Severe Thunderclap Headache Research Articles

Reversible cerebral vasoconstriction syndrome : Arare cause of stroke

Reversible cerebral vasoconstriction syndrome (RCVS) is a complex and etiologically diverse neurovascular disorder that typically presents with severe thunderclap headaches (TCH) as the primary symptom, accompanied by reversible vasoconstriction of the cerebral arteries. The clinical course may include focal neurological deficits or epileptic seizures. There are two types: idiopathic RCVS and secondary RCVS, the latter triggered by various substances, medical interventions, or diseases. In clinical practice, various medical specialists may initially encounter this condition, underscoring the importance of accurate recognition and diagnosis of RCVS. The clinical course often appears monophasic and self-limiting, with recurrences reported in only 1.7% of cases annually. Complications such as cerebral hemorrhages and cerebral ischemia can lead to death in 5-10% of cases. This article utilizes a case study to explore RCVS, its complications, and the diagnostic procedures involved.

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

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.

Abstract TP179: Reversible Cerebral Vasoconstriction Syndrome (RCVS): A Retrospective Analysis of 79 Cases

Background: RCVS is characterized by severe thunderclap headaches often triggered by medications or sexual activity. Convexity subarachnoid hemorrhage, and less commonly, ischemic stroke and intracerebral hemorrhage can occur. There are few studies of the clinical-imaging features of RCVS (Singhal, 2011; Ducros, 2007). The pathogenesis is yet to be understood, and further studies looking into various triggers and outcomes, such as our present one, is essential to characterize the condition and develop targeted treatments. Methods: We performed an EMR search (2012-2023) for patients over 18Y of age with a diagnosis of RCVS in inpatient and outpatient settings. We retrospectively analyzed clinical (demographics, triggers, and discharge mRS)) and imaging features (CTA, MRA, DSA, and transcranial doppler (TCD)) to confirm RCVS diagnosis. RCVS score was calculated. Discharge mRS was inferred from EMR. Diagnosis adjudication was performed by RSM. Student t-test and Chi-square test were used to analyze outcomes. Results: Seventy-nine patients were identified (mean age 40±11.5Y, 91% women). The most common triggers were medications (39%), sexual activity (11.4%), and marijuana use (5%). One-third (35%) had chronic headache history (migraines 22%). Twenty-nine (37%) were postpartum (n=19) or pregnant (n=10). Fourteen had concurrent pre-eclampsia (17%). Twelve (15%) also had imaging features of posterior reversible encephalopathy syndrome (PRES). Vasoconstriction was seen on DSA (n=15), CTA (n=25), and MRA (n=23); In 14 patients, vasoconstriction was evident only on TCD. SAH occurred in 26 (33%), ischemic stroke in 8, and ICH in 9. Median RCVS score was 7 (IQR 6-9, range 4-10). CSF profile (n=19) was normal, aside from mildly elevated lymphocyte count (n=2, range 10-13 cells) or protein (n=5, range 50-80 mg/dL). Discharge mRS was 0-1 in 83%. Patients without RCVS trigger (n= 40) had higher ischemic stroke or hemorrhage occurrence ( χ2 = 3.8, P=0.05 ). RCVS scores in pregnant/postpartum patients were similar to others ( t = 2.01, P = 0.06). Conclusion: In this case series, absence of an RCVS trigger was associated with occurrence of stroke or hemorrhage. Most patients had favorable prognosis. These findings need to be confirmed in prospective studies.

The Music Within: A Doppler Harmonic Pattern Report in Non-Subarachnoid Hemorrhage Related Cerebral Vasospasm

A 40-year-old male presented an episode of severe thunderclap headache with right hemiparesis. Imaging revealed severe stenosis in the left middle cerebral artery, associated with increased mean velocities detected by Transcranial Doppler Ultrasound (TCD). Notably, a distinctive "tin whistle" sound, known as a doppler harmonic effect, near the highest velocity point was observed during the examination. Extensive workup was performed, including CSF analysis and laboratory investigations, and the diagnosis of Reversible Cerebral Vasoconstriction Syndrome (RCVS) was established. Treatment involving medication and daily monitoring led to a decline in the left MCA's velocity, enabling the patient's discharge with no recurrent headaches or neurological deficits. Notably, a follow-up MRI exhibited the disappearance of the left MCA stenosis. This report discusses the rare occurrence of "musical murmurs" in cerebrovascular diseases, underscoring the potential for early diagnosis using techniques like TCD in emergency settings, particularly in conditions like RCVs.

