The peripartum period, covering late pregnancy through postpartum, brings significant changes that increase the risk of neurological disorders such as cortical vein thrombosis (CVT), osmotic demyelination syndrome (ODS), pituitary apoplexy, postpartum cerebral angiopathy (PCA), posterior reversible encephalopathy syndrome (PRES), and intracranial hypotension (IH). Accurate diagnosis relies heavily on MRI and CT, with MRI being especially useful for its detailed images. CVT often presents with severe headaches and seizures, detected on MRI through characteristic signs like the “empty delta sign.” ODS, linked to the rapid correction of low sodium levels, appears as T2 hyperintense lesions at specific locations. Pituitary apoplexy, involving sudden hemorrhage within a pituitary adenoma, typically requires high-dose corticosteroids and, in severe cases, surgery. PCA results from hormonal changes and shows as transient artery narrowing on MR angiography, managed with supportive care. PRES, associated with high blood pressure disorders, manifests as vasogenic brain edema, treated by managing blood pressure. IH, often seen after a dural puncture, leads to positional headaches and shows brain sagging on MRI, with treatments ranging from rest to epidural blood patches. Recognizing these imaging patterns is critical for timely diagnosis and effective treatment, ultimately enhancing outcomes for mothers & preventing peripartum morbidity & mortality.

Reversible cerebral vasoconstriction syndrome (RCVS) is uncommon in childhood. Although it usually has favorable outcomes, it still carries a risk of serious complications, including intracranial bleeding and ischemic stroke. RCVS may arise idiopathically, from vasoactive triggers or from daily activities such as defecation, urination, exertion, or sexual activity. Whole-body cryotherapy (WBC) is not officially recognized as a trigger for RCVS. We present a case of RCVS in an adolescent who underwent a WBC session preceding his symptoms and diagnosis. Although an association between cold weather exposure and stroke is recognized, the connection between cold weather and RCVS is less established. Furthermore, there is limited to no evidence linking WBC to stroke or RCVS. We aim to highlight a potential side effect of WBC, an increasingly popular intervention lacking evidence-based benefits and well-studied side effects.

Catecholamine-Induced Reversible Cerebral Vasoconstriction Syndrome: An Overlooked Cause of Thunderclap Headache

CasePrimary headache associated with sexual activity (PHASA) is uncommon and can resemble serious secondary causes such as subarachnoid haemorrhage or reversible cerebral vasoconstriction syndrome. We report a 47-year-old woman with a history of migraine with aura who developed thunderclap headaches exclusively at orgasm after her transdermal oestradiol dose was increased from 50µg to 75µg twice weekly. Neuroimaging was normal. She also noticed a significant increase in libido during the higher dose period.DiscussionBoth the headaches and libido changes resolved after reducing oestradiol to 50 µg. Clinicians should consider HRT as a potentially reversible trigger in PHASA.

