Reversible cerebral vasoconstriction syndrome (RCVS) is a potentially life-threatening neurological condition characterized by thunderclap headaches and multifocal cerebral arterial vasoconstriction resolving within 3 months. Context-dependent diagnostic bias in psychiatric settings may delay recognition of life-threatening conditions including RCVS. A 52-year-old Japanese woman with bipolar II disorder stable on lithium developed recurrent thunderclap headaches 9 days after mild COVID-19 infection. Headaches were consistently triggered by hot showers, reached maximal intensity within seconds, and were described as the worst headache of her life. Initial neurosurgical evaluation included non-contrast head CT but attributed symptoms to tension-type headache without vascular imaging. The patient, dissatisfied with this explanation, sought re-evaluation through our psychiatry outpatient clinic. Psychiatric consultation identified characteristic RCVS features, prompting urgent referral to a headache specialist. Magnetic resonance angiography on Day 31 revealed multifocal segmental vasoconstriction confirming RCVS. Calcium channel blocker treatment led to complete symptom resolution with radiological resolution confirmed at Day 100. This case illustrates how context-dependent diagnostic bias can dangerously delay RCVS recognition in psychiatric settings. Thunderclap headache warrants immediate neuroimaging regardless of psychiatric comorbidity. Psychiatric consultation enabled appropriate diagnosis through collaborative evaluation with specialist neurology, underscoring the essential role of consultation-liaison psychiatry at the medical-psychiatric interface.

Serotonin syndrome is a life-threatening adverse drug reaction caused by excessive serotonergic activity from therapeutic use, overdose or drug interactions. Its recognition is challenging, as manifestations range from subtle to severe and fatal. Key diagnostic features are autonomic dysfunction, motor hyperactivity and exaggerated reflexes, including clonus. We report a young woman with severe serotonin syndrome due to serotonergic polypharmacy who developed reversible cerebral vasoconstriction syndrome and overlapping posterior reversible encephalopathy syndrome. The diagnosis was initially delayed because attention had focused on her prominent vascular features with severe focal neurological deficits rather than the underlying toxidrome. We diagnosed serotonin syndrome as she developed more characteristic features. This case highlights the importance of considering serotonin syndrome in patients receiving serotonergic medications who develop motor findings, autonomic dysfunction or unexplained neurological deterioration.

Digital subtraction angiography is considered the reference standard for diagnosing reversible cerebral vasoconstriction syndrome (RCVS); however, its invasive nature limits routine application. Transcranial Doppler ultrasonography (TCD) represents a noninvasive and bedside-accessible alternative, but its diagnostic and monitoring value in RCVS remains uncertain. A systematic review was conducted in accordance with PRISMA 2020 guidelines. Searches were performed in PubMed, Embase, Cochrane Library, Scopus, and Web of Science up to January 2024. Eligible studies included case reports, case series, and observational designs involving adults with angiographically confirmed reversible vasoconstriction that reported TCD or color-coded sonography parameters (e.g., mean flow velocity, vasospasm). Risk of bias was assessed with ROBINS-I or Joanna Briggs Institute tools. Due to heterogeneity, results were synthesized descriptively. From 709 records, 8 studies encompassing 128 patients were included. TCD demonstrated increased mean flow velocities in the middle cerebral artery during the acute phase of RCVS, with reported peaks up to 146 cm/s, followed by gradual return to baseline within 6-12 weeks. Vasospasm was observed in up to 93.3% of patients, usually peaking between days 13 and 28. The Lindegaard index, ranging from 2.2 to >7, was valuable in distinguishing hyperemia from vasospasm. Serial bedside examinations, often every 24-48 hours during hospitalization, facilitated timely detection and monitoring of evolving hemodynamic changes. Nonetheless, included studies were small, heterogeneous, and methodologically limited. Transcranial Doppler ultrasonography appears promising as a noninvasive method for detecting cerebral vasospasm and monitoring temporal hemodynamic trajectories in RCVS.

Postpartum reversible cerebral vasoconstriction syndrome (RCVS), also known as postpartum cerebral angiopathy, is an uncommon but potentially serious cause of thunderclap headache. Early diagnosis is challenging, and there may be a misdiagnosis due to non-specific clinical presentation and frequently normal initial imaging studies.We report a case of a primigravid woman in her early 30s who developed a sudden, severe holocranial headache on the fourth postpartum day, with no associated neurological findings. Initial head CT, CT angiography, cerebral CT venography and MRI showed no abnormalities. However, digital subtraction angiography (DSA), revealed multifocal segmental narrowing of intracranial arteries, with complete reversibility after 3 months, consistent with RCVS.The patient was treated with oral nimodipine and experienced gradual symptom resolution. There was no complication associated, with no recurrence so far.