Abstract 099: Reversible Cerebral Vasoconstriction Syndrome Secondary to Weight Loss Patch: A Case Report​

Introduction Reversible Cerebral Vasoconstriction Syndrome (RCVS) is a clinico‐radiographical syndrome characterized by severe thunderclap headache and reversible multifocal arterial vasoconstriction1. RCVS can be spontaneous or related to a trigger such as vasoactive medication/supplements. There is no previous data on the association of weight loss patch formulation in the genesis of unexplained RCVS. Methods A woman in her 40s presented with five days of recurrent acute onset severe right frontal headaches after starting Thrive weight loss patch supplementation. Head CT showed right frontal lobe hemorrhage with bilateral SAHs (Figure1). Brain MRI redemonstrated hemorrhages, numerous scattered foci of restricted diffusion, and a large area of restricted diffusion in the left insular cortex (Figure 2). Cerebral angiogram showed diffuse multifocal narrowing with a ‘beads‐on‐a‐string’ appearance of the cerebral vasculature and no aneurysms (Figure 3). Thrive patch contains undisclosed amounts of sympathomimetics and vasoactive compounds. Given the history, clinical symptoms of recurrent thunderclap headaches, and angiographic findings, the diagnosis of RCVS was made. Brain MRA 3 months after discharge showed no areas of cerebrovascular focal stenosis (Figure 4). At 4 month follow up, she reported 90% improvement of her symptoms. Results We report a temporal relationship between RCVS in a woman in her 40s and usage of a Thrive weight loss patch, which contains green tea extract, L‐arginine, 5‐hydroxytryptophan (5‐HTP), and Yerba Mate. We believe this report represents the first case of RCVS triggered by a weight loss patch. Multiple compounds within the Thrive patch have vasoactive properties that may contribute to RCVS genesis. Epigallocatechin (component of green tea extract) and 5‐HTP are metabolic compounds with potent vasoactive properties. They are components of weight loss and SSRI/SNRI medications respectively. Numerous studies have documented a temporal relationship between their use and subsequent development of RCVS2,3. Resolution of RCVS is reported after their discontinuation. Only one other case in our literature review investigated a patch modality in a temporal relationship with RCVS. It reported development and resolution of RCVS six days after nicotine patch use and discontinuation4. While Thrive patch does not contain nicotine, this case provides a further avenue for exploration as to whether pharmacokinetics of a patch modality influences a patient’s presentation with RCVS, as all prior reports document oral ingestion of substances. Conclusion Clinicians should be aware of the role of weight loss patches in RCVS, and their use should be assessed in large RCVS cohorts to clarify the association described in this report.

Cerebral Gnathostomiasis: An Unusual Course of Recurrent Hemorrhagic Stroke.

Cerebral Gnathostomiasis: An Unusual Course of Recurrent Hemorrhagic Stroke.

Reversible Cerebral Vasoconstriction Syndrome(RCVS)and Posterior Reversible Encephalopathy Syndrome(PRES)

Reversible cerebral vasoconstriction syndrome(RCVS)is a clinical and radiological syndrome that is characterized by recurrent severe thunderclap headaches with or without other neurological symptoms and diffuse segmental constriction of cerebral arteries that usually resolves spontaneously within three months. Posterior reversible encephalopathy syndrome(PRES)is also a clinical and radiological syndrome characterized by headache, seizures, altered consciousness, cortical blindness, other focal neurological signs, and a diagnostic imaging picture of brain vasogenic edema. Both syndromes can occur in similar clinical contexts such as hypertension, pre-eclampsia/eclampsia, drug neurotoxicity, uremia, and some autoimmune diseases, and are frequently associated. Although the syndromes are usually fully reversible with early diagnosis and prompt treatment, some cases can develop hemorrhagic or ischemic brain lesions, often resulting in permanent disability. We need to be aware of the typical and atypical imaging manifestations of the syndromes to make an accurate diagnosis.

