EMed

Reversible Cerebral Vasoconstriction Synd. (RCVS)

Background

Reversible (but prolonged) multifocal cerebral artery spasm
Many associated (e.g. migraine, post partum, arteritis)
Possible risks include exertion, pregnancy, SSRIs, vasculitis

Clinical

Symptoms

Recurrent thunderclap headache
±focal neuro deficit (stroke or local oedema)
±seizure
Middle aged adults (F>M)

Signs

Possible focal deficits (incl. bulbar)
Ocular symptoms/signs may be prominent

Differential Dx

SAH
Stroke (incl. dissection)/ ICH
PRES
Migraine (±Todd's paresis)
Other causes thunderclap headache

Investigations

CT usually normal (± punctate haemorrhages)
CSF normal but avoid LP if recurrent thunderclap headaches - move directly to imaging
Oedema (CT or FLAIR on MRI)
CTBA diagnostic - multifocal ("sausage") spasm
Serum VMA and 5HIAA normal
Negative tox. screen

Management

Supportive care (analgesia)
Discuss Mx severe ↑BP with your senior/stroke team
Avoid seizure prophylaxis (unless present with seizure)
No empiric steroids
Consider PO magnesium

Links/references

Mijalski C et al Magnesium for Treatment of Reversible Cerebral Vasoconstriction Syndrome: Case Series. Neurohospitalist. 2016 Jul;6(3):111-3. doi: 10.1177/1941874415613834. Epub 2015 Oct 30. PMID: 27366294; PMCID: PMC4906552

Content by Dr Íomhar O' Sullivan. Last review Dr ÍOS 24/09/24.