Introduction Reversible cerebral vasoconstriction syndrome (RCVS) is a less considered etiology of acute severe headache in the pediatric population. It is classically characterized by thunderclap headache that is recurrent and reversible multifocal cerebral artery narrowing. While it has been linked to vasoactive medication, immunosuppression, and systemic illness, case reports in the field of pediatric hematology‐oncology are rare. No previous cases have linked RCVS with tovorafenib, an oral pan‐RAF inhibitor in clinical investigation for pediatric BRAF V600E‐mutated malignancies. Because RCVS can be imitated by other neurologic disorders and noninvasive vascular testing can be normal, the diagnosis usually necessitates catheter‐based angiography. Intra‐arterial calcium channel blockers have been utilized in endovascular therapy to obtain both diagnostic accuracy and immediate therapeutic benefit. We describe the first documented case of childhood RCVS associated with tovorafenib with successful endovascular diagnosis and intra‐arterial verapamil treatment. Materials and Methods A 12‐year‐old female with multifocal osseous relapsed Langerhans cell histiocytosis (LCH) harboring BRAF V600E mutation started tovorafenib in February 2025. After six cycles, she developed recurrent thunderclap headache that woke her up from sleep, sometimes followed by brief confusion characteristic of postictal states. Tovorafenib was withheld, and she was evaluated via multidisciplinary evaluation. Comparison brain MRI revealed minimal Chiari I malformation and small sphenoid hyperintensity on the left side. Head and neck CT angiogram was normal. EEG, with 2‐hour study during symptomatic attack, revealed no epileptiform discharge. Ophthalmological examination revealed no papilledema. Because of the persistence of thunderclap headache and nonrevealing noninvasive studies, diagnostic cerebral angiography was done. Results Digital subtraction angiography disclosed focal segmental narrowing of the right A3 segment of the anterior cerebral artery characteristic of RCVS. Verapamil (5 mg) was administered intra‐arterially, with resultant immediate angiographic resolution of the vasospasm. Lumbar puncture ruled out infection and inflammation. The patient was switched to oral verapamil with rapid resolution of her thunderclap headaches. Interestingly, tovorafenib was resumed on hospitalization day with continuation of verapamil, and no additional RCVS events were experienced. Discharge on oral verapamil with follow‐up as scheduled in neurology, neurosurgery, and oncology clinics was successful. Conclusion This case highlights the critical importance of endovascular evaluation and treatment of potential pediatric RCVS, especially when vasoconstriction is not detected by noninvasive imaging. In this patient, both therapeutic and diagnostic angiography was in keeping with RCVS and reversible following intra‐arterial verapamil infusion. Temporal correlation of tovorafenib exposure and onset of symptoms, together with angiographic response to calcium channel blockade, is compatible with drug‐related mechanism. One possible explanation would be inhibition of RAF pathway altering vascular smooth muscle or endothelial tone, which predisposes to vasoconstriction. To our knowledge, this is the first description of tovorafenib‐associated RCVS. This presentation underscores the need to heighten awareness of RCVS as an emergent side effect of new targeted therapies in children. Early diagnosis, multidisciplinary assessment, and prompt endovascular therapy will prevent morbidity and enable resumption of potentially life‐extending oncologic therapy. Additional pharmacovigilance and further study are necessary to better clarify the incidence, pathogenesis, and treatment of this new complication.

Introduction Reversible cerebral vasoconstriction syndrome (RCVS) is a rare but increasingly recognized cause of thunderclap headaches and non‐aneurysmal subarachnoid hemorrhage (SAH). Characterized by reversible multifocal narrowing of cerebral arteries, often in response to various triggers including vasoactive agents, stress, less commonly, thermal stimuli such as those during showering have been implicated. We report a unique case of RCVS triggered by a routine shower, resulting in convexal SAH and angiographically confirmed vasospasm. Case Presentation A 65‐year‐old woman with no significant medical history presented with a sudden‐onset headache while showering. She had been discharged from the emergency department three days earlier for a similar headache that had resolved with medical treatment. she reported that her initial headache began after getting out of the pool following a swimming session. On re‐presentation, she was neurologically intact and hemodynamically stable, but again noted that her headache started shortly after she began showering but again resolved with medical treatment. She denied any use of illicit drugs, medications, or supplements. Non‐contrast CT head revealed subarachnoid hemorrhage within the interhemispheric fissure and medial cortical sulci of the bilateral frontal and parietal lobes. CT angiography identified a 4 mm focal dilatation of the left anterior cerebral artery's inferior internal parietal branch, with no evidence of aneurysm or vascular malformation which prompted a catheter angiogram.A diagnostic cerebral angiogram demonstrated distal vasospasm predominantly involving the right anterior cerebral artery and bilateral middle cerebral arteries. Intra‐arterial verapamil was administered, resulting in marked improvement in vessel caliber. The patient was started on oral verapamil and discharged in stable condition after she was able to tolerate a shower prior to discharge from the hospital. Discussion RCVS should be considered in the differential diagnosis of thunderclap headaches and atypical non‐aneurysmal SAH, especially in patients lacking structural lesions or vascular malformations. Though less common, thermal stimuli and showering can provoke autonomic dysregulation, leading to cerebral vasoconstriction. Early cerebral angiography and prompt intra‐arterial therapy can result in rapid improvement. Recognition of atypical triggers is critical for timely diagnosis and prevention of recurrence or unnecessary interventions. Conclusion This case highlights a rare instance of shower induced RCVS presenting with convexal SAH and emphasizes the importance of early neurovascular imaging in similar presentations. Clinicians should maintain a high index of suspicion for RCVS in patients with recurrent thunderclap headaches, even in the absence of traditional risk factors or obvious triggers. image

