries on angiography.
She had significant clinical and radiological improvement on follow-up.
Conclusions: The presentation of our patient’s reversible cerebral vasoconstriction syndrome is unusual as she has two
possible precipitating factors. In addition to being in the postpartum state, she also has a long history of chewing khat,
a vasoactive substance commonly used by immigrants from Yemen. We hope that this case report will increase
awareness among physicians about the use of this plant by immigrants from the horn of Africa and Yemen.
Keywords: Reversible cerebral vasoconstriction syndrome, Khat, Postpartum cerebral angiopathy, Call–Fleming
syndrome
Background
Postpartum reversible cerebral vasoconstriction syn-
drome (RCVS) is one of the rare RCVSs, and commonly
occurs shortly after pregnancy [1]. The syndromes have
been given various names, including Call–Fleming syn-
drome, postpartum cerebral angiopathy, benign angiopa-
thy of the central nervous system, thunderclap headache
with reversible vasospasm, migrainous vasospasm, or
migraine angiitis [1]. The syndromes are more common
in women than in men and peak close to age 40 [2].
RCVS is clinically characterized by acute onset of severe
headaches, with neurologic signs and symptoms, and
reversible multifocal vasoconstriction of large and
medium-sized cerebral arteries, which spontaneously re-
solves within 3 months [2]. Although the pathogenesis
remains unknown, the leading hypothesis involves a dis-
turbance in cerebral vascular tone that leads to multi-
focal and segmental arterial constriction [3]. RCVS may
occur spontaneously or be provoked by various precipi-
tating factors, most commonly the postpartum state or
exposure to various vasoactive substances such as co-
caine or serotonin reuptake inhibitors [4]. Diagnosis
requires demonstration of the characteristic “string of
beads” on cerebral angiography with resolution on
follow-up imaging [2]. Calcium channel blockers are the
most commonly used treatment [2].
We report the case of a patient with headache and focal
neurological deficit that occurred 1 week after delivery,
with segmental narrowing of cerebral arteries on angiog-
raphy and significant clinical and radiological resolution
on follow-up. The patient has a history of chewing khat
(which contains various amphetamine-like substances),
which we think may have provoked her symptoms.
Case presentation
A 35-year-old Yemeni woman (gravida 10, para 11) with
no significant past medical history but a long history of
chewing khat developed throbbing headaches that
started 5 days after delivery. Ten days after delivery she
developed tongue heaviness and difficulty speaking with
* Correspondence: Harith.baharith@medportal.ca
1Department of Medicine, New York Methodist Hospital, Brooklyn, NY, USA
Full list of author information is available at the end of the article
© The Author(s). 2016 Open Access This article is distributed under the terms of the Creative Commons Attribution 4.0
International License (http://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, and
reproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link to
the Creative Commons license, and indicate if changes were made. The Creative Commons Public Domain Dedication waiver
(http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated.
Baharith and Zarrin Journal of Medical Case Reports  (2016) 10:351 
DOI 10.1186/s13256-016-1155-5
right-sided weakness, tingling, and decreased sensation
and presented to our hospital’s Emergency Department.
She had normal vital signs and normal cardiovascular,
pulmonary, and gastrointestinal physical examinations. A
neurological examination showed right facial droop, di-
minished power of her right upper (2/5) and lower (3/5)
extremities, and decreased pain and light touch on her
right hemibody. A blood workup, including complete
blood count, chemistry panel, C-reactive protein, erythro-
cyte sedimentation rate, and autoimmune studies that in-
cluded antinuclear antibodies (ANA), double-stranded
DNA (dsDNA), rheumatoid factor, proteinase 3, myelo-
peroxidase, SS-A, SS-B, Smith, ribonucleoprotein (RNP),
and Jo-1 were all unremarkable. An antiphospholipid anti-
body panel (beta-2 glycoprotein, phosphatidylserine, and
cardiolipin), hepatitis profile, and syphilis antibody as well
as electroencephalogram and echocardiogram were all un-
remarkable. On admission, magnetic resonance imaging
(MRI) of her brain showed an acute left frontal lobe ische-
mic infarct. In addition, magnetic resonance angiography
(MRA) of her head showed vasoconstriction of her prox-
imal anterior, middle, and posterior cerebral arteries
(Fig. 1), and a presumptive diagnosis of postpartum RCVS
was made. She was started on verapamil to help decrease
vasoconstriction. A repeat head MRA at approximately 1
week showed significant improvement in the vasospasm
(Fig. 1). Out-patient follow-up 3 months later revealed
complete clinical resolution.
