Reversible Cerebral Vasoconstriction Syndrome: A Common Occurrence but Rare Diagnosis

Reversible cerebral vasoconstriction syndrome (RCVS) is an under-diagnosed condition that results from reversible segmental and multifocal vasoconstriction of cerebral arteries. It can present with a variety of symptoms including sudden "thunder clap" headaches, neurologic deficits, photophobia, phonophobia, nausea, vomiting, and can mimic life-threatening conditions such as a ruptured intracranial aneurysm, primary angiitis of the central nervous system, and cervical artery dissection. The pathology of this condition is still not fully understood and the etiologies vary, making treatment difficult. Our objective is to draw attention to an under-diagnosed condition with common presenting symptoms. We present a 60-year-old male with sudden onset of severe headache, left-sided numbness and weakness, blurred vision, ataxia, nausea, and dyspnea. CT and MRI brain showed no evidence of infarct or hemorrhage. CT angiography (CTA) of the head and neck showed a narrow caliber basilar artery. With the patient's clinical presentation and imaging findings, RCVS was suspected and the patient was started on a calcium channel blocker and glucocorticoids. A repeat CTA of the head and neck was performed after initiation of therapy and showed dilation of the basilar artery. Treatment with verapamil and prednisone was continued and the patient's symptoms gradually improved. He was discharged to skilled nursing for continued physical therapy. RCVS is a little-understood, under-diagnosed condition that needs to be considered in patients presenting with headaches and neurologic deficits. Additionally, more research needs to be done to truly understand the etiology of this condition.

Keywords: headache; neuroimaging; neurology; rcvs; reversible cerebral vasoconstriction syndrome; thunderclap headache.