Reversible cerebral vasoconstriction syndrome - A narrative revision of the literature

Prospective Observational Case-Control Study on the Potential of Maternal Ophthalmic Artery Doppler Velocimetry in the Evaluation of Preeclampsia

Background and objective Preeclampsia (PE) is a lethal hypertensive disorder that significantly contributes to maternal as well as fetal morbidity besides mortality, especially in low-resource settings like India. Thus, it is essential to diagnose and manage early to prevent poor maternal and fetal outcomes. PE causes cerebrovascular endothelial dysfunction and impairs cerebral autoregulation due to systemic hypertension. So, monitoring of cerebrovascular alteration is crucial for preventing severe neurological outcomes. In this study, we have used maternal ophthalmic artery Doppler (OAD) as a key tool for monitoring hemodynamic parameters and severity of the disease in PE and normotensive pregnant women. Methodology A prospective observational case-control study took place in a medical facility that provided tertiary care from April 2023 to March 2025, including 170 pregnant women (85 PE cases and 85 normotensive controls). OAD metrics, such as pulsatility index (PI), resistivity index (RI), peak systolic velocity, and end-diastolic velocity, were measured using high-resolution ultrasound with a 7-10MHz transducer. Data were analyzed using IBM SPSS Statistics for Windows, Version 20 (Released 2011; IBM Corp., Armonk, New York, United States), and cutoff values for determining PE severity were determined using receiver operating characteristic (ROC) curve analysis. Results PE patients demonstrated significantly higher RI and PI values compared to controls (p<0.001). ROC analysis identified RI >0.72 and a strong predictor of PE severity (sensitivity 82.3%, specificity 79.4%). Increased OAD indices correlated with adverse maternal and fetal consequences, including intrauterine growth restriction as well as preterm birth. Conclusion This prospective observational case-control study demonstrates the maternal OAD velocimetry as a valuable tool in evaluating and predicting PE in pregnancy. Increased resistance in the right ophthalmic artery and lower pulsatility suggest cerebrovascular dysfunction and impaired autoregulation in PE. As it serves as a promising surrogate marker for cerebrovascular dysfunction, its integration into routine obstetric evaluation may aid in early detection and risk stratification.

Intracerebral hemorrhage as a complication of reversible cerebral vasoconstriction syndrome in the postpartum periods: a case report

Reversible cerebral vasoconstriction syndrome (RCVS) is a cerebrovascular condition marked by the diffuse, reversible narrowing of multiple segments of cerebral arteries. This syndrome predominantly affects women and most commonly presents around the age of 42. It can develop spontaneously or be induced by factors such as the postpartum period or exposure to vasoactive substances. This case report describes an uncommon presentation of RCVS in a 24-year-old woman who developed an intraparenchymal hemorrhage shortly after a spontaneous vaginal delivery, despite the absence of conventional stroke risk factors. Diagnostic imaging with digital subtraction angiography (DSA) revealed multifocal vasoconstriction in the right and left anterior and middle cerebral arteries, along with the vertebrobasilar system, an indication of RCVS. Notably, vasoconstriction improved following intra-arterial nimodipine administration. This case underscores the importance of considering RCVS in postpartum women presenting with headaches and neurological deficits, as timely magnetic resonance imaging, computed tomography (CT) angiography, or brain angiography is critical for accurate diagnosis and optimal management, ultimately reducing the risk of poor prognosis.

Headache Attributed to Reversible Cerebral Vasoconstriction Syndrome (RCVS)

Reversible cerebral vasoconstriction syndrome (RCVS) is a condition with variable outcomes presenting a new onset thunderclap headache accompanied by focal neurological symptoms or seizures. It can be idiopathic or arise secondarily to a variety of trigger factors. The condition is increasingly recognized in clinical practice, but many facets remain poorly understood. This article aims to clarify the headache characteristics in RCVS, the temporal association of angiographic findings, the potential association of the condition with SARS-CoV-2 infection, and the clinical presentation of RCVS in children and is based on a systematic PRISMA search for published analytical or large descriptive observational studies. Data from 60 studies that fulfilled specific criteria were reviewed. Most people with RCVS exhibit a typical thunderclap, explosive, or pulsatile/throbbing headache, or a similar acute and severe headache that takes longer than 1 min to peak. Atypical presentations or absence of headaches are also reported and may be an underrecognized phenotype. In many cases, headaches may persist after resolution of RCVS. Focal deficits or seizures are attributed to associated complications including transient ischemic attacks, posterior reversible encephalopathy syndrome, ischemic stroke, cerebral edema, and intracranial hemorrhage. The peak of vasoconstriction occurs usually within two weeks after clinical onset, possibly following a pattern of centripetal propagation, and tends to resolve completely within 3 months, well after symptoms have subsided. There are a few reports of RCVS occurring in relation to SARS-CoV-2 infection, but potential underlying pathophysiologic mechanisms and etiological associations have not been confirmed. RCVS occurs in children most often in the context of an underlying disease. Overall, the available data in the literature are scattered, and large-scale prospective studies and international collaborations are needed to further characterize the clinical presentation of RCVS.