Discussion
RCVS is a rare, poorly understood and often underdiag-
nosed syndrome, but recently disease recognition is
Fig. 1 Magnetic resonance angiography on admission and follow-up. Magnetic resonance angiography of the head performed on day 1 (a, b)
and day 6 (c, d) of admission. Axial (a, c) and sagittal (b, d) projections of the intracranial arteries by three-dimensional time of flight imaging.
Note the decreased flow in the proximal anterior cerebral, middle cerebral, and posterior cerebral arteries bilaterally on day 1 (a, b) that significantly
improves on day 6 (c, d), suggesting partial resolution of vasospasm. Internal carotid arteries were normal in both sets of images. ACA anterior cerebral
artery, ICA internal carotid artery, MCA middle cerebral artery, PCA posterior cerebral artery
Baharith and Zarrin Journal of Medical Case Reports  (2016) 10:351 Page 2 of 3
increasing [5, 6]. The disorder may be short lived and re-
versible or neurological deficits may become persistent
with poor outcome if severe vasoconstriction leads to
brain ischemia or hemorrhage [7]. RCVS may occur
spontaneously during the postpartum period or as a re-
action to various drugs. Our patient presented 1 week
after delivery and despite MRI showing a left frontal
stroke, she fortunately recovered completely from a clin-
ical standpoint. In the literature, many RCVS precipitat-
ing factors have been reported for patients not in the
postpartum period, including cannabis, cocaine, sero-
tonin reuptake inhibitors, catecholamine-secreting tu-
mors, immunosuppressants, and many other vasoactive
substances [8]. Only a few cases have been reported on
the development of postpartum RCVS after the use of
vasoactive drugs [9–12]. In our case, the patient pre-
sented in her tenth pregnancy; no similar postpartum
complication occurred in her nine previous pregnancies.
Most reported cases of postpartum RCVS occur within
the first three pregnancies [4]. Therefore, we suspect that
she may have an additional inciting factor: use of khat.
The khat plant (Catha edulis) is commonly chewed in so-
cial settings in Yemen, Somalia, and Ethiopia [13, 14]. It
contains cathinone, a stimulant drug similar to amphet-
amines, which is illegal in many Western countries, in-
cluding the USA and Canada; despite that, many
immigrants to these countries still use khat, as did our pa-
tient. We suspect her long history of khat usage may have
precipitated her condition. We think khat plant usage
needs to be recognized among Yemeni immigrants who
currently live in developed countries. To the best of our
knowledge, there are only a few reported cases of stroke
in patients consuming khat [15, 16] and one case report
on khat usage and RCVS [17].
Conclusions
RCVS is no longer an unrecognized disease. In this case,
our patient with nine uncomplicated pregnancies devel-
oped postpartum RCVS on her tenth pregnancy, which
is unusual. We therefore conclude that her long history
of khat usage may be causally associated with her RCVS.
We want the medical community to be aware that khat
is a common illicit drug used by immigrants from the
horn of Africa and Yemen.
Acknowledgements
The authors thank Dr Jeffrey Benjamin (Center for Neuroscience, Department
of Medicine, New York Methodist Hospital) for his insight in reviewing this
manuscript.
Funding
No funding was received for this manuscript.
Authors’ contributions
HB Drafting/writing the manuscript, interpretation of data, and study design.
AZ Critically revised the manuscript for intellectual content, analysis,
interpretation of data, and supervised the manuscript. Both authors read and
approved the final manuscript.
Competing interests
The authors declare that they have no competing interests.
Consent for publication
Written informed consent was obtained from the patient for publication of
this case report and any accompanying images. A copy of the written
consent is available for review by the Editor-in-chief of this journal.
Disclosure
The authors have no conflict of interest or disclosure related to this
manuscript. This case report has not been published and is not under
consideration for publication elsewhere.
Author details
1Department of Medicine, New York Methodist Hospital, Brooklyn, NY, USA.
2Department of Medicine, Center for Neuroscience, New York Methodist
Hospital, Brooklyn, NY, USA.
Received: 29 March 2016 Accepted: 23 November 2016
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Khat – a new precipitating factor for reversible cerebral vasoconstriction syndrome: a case report

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Khat – a new precipitating factor for reversible cerebral vasoconstriction syndrome: a case report

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