# Reversible Cerebral Vasoconstriction Syndrome With Typical and Atypical Symptoms: A Case Series

## TL;DR

This case series shows that Reversible Cerebral Vasoconstriction Syndrome can present with or without severe headache, highlighting the importance of imaging for diagnosis.

## Contribution

The study highlights atypical presentations of RCVS without thunderclap headache, expanding diagnostic awareness.

## Key findings

- Three patients presented with focal neurological deficits without headache.
- Neuroimaging showed subarachnoid hemorrhage and arterial narrowing that resolved over three months.
- Thunderclap headache absence does not rule out RCVS when other symptoms or imaging findings are present.

## Abstract

Introduction

Reversible cerebral vasoconstriction syndrome (RCVS) is most commonly characterized by focal or diffuse severe thunderclap headache with or without focal neurological deficits and associated transient focal vasoconstriction of the intracerebral arteries lasting up to three months. We present six patients diagnosed as RCVS, with three patients presenting with focal neurological deficits without headache and the remaining three with severe headache alone. Neuroimaging revealed focal subarachnoid bleed with or without segmental intracerebral vasospasm, which resolved over three months. Despite thunderclap headache being the most prevalent symptom associated with RCVS, the absence of this symptom should not preclude the diagnosis, especially in the presence of cortical subarachnoid hemorrhage (SAH) or focal segmental intracerebral arterial narrowing.

Methods

This case series is a retrospective analysis of all patients diagnosed with RCVS between 2018 and 2022, focusing on clinical symptoms, imaging findings, and management.

Results

Six patients (three males and three females) were diagnosed with RCVS between 2018 and 2022. Three patients presented with typical symptoms, while the remaining three presented with atypical symptoms. Neuroimaging findings ranged from normal to focal SAH with or without arterial narrowing.

Conclusion

This case series underscores the diverse clinical presentations of RCVS, emphasizing that while thunderclap headache is the predominant symptom, its absence should not exclude the possibility of RCVS, especially when accompanied by focal neurological deficits or cortical SAH. Neuroimaging played a crucial role in identifying the spectrum of findings. These findings highlight the importance of comprehensive evaluation and consideration of RCVS in patients presenting with neurological symptoms, even in the absence of typical headache features.