Introduction/Purpose Reversible cerebral vasoconstriction syndrome (RCVS) is characterized by multifocal arterial narrowing of cerebral vessels. Numerous studies have demonstrated improvement in cerebral vessel caliber following administration of intra‐arterial verapamil (IAV), though these studies have traditionally used subjective methods for determining improvements in vessel caliber. Additionally, the link between location and severity of vasoconstriction and functional outcome or hemorrhagic complications is also not clear. In this study we devised a method for objective quantification of vessel caliber improvement following IAV and recorded these changes across different vascular territories. We hypothesize that the magnitude of vessel caliber change following IAV is a surrogate for severity of vasoconstriction and has an association with functional outcomes. Materials/Methods Patients diagnosed with RCVS between 2019 to 2025 at the University of Iowa were included in the study. Picture archiving and communication software was used to measure the proximal and distal caliber of the most stenotic portion of each affected cerebral artery before and after IAV administration. Patient functional outcomes were determined using the modified Rankin scale (mRS), with functional independence defined as mRS < 2 at 90 days. Hemorrhagic complications on admission including intraparenchymal hemorrhage (IPH), cortical subarachnoid hemorrhage (cSAH), and subdural hematoma (SDH) were tracked. Data were analyzed using univariate and multivariate logistic regression to assess the relationship between clinical features (thunderclap headache, systolic blood pressure) and hemorrhagic complications, functional independence, and percent change in area of cerebral vessels following IAV. Results Imaging data from thirty‐two patients with RCVS were analyzed. Greater arterial caliber improvement following IAV in distal vascular territories correlated with cSAH on admission (aOR: 1.07, 95% CI: 1.01 ‐ 1.12, P < 0.01), particularly in distal anterior cerebral artery segments (aOR: 1.10, 95% CI: 1.01 ‐ 1.22, P < 0.001). Furthermore, a greater degree of arterial caliber improvement after IAV in distal segments was also associated with decreased odds of functional independence (aOR: 0.95, 95% CI: 0.93 ‐ 0.98, P = 0.02). From a clinical standpoint, greater systolic blood pressure on admission was also associated with decreased odds of functional independence (aOR: 0.96, 95% CI: 0.92 ‐ 0.99, P = 0.03; see Figure 1). Conclusion In this study involving patients with RCVS, a larger change in distal cerebral vessel area following IAV administration was associated both with cSAH on admission as well as poor functional outcomes. image

Introduction Although Reversible Cerebral Vasoconstriction Syndrome (RCVS) is generally considered a benign condition, it can lead to multiple serious complications, including hemorrhagic or ischemic strokes and Posterior Reversible Encephalopathy Syndrome (PRES). It is both more frequent and morbid in females as compared to males. Patients usually present with a thunderclap headache, and the RCVS2 score aids in the diagnosis based on clinical and imaging‐related factors. In approximately 90‐95% of cases, resolution occurs without medical intervention; however, agents such as nimodipine, verapamil, and milrinone are employed if clinical progression, worsening, or complications are noted. A standard approach remains lacking, particularly in managing complex cases. Case report We report a case of a 42‐year‐old female with uncontrolled type II diabetes mellitus, hypertension, and marijuana use who presented with lower extremities and right arm weakness, facial and tongue numbness that resolved. The initial magnetic resonance imaging (MRI) showed a left parietal lobe acute infarct and edema in the bilateral parietal lobes concerning PRES. Her hospital course was complicated by worsening symptoms, including right upper extremity weakness, aphasia, and confusion. Repeat MRI showed a new stroke in the right parietal lobe and worsening PRES. Her vascular imaging raised suspicion for vasculitis or RCVS. CTAs revealed progressive vasospasm, and an angiogram with vasodilator challenge showed some response, which favored the diagnosis of RCVS. Despite treatment, she later developed papilledema and occipital lobe strokes. Serial transcranial dopplers were obtained to assess the degree of fluctuating vasospasm. The patient was treated with intra‐arterial nicardipine and milrinone, followed by a course of intravenous milrinone. Due to persistent vasospasm, oral nimodipine, then oral sildenafil, was initiated. The patient was ultimately discharged on verapamil. Conclusion RCVS is a rare but life‐threatening disease associated with rapid neurological decline and poor outcomes. Standard therapy with calcium channel blockers may be insufficient in severe cases, highlighting the need for consideration of alternative agents like sildenafil. Early recognition of risk factors, including substance use and certain prescription medications, coupled with timely escalation of care, is critical to improving prognosis and guiding future therapeutic approaches.

