title: A Case Report of Thunderclap Headache with Sub-arachnoid Hemorrhage and Negative Angiography: A Review of Call-Fleming Syndrome and the use of Transcranial Dopplers in Predicting Morbidity.
abstract: BACKGROUND
  We present a case report in a patient with severe, recurrent, thunderclap with computed tomography (CT) evidence of subarachnoid blood and negative work-up for aneurysm. This case is an example of Call-Fleming syndrome with subarachnoid hemorrhage in which transcranial Doppler (TCD) was used for monitoring of cerebral vasoconstriction when angiography did not evidence vasoconstriction. We will review Call-Fleming syndrome and the utility of transcranial doppler imaging to assess cerebral vasoconstriction.
  
  
  METHODS
  A review of the current literature regarding diagnostics, treatment, and morbidity in Call-Fleming (reversible cerebral vasoconstriction syndrome) as well as a review of the data using transcranial color-coded sonography and transcranial doppler imaging to assess vasospasm in these cases.
  
  
  RESULTS
  The patient underwent computed tomography angiography (CTA) and venography (CTV), catheter angiography, lumbar puncture, and vasculitis work-up which were all negative. His magnetic resonance imaging (MRI) showed T2 weighted and fluid attenuation inversion recovery (FLAIR) hyper-intensities in the posterior frontal lobes as well as subarachnoid blood along bilateral occipital convexities. TCDs were obtained which showed elevated mean velocities.
  
  
  CONCLUSIONS
  The use of bedside transcranial doppler imaging is a non-invasive means of assessing vasospasm in Call-Fleming syndrome; even in cases where angiography is negative. Determining the degree of vasospasm based on the data in subarachnoid hemorrhage, we are able to predict a patient's risk of complications related to vasospasm including reversible posterior leukoencephalopathy and ischemic events.
authors.affiliation: Department of Neurology, Mayo Clinic Florida, Jacksonville, Florida.
authors.forename: Brennen
authors.initials: B
authors.lastname: Bittel
authors.forename: Kathrin
authors.initials: K
authors.lastname: Husmann