Reversible cerebral vasoconstriction syndrome: the importance of follow‐up imaging within 2 weeks

Abstract

Aim In patients with thunderclap headaches, reversible cerebral vasoconstriction syndrome (RCVS) should be considered as a differential diagnosis. However, RCVS diagnosis in the emergency department (ED) remains challenging. This report describes the clinical features and factors related to RCVS diagnosis and suggests diagnostic strategies for its management. Methods We retrospectively reviewed the medical records of eight patients diagnosed with RCVS from January 2010 to March 2019 (aged 18–69 years, 5 women). Results The median duration from the ED visit to RCVS diagnosis was 6 days (range, 1–11 days). Of the eight patients, seven were middle‐aged, six had apparent triggers, six had subarachnoid hemorrhage (SAH), five had high systolic blood pressure, and none had any specific abnormality observed upon physical examination. At the initial visit, RCVS was diagnosed in only one patient who had a history of RCVS. Of the other patients, SAH was diagnosed in two, and primary headache was diagnosed in four patients with negative computed tomography (CT) findings. Based on follow‐up angiography (e.g., magnetic resonance angiography), seven of eight patients with convexal SAH were diagnosed with RCVS (as the cause of SAH). Conclusion Reversible cerebral vasoconstriction syndrome with negative CT findings at the ED visit was likely to be misdiagnosed as a primary headache. In patients with thunderclap headache and negative CT findings, physicians should consider RCVS as a differential diagnosis, inform patients of the risk of RCVS, and undertake follow‐up imaging within 2 weeks.

Headache Attributed to Reversible Cerebral Vasoconstriction Syndrome (RCVS)

“…As far as the timing of vasoconstriction is concerned in relation to symptom onset, our search of published observational studies demonstrated that visible vasoconstriction could occur on the same day as symptom onset, as has been reported by Shimoda et al [56]. There are also reports of vasoconstriction being visible 1-3 days afterward [25,31], but it is most commonly evident some days into the disease course [18,37,44,46]. According to two reviews focusing on the neuroimaging evaluation of the syndrome, the peak of vasoconstriction is around 16 days after clinical onset, and it resolves within 3 months [80,81].…”

“…The study hypothesized that CPV gradually progresses after the onset of RCVS, peaks at the time of TCH remission, and does not progress further afterward [57]. Fukaguchi et al also propose performing clinical and imaging follow-ups for at least 2 weeks to exclude the syndrome [31].…”

Reversible cerebral vasoconstriction syndrome: review of neuroimaging findings

“…The exam may result negative in more than half of the cases [ 24 ]. Therefore, Fukaguchi et al have proposed to perform clinical and imaging follow-up for at least 2 weeks to exclude the syndrome [ 25 ].…”