Reversible cerebral vasoconstriction syndrome: review of neuroimaging findings

Reversible cerebral vasoconstriction syndrome (RCVS) is a group of disorders characterized by segmental narrowing and dilatation of medium-to-large cerebral arteries, clinically presenting with recurrent episodes of sudden-onset thunderclap headaches, with or without focal neurological deficits. Cerebral vasoconstriction is typically reversible, with spontaneous resolution within 3 months. Although the syndrome has generally a benign course, patients with neurological deficits may experience worse outcome. The main imaging finding is segmental constriction of intracranial arteries, which can be associated with subarachnoid hemorrhage and/or ischemic foci. Other possible findings are intracranial hemorrhage, subdural bleeding and cerebral edema. The latter may have a pattern which can resemble that of posterior reversible encephalopathy syndrome, a condition that can overlap with RCVS. New imaging techniques, such as vessel wall imaging and arterial spin labeling, are proving useful in RCVS and are giving new insights into the pathophysiology of this condition. In this paper, we aim to review neuroimaging findings of RCVS.

Vessel Wall Magnetic Resonance Imaging in Cerebrovascular Diseases

Cerebrovascular diseases are a leading cause of disability and death worldwide. The definition of stroke etiology is mandatory to predict outcome and guide therapeutic decisions. The diagnosis of pathological processes involving intracranial arteries is especially challenging, and the visualization of intracranial arteries’ vessel walls is not possible with routine imaging techniques. Vessel wall magnetic resonance imaging (VW-MRI) uses high-resolution, multiparametric MRI sequences to directly visualize intracranial arteries walls and their pathological alterations, allowing a better characterization of their pathology. VW-MRI demonstrated a wide range of clinical applications in acute cerebrovascular disease. Above all, it can be of great utility in the differential diagnosis of atherosclerotic and non-atherosclerotic intracranial vasculopathies. Additionally, it can be useful in the risk stratification of intracranial atherosclerotic lesions and to assess the risk of rupture of intracranial aneurysms. Recent advances in MRI technology made it more available, but larger studies are still needed to maximize its use in daily clinical practice.

A Case of Reversible Cerebral Vasoconstriction Syndrome: Postpartum Cerebral Angiopathy in a 32-Year-Old Primigravid Treated with Intravenous Immunoglobulin

This is a case of a 32-year-old primigravid who developed sudden severe headache on the 7th day postpartum associated with focal neurologic deficits and altered sensorium. She had a GCS score of 6, anisocoric pupils and an NIHSS score of 31. Cranial MRI with MRA showed multifocal hyperacute to acute infarcts on the left occipital lobe, left thalamus, and midbrain which was more prominent on the right. Due to clinical deterioration, a repeat Cranial MRI with MRA was done and showed progression of infarcts involving both thalami and right pons with interval appearance of contour irregularities in the proximal anterior cerebral, posterior cerebral, basilar and internal carotid arteries. Serial transcranial Doppler showed significant distal right middle cerebral artery vasospasm. She was managed as a case of reversible cerebral vasoconstriction syndrome, associated with postpartum cerebral angiopathy. Intravenous pulse methylprednisolone was started subsequently IVIG was initiated. Intravenous immunoglobulin was given for 5 days. The patient gradually improved, underwent rehabilitation therapy, and was discharged stable after 6 weeks.

Stellate ganglion block used to treat reversible cerebral vasoconstriction syndrome

BACKGROUND

We present a case report of a patient who developed severe reversible cerebral vasoconstriction syndrome, which was worsening despite typical interventional and supportive care. We administered a stellate ganglion block (SGB) and monitored the vasospasm with transcranial Doppler measurements.

CASE REPORT

A 25-year-old woman was admitted with recurrent headaches and neurological symptoms, which angiography showed to be caused by diffuse, multifocal, segmental narrowing of the cerebral arteries leading to severe ischemia in multiple regions. Typical treatment was initiated with arterial verapamil followed by supportive critical care, including nimodipine, intravenous fluids, permissive hypertension, and analgesia. Vasospasm was monitored daily via transcranial Doppler ultrasound (TCD). After symptoms and monitoring suggested worsening vasospasm, an SGB was administered under ultrasound guidance. Block success was confirmed via pupillometry, and repeat TCD showed improved flow through the cerebral vasculature. Improvement in vascular flow was accompanied by a gradual reduction in acute neurological symptoms, with the patient reporting no headaches the following morning.

CONCLUSIONS

For patients with reversible cerebral vasoconstriction syndrome who develop severe signs or symptoms despite typical treatment, sympathetic blockade may be a possible rescue therapy. This may extend to other causes of severe vasospasm as well, and further study is needed to determine if the SGB should be included in routine or rescue therapy.

A systemic lupus erythematosus patient with thunderclap headache: reversible cerebral vasoconstriction syndrome

Headaches are common in patients with systemic lupus erythematosus (SLE). It is important to identify the exact cause of headaches in SLE to avoid unnecessary steroid or immunosuppressive therapy like in neuropsychiatric SLE. A 35-year-old woman with SLE suddenly developed severe headache. Magnetic resonance angiography showed multifocal segmental narrowing of cerebral arteries, suggestive of central nervous system vasculitis. However, lack of abnormal enhancement in vessel wall imaging indicated reversible cerebral vasoconstriction syndrome (RCVS) rather than central nervous system vasculitis. The patient was treated with oral nimodipine and she recovered over a period of two months. Following magnetic resonance angiography on day 90 was normal. Herein we report a case of reversible cerebral vasoconstriction syndrome in an SLE patient with literature review.