Objective To describe a case of a treatment refractory cerebral medium vessel arteriopathy, likely representing a severe case of reversible cerebral vasoconstriction syndrome (RCVS). Background RCVS is a cerebrovascular dysregulation syndrome typically characterized by acute, segmental cerebral arterial narrowing. The most common presenting symptom is acute onset thunderclap headache. The term “reversible” refers to reversibility of angiopathic abnormalities; however, the cerebral vasoconstriction is not always reversed. This case highlights a severe case of RCVS with unclear etiology and novel treatment approach. Design/Methods N/A Results Patient is a 55‐year old female who presented to the ED with acute onset of left‐sided numbness. Her initial workup included CT angiography of the neck which demonstrated an unstable thrombus in the distal right common carotid artery and high‐grade stenosis of the right carotid bulb. She was initiated on intravenous heparin for the unstable thrombus in addition to aspirin 81 mg daily. The patient underwent carotid endarterectomy (CEA) with vascular surgery 2 days after admission. She was discharged the following day on aspirin 81 mg daily as antiplatelet monotherapy. She presented again 11 days following discharge with acute onset of left leg weakness and recurrent, acute onset thunderclap headache. CT angiogram head and neck demonstrated multifocal high‐grade stenosis and occlusions along the right MCA and bilateral ACAs, suspicious for RCVS. Pertinent medications at the time of admission included tramadol (recently initiated for new headache) and nicotine patch; the patient denied any additional changes in medications including use of serotonergic agents. The patient was initiated on a non‐dihydropyridine calcium channel blocker with verapamil 40 mg three times daily and discharged 5 days after admission with resolution of her symptoms. The patient presented again to the ED the following day with acute onset of post‐coital left leg weakness. Initial imaging was significant for interval worsening of previously demonstrated vasospasms of the right MCA and bilateral ACAs. The patient was ultimately admitted for over one month, with multiple treatments attempted based on the refractory nature of her disease. With concern for an autoimmune component to her focal arteriopathy, considered potentially secondary to a hypersensitivity reaction to the bovine graft in CEA, she was initiated on intravenous methylprednisolone. Intravenous or oral corticosteroids were continued throughout admission. The patient also underwent multiple angiographies with intraarterial administration of verapamil, milrinone, and nicardipine, with only transient improvement in vasoconstriction following each treatment. Extensive serum and cerebrospinal fluid testing failed to demonstrate a causative etiology for her refractory symptoms. 3 weeks into admission, the patient was initiated on plasmapheresis for five days. Her exam stabilized, and she was successfully discharged to a long term acute care facility. Conclusions Although typically a self‐limited condition, RCVS can be treatment‐refractory and result in irreversible changes in cerebral function. Our case demonstrates a severe, refractory multifocal cerebral vasoconstriction syndrome, resistant to multiple therapies, which ultimately responded to treatment with plasmapheresis.

Background and ObjectivesBlood-brain barrier (BBB) disruption was found to be critical in the pathogenesis of reversible cerebral vasoconstriction syndrome (RCVS). We hypothesized that increased central arterial stiffness, resulting in the excessive transmission of central pulsatile flow to the dysregulated cerebral microcirculation, may contribute to the disruption of BBB.MethodsThis is a cross-sectional study. Participants with RCVS in the acute phase were recruited from both outpatient and inpatient settings between January 2018 and September 2020. The diagnosis was established based on clinical presentations and neuroradiologic evidence. Age-matched and sex-matched healthy controls (HCs) were recruited from nearby communities. Patients with RCVS were recruited and underwent 3-dimensional isotropic contrast-enhanced T2 fluid-attenuated inversion recovery imaging to visualize BBB disruption. The central arterial stiffness was assessed with hemodynamic parameters such as carotid-femoral pulse wave velocity (cfPWV), carotid augmentation index (cAI), and central blood pressure (ceBP). Arterial stiffness was compared between patients with RCVS and HCs, and between patients with RCVS with and without BBB disruption.ResultsSixty-five patients with RCVS (mean age 44.3 ± 9.6 years; 42 women) and 65 HCs (mean age 45.4 ± 8.9 years; 42 women) completed the study. Among the patients with RCVS, 33 exhibited imaging-proven BBB disruption. Those with BBB disruption were older (48.3 ± 9.2 vs 40.2 ± 8.3 years, p < 0.001) and had a higher proportion of women (81.8% vs 46.9%, p = 0.003). Arterial stiffness was increased in patients with RCVS, as indicated by a higher cfPWV compared with controls (10.8 ± 2.5 m/s vs 9.2 ± 2.3 m/s, p < 0.001). Among patients with RCVS, those with BBB disruption had greater central arterial stiffness, reflected by higher cfPWV and cAI (11.4 ± 2.7 m/s vs 10.1 ± 2.1 m/s, p = 0.036; 15 ± 18% vs 2 ± 19%, p = 0.007). There were no significant differences in ceBP between patients with RCVS (regardless of BBB disruption) and HCs.DiscussionOur study confirmed increased central arterial stiffness in patients with RCVS, especially among those with BBB disruption. These findings suggest a potential contribution of central arterial stiffness and excessive pulsatile flow to cerebral microvascular dysfunction in the pathogenesis of RCVS.

BackgroundTriptans are commonly employed for acute migraine relief, yet concerns remain regarding their potential association with ischemic adverse events (IAEs). This study aimed to evaluate the association between triptan use and IAEs using real-world data from the FDA Adverse Event Reporting System (FAERS).MethodsWe performed a retrospective pharmacovigilance analysis utilizing FAERS data spanning from Q1 2004 to Q3 2024. Reports of IAEs (stroke, including myocardial infarction, and other ischemic events) in patients using triptans were analyzed. The signal strength of triptan-associated IAEs was evaluated using disproportionality analysis with the reporting odds ratio (ROR) and Bayesian confidence propagation neural network (BCPNN).ResultsAnalysis of the FAERS database (2004–2024) identified 1305 ischemic adverse events (AEs) linked to triptans, accounting for 6.60% of all triptan-related AEs. The report proportion varied among triptans, with naratriptan (12.23%) and almotriptan (12.15%) showing the highest rates, while sumatriptan (4.74%) had the lowest. Females comprised 69.4% of cases, and 20.4% of reports involved life-threatening outcomes or death. Disproportionality analysis revealed significant signals for almotriptan (ROR=3.34), naratriptan (ROR=2.96), and rizatriptan (ROR=2.41), with almotriptan exhibiting the strongest association. The most frequent ischemic AEs included arteriospasm coronary (ROR=33.59), reversible cerebral vasoconstriction syndrome (ROR=63.92), and coronary artery dissection (ROR=93.17). Mortality rates exceeded 6% for ischemic stroke and acute myocardial infarction. Time-to-onset analysis showed frovatriptan had the earliest median onset (3.5 days), while almotriptan had the longest (284 days). Serious AEs were more frequently reported for cerebral vasoconstriction, cerebral ischemia, and coronary artery disease (p<0.05). These findings suggest notable ischemic safety signals associated with triptans, particularly specific drug subtypes.ConclusionThis pharmacovigilance study suggests a potential association between triptan use and ischemic adverse events, particularly in high-risk patients. Clinicians should carefully evaluate cardiovascular risk factors before prescribing triptans and consider alternative treatments for susceptible individuals. Additional prospective studies are required to validate these findings.

Factors associated with complications in reversible cerebral vasoconstriction syndrome: A seven-year study at a comprehensive stroke center.

The most common cause of convexity subarachnoid hemorrhage (cSAH) in younger patients (younger than 60 years) is reversible cerebral vasoconstriction syndrome (RCVS). Evidence on the long-term outcomes of future vascular events and functional outcome after cSAH due to RCVS is limited. We aimed to assess the rates and baseline predictors of our primary outcomes (cSAH, intracerebral hemorrhage (ICH), and ischemic stroke), functional outcome, and mortality after cSAH attributed to RCVS. Individual patient data pooled analysis in patients with cSAH attributed to RCVS. A systematic literature search was conducted in PubMed and EMBASE. Two independent reviewers screened studies and extracted data. Quality assessment was assessed using the Newcastle-Ottawa Scale. Early events during the accepted time frame of an RCVS episode (<3 months) were classified as progression rather than recurrence. Follow-up was truncated at 5 years. Primary outcomes were recurrent cSAH, ICH, and ischemic stroke. Secondary outcomes were mortality and functional status measured by modified Rankin Score (mRS). We identified 21 eligible cohorts finally including 138 patients from 9 collaborative centers, which provided individual patient data. The mean age was 49.3 ± 12.1 years, and 110 (79.7%) were female. During a mean follow-up of 1.8 years, annual rates were cSAH recurrence 0.81% (95% CI 0.1-2.91), ICH 0.81% (95% CI 0.1-2.91), and ischemic stroke 0.81% (95% CI 0.1-2.91). Progression during the initial episode (shortly after admission) occurred in 10 patients for cSAH, 2 for ICH, and 8 for ischemic stroke, respectively. Of 106 patients (76.8%) with available outcome data, 100 (94.3%) achieve a mRS of ≤1 at follow-up, indicating no significant disability. Two patients died (annual rate 0.5%, 95% CI 0.09-2.9): one within 10 days and the other within 2 months of the cSAH. Our data suggest a favorable prognosis for most patients after RCVS-associated cSAH with low rates of recurrent events and a high proportion achieving functional independence. Major limitations include retrospective data collection and potential selection bias from centers providing individual patient data. Nevertheless, these findings provide prognostic information to inform clinical practice.

Reversible cerebral vasoconstriction syndrome: not just a “reversible” condition. Retrospective observational study and literature review

Reversible cerebral vasoconstriction syndrome (RCVS) encompasses a group of clinical and radiological conditions characterized by acute onset recurrent thunderclap headaches and reversible cerebral angiopathy. The pathophysiology is largely unknown, nevertheless, research indicates several possible triggering factors and associated conditions such as stress, physical exertion, drugs or medications, and pregnancy. Neuroimaging may show multifocal narrowing and dilation of the cerebral arteries but often may be normal. Diagnosis remains difficult due to the wide range of differentials with similar clinical and imaging features. Outcomes are typically benign with supportive treatment; however, it is important for the radiologist to distinguish RCVS from other entities to exclude serious causes of morbidity and mortality to optimize management.

Reversible Cerebral Vasoconstriction Syndrome: A Review of Diagnostic Imaging and Mimics

Reversible cerebral vasoconstriction syndrome (RCVS) is characterized by thunderclap headaches and transient cerebral vasoconstriction. The influence of environmental factors, particularly air pollution and weather conditions, on RCVS remains poorly understood. From 2010 to 2022, clinical data from two hospitals were analyzed alongside air pollution and meteorological data provided by Air Pays de la Loire and Météo-France. A time-stratified case-crossover design was used to evaluate the association between RCVS onset and daily mean concentrations of O3, PM10, PM2.5, and NO2, using spatial modeling of residential exposure. Pollutant effects were examined over lag periods of up to three days, with adjustments for temperature and atmospheric pressure. A total of 216 patients were included (mean age: 39.9years; SD: 12.3; sex ratio: 1:1). In the three days preceding RCVS onset, only PM10 concentrations remained significantly higher compared to the day of onset (19.03 vs. 17.99µg/m3, P = 0.0029). A significant downward trend in PM10 levels was observed over this period (slope -0.735, P = 0.0286), whereas no significant changes were found for PM2.5, O3, or NO2. PM10 was the only pollutant significantly associated with RCVS onset across lag days (Lag 0: OR 0.747, 95% CI: 0.579-0.962, P = 0.024; Lag 1: OR 0.770, 95% CI: 0.599-0.989, P = 0.041; Lag 2: OR 0.776, 95% CI: 0.604-0.997, P = 0.047; Lag 3: OR 0.768, 95% CI: 0.599-0.984, P = 0.037). After adjusting for atmospheric pressure and temperature, these associations were no longer statistically significant. This study suggests a short-term decrease in PM10 levels prior to RCVS onset and a negative association between PM₁₀ concentration and occurrence. These findings contribute to understanding the potential environmental triggers of RCVS in the context of changing air quality and climate.