Pediatric Reversible Cerebral Vasoconstriction Syndrome: Two Unique Cases with a Review of all Reported Children

AbstractReversible cerebral vasoconstriction syndrome (RCVS) has been well described in adults, but pediatric cases are yet under recognized. We described two children with RCVS and review similar already published pediatric cases. The first patient was a 10-year-old girl who presented with severe headaches and seizures 3 days after blood transfusion. Brain magnetic resonance imaging (MRI) showed changes compatible with posterior reversible encephalopathy syndrome and subarachnoid hemorrhage. Magnetic resonance angiogram showed diffuse vasoconstriction of multiple cerebral arteries. The second patient was a 9-year-old male child who presented with severe thunderclap headaches. Brain MRI showed isolated intraventricular hemorrhage. Computed tomography/MR angiogram and digital subtraction angiogram were normal. A week later, he developed focal neurological deficits. Repeated MR angiogram showed diffuse vasospasm of multiple intracranial arteries. Both children recovered completely. A clinico-radiological review of previously reported childhood RCVS is provided.

Reversible Cerebral Vasoconstriction Syndrome Associated with a Suprarenal Mass.

Reversible cerebral vasoconstriction syndrome (RCVS) is characterised by severe thunderclap headaches (with or without the presence of acute neurological symptoms) and segmental vasoconstriction of cerebral arteries that resolves spontaneously in a period of three months. Cases have been described in the literature with producing and non-producing masses of metanephrines. Within these reports, associations with cavernous haemangioma, medulloblastoma, colon cancer, paraganglioma, pheochromocytoma, uterine fibroids, among others were found. However, no association with adrenal masses which do not produce metanephrines was found. In this context, we reported the case of a woman with this type of tumour associated with RCVS which provided a treatment challenge, as well as we reviewed the literature on cases of RCVS associated with masses.

Thunderclap headache and reversible cerebral vasoconstriction syndrome: Current theory and accumulated data

AbstractReversible cerebral vasoconstriction syndrome (RCVS) is characterized by recurrent severe thunderclap headache and segmental vasoconstriction of cerebral arteries that resolves by 3 months. RCVS can either occur spontaneously or relate to an exogenous trigger, but the precise pathophysiology of RCVS remains unknown. Postulated mechanisms include small vessel and endothelial dysfunction, mitochondrial dysfunction with oxidative stress, hormonal and biochemical factors, and genetic predisposition. A prior history of migraine has been reported in 17%–40% of cases, suggesting that migraine and RCVS share mechanisms. Most RCVS patients have a favorable prognosis; however, for some patients, the condition may result in permanent disability or even death in a small minority of patients, secondary to complications such as ischemic stroke or intracranial hemorrhage. There is no proven treatment, so the cornerstone of RCVS management remains largely supportive, with prescription of bed rest, analgesics, and the removal of precipitating factors. The majority of clinical series studying RCVS treatment have investigated the efficacy of calcium channel antagonists. Although prescription of triptans for migraine is not suitable for patients with a history of RCVS, lasmiditan, a highly selective 5‐HT1F receptor agonist, may be suitable in such cases. Typical segmental vasoconstriction of major vessels is not seen in approximately 30% of patients eventually diagnosed with RCVS; if this diagnosis is suspected, repeat imaging should be performed. Early diagnosis of RCVS is important, as it allows progression to be prevented by the prompt removal of precipitating factors, unnecessary diagnostic procedures to be avoided, and appropriate management to be commenced.

B-01 Cognitive Deficits Following Hemorrhagic Stroke in Reversible Cerebral Vasoconstriction Syndrome: A Case Study

Abstract Objective Reversible cerebral vasoconstriction syndrome (RCVS), a relatively rare condition presenting as severe thunderclap headache