RCVS - Reversible Cerebral Vasoconstriction Syndrome



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


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 hypertension with stroke team
  • Avoid seizure prophylaxis (unless present with seizure!)
  • No empiric steroids
  • Consider PO magnesium


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 24/08/21.