Reversible cerebral vasoconstriction syndrome (RCVS) can develop in the early postpartum period and generally has a good prognosis. A 35-year-old woman developed postpartum RCVS, which had started as severe headache after a blood transfusion; a diagnostic cerebral angiogram showed diffuse vasospasm of intracranial vessels. Her clinical course was complicated by subarachnoid haemorrhage, strokes, seizure and recurrent vasospasm, which lasted for 4 weeks. The vasospasm was refractory to nifedipine and nimodipine but improved with intra-arterial verapamil, followed by oral verapamil and magnesium oxide.

National studies on reversible cerebral vasoconstriction syndrome (RCVS) point to differences between Asian and European patients. We investigated geographic variations in neurological complications, outcomes, and causes. We conducted an exploratory analysis of pooled individual patient data from the Reversible Cerebral Vasoconstriction Syndrome International Collaborative network, a multicenter observational cohort study including patients with definite RCVS from 2 French, 32 Italian, 1 South Korean, and 1 Taiwanese centers. Data on demographics, precipitants, symptoms, imaging, treatment, and outcomes were collected. The primary end point was RCVS-associated brain lesions, including ischemic stroke, cortical subarachnoid hemorrhage, intracerebral hemorrhage, posterior reversible encephalopathy syndrome, and subdural hematoma. Secondary end points included unfavorable 3-month outcomes (modified Rankin Scale score ≥1) and causes (idiopathic versus secondary). Odds ratios and 95% CIs were calculated using multivariable logistic regression, adjusting for potential confounders. From 2009 to 2021, we included 1127 patients (528 European and 599 Asian). Recruitment occurred either through emergency settings or outpatient clinics, with most Asian patients recruited from outpatient clinics (65.8%) and most European patients from emergency settings (99.8%). Brain lesions were more frequent in European patients (29.2% versus 6.3%; odds ratio, 4.09 [95% CI, 2.66-6.30]). In a sensitivity analysis restricted to hospitalized patients (n=651), the association persisted. Unfavorable 3-month outcomes (5.5% versus 1.7%; odds ratio, 3.01 [95% CI, 1.35-6.68]) and secondary RCVS (50.4% versus 10.9%; odds ratio, 7.09 [95% CI, 5.14-9.76]) were also associated with European residency. RCVS presentations vary across regions, with higher lesion rates, more secondary forms, and worse outcomes in European patients. While these exploratory results may reflect selection bias from differing health care structures, further research is needed to determine the contribution of genetic, environmental, and societal factors.

Objectives/BackgroundAlthough nimodipine is commonly used to treat reversible cerebral vasoconstriction syndrome (RCVS), its disease‐modifying effects are not yet understood. We prospectively investigated the effect of nimodipine and treatment initiation timing on the prevention of worsened vasoconstriction in patients with angiogram‐proven RCVS.MethodsIn this prospective cohort study, we recruited patients with angiogram‐proven RCVS who visited a single headache clinic between June 2019 and November 2021. To evaluate the mean flow velocities (MFVs) of the middle cerebral arteries, patients underwent transcranial Doppler at baseline and were then serially followed up after 10, 20, 30, and 90 days. Oral nimodipine treatment was initiated after the baseline transcranial Doppler study. We estimated the worsening of vasoconstriction using the area of total time spent with MFVs above the baseline value (“MFV area”).ResultsA total of 32 patients (51.5 ± 10.3 years old, 91% female) completed this study. During nimodipine treatment, MFVs gradually decreased in 94% (n = 30/32) of patients (p < 0.001). The MFVs in the early treatment group (<7 days after onset) were lower than the untreated baseline MFVs of the late treatment group (≥7 days) at the same time point after onset (69.8 ± 19.4 vs. 86.1 ± 23.7 cm/s, p = 0.032). Earlier treatment with nimodipine correlated with reduced MFV area (r = 0.37, p = 0.038), and this relationship remained significant after adjustment for covariates (β = 58.46, 95% confidence interval = 2.31–114.62, p = 0.041).ConclusionOur study shows an independent association between the timing of oral nimodipine administration and exacerbation of cerebral vasoconstriction in patients with RCVS, suggesting that early administration of nimodipine may have a role in mitigating vasoconstriction. A potential disease‐modifying role of nimodipine should be tested in future studies using a hypothesis‐testing design.