Preeclampsia is one of the most significant medical and social problems of modern obstetrics. This complication of pregnancy not only threatens the life of the mother and fetus during pregnancy, but also serves as a predictor of severe cerebrovascular and cardiovascular complications in the long term. Preeclampsia causes both acute and chronic cerebrovascular diseases, which are caused by increased permeability of the blood-brain barrier, impaired cerebral autoregulation, hypercoagulation and inflammation. This literature review analyzes papers published from January 2010 to June 2025 and cited by PubMed, Scopus, MEDLINE, and eLibrary. The features of regulation of cerebral blood flow during normal pregnancy and preeclampsia are described. Cerebrovascular complications of preeclampsia during pregnancy include posterior reversible encephalopathy syndrome, reversible cerebral vasoconstriction syndrome, hemorrhagic and ischemic stroke, and cerebral venous sinus thrombosis. In the long-term postpartum period, women with a history of preeclampsia have an increased risk of neurocognitive disorders, including impaired executive function and memory. There are also significant psychosocial consequences, i.e. decrease in the quality of life and social functioning, increased levels of anxiety, depression, which reduces adaptation to stressful situations of everyday life. Chronic dysfunction of the blood-brain barrier can cause not only functional neurovascular disorders, but also morphological changes. In the long term, preeclampsia is associated with an increased risk of vascular dementia, Alzheimer's disease, and stroke. Offspring born to mothers with preeclampsia have an increased risk of neurological diseases, including cognitive impairment, attention deficit hyperactivity disorder, autism spectrum disorders, depressive disorders, epilepsy, and cerebral palsy.

A 55-year-old woman presented with a recurrent thunderclap headache triggered by bathing, showering, and the Valsalva maneuver. Laboratory investigations revealed hyperthyroidism, whereas magnetic resonance imaging demonstrated a convexity subarachnoid hemorrhage and vasospasm of the cerebral arteries. The patient was diagnosed with reversible cerebral vasoconstriction syndrome (RCVS) and hyperthyroidism. The association between RCVS and hyperthyroidism has received only limited attention in literature. We herein report a case of RCVS with hyperthyroidism and discuss the association between RCVS and the thyroid function.

Neurovascular emergencies in the peripartum period, though rare, represent a significant cause of maternal morbidity and mortality worldwide. These conditions include ischemic and hemorrhagic strokes, cerebral venous sinus thrombosis, reversible cerebral vasoconstriction syndrome, posterior reversible encephalopathy syndrome, and cervical artery dissection. Clinical presentation can be subtle or nonfocal, delaying diagnosis. Early recognition through high clinical suspicion, prompt neuroimaging, and involvement of a neurological team is critical. This review highlights the most common neurovascular emergencies in the peripartum period and proposed interventions to better prevent, diagnose, and treat them.

ABSTRACTReports of postpartum women with concurrent reversible cerebral vasoconstriction syndrome (RCVS) and bilateral vertebral artery dissection (VAD) are rare. Guidelines on the management of future pregnancies in these patients are also limited. We present a case of a 33‐year‐old female who developed a severe, sudden‐onset headache 2 h after a vaginal birth in a maternity hospital. The severe headaches recurred and were associated with neck pain, nausea, vomiting, and photophobia. Preliminary neuroimaging only included a noncontrast CT brain. This was normal and she was treated with triptans for presumed migraines. However, she had ongoing headaches that were refractory to treatment. On Day 14 postpartum, neuroimaging that included vessel imaging revealed multifocal vasoconstriction of the cerebral arteries (highly suggestive of RCVS), bilateral VAD, and five small cerebral infarcts. She was transferred to a tertiary hospital and treated with verapamil and aspirin, and triptans were ceased. Following her index event, the patient recovered well with no neurological sequelae apart from chronic migraine. Three years later, with effective management that included routine preeclampsia prevention, she had a safe subsequent pregnancy and birth.

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.

Reversible cerebral vasoconstriction syndrome (RCVS), characterized by thunderclap headaches (TCH) and other clinical and radiological manifestations, typically occurs under some triggering conditions. This is the report of a 43 years old woman with known paroxysmal nocturnal hemoglobinuria (PNH) who received regular blood transfusion and glucocorticoid treatment, and developed RCVS. The association between PNH and RCVS has not been previously reported.

Background: Nontraumatic convexal subarachnoid hemorrhage (cSAH) is a distinct subtype of intracranial hemorrhage confined to the cortical sulci. Given its diverse etiologies, accurate diagnosis requires careful clinical and radiological evaluation. The present study aims to characterize the clinical profile, risk factors, neuroimaging features, and etiological spectrum of cSAH in a cohort of South Indian patients. Methods: We prospectively studied 17 consecutive patients with cSAH presenting to our tertiary care centre in Chennai, India, from 2023 to 2024. Data on demographics, clinical features, risk factors, neuroimaging, and etiologies were collected. Findings were compared with international cohorts. Results: The mean patient age was 46 years, and 47% were female. Headache occurred in 88%, seizures in 41%, and focal deficits in 35%. Parietal (71%) and frontal (65%) lobes were the most frequent hemorrhage sites; 35% had bilateral involvement. Cerebral venous thrombosis (CVT) was the leading cause (71%), followed by posterior reversible encephalopathy syndrome (12%), reversible cerebral vasoconstriction syndrome (6%), and arteriovenous malformation (6%). Compared with other published cohorts, our patients were younger, had a higher seizure incidence, and a predominance of CVT. Conclusion: In South Indian patients, cSAH most often results from CVT, especially in younger individuals. Prompt MRI with MR venography is critical for early diagnosis and management.

Bipolar patient on lithium maintenance therapy with reversible cerebral vasoconstriction syndrome after COVID-19 infection

Transfusion-related reversible cerebral vasoconstriction syndrome: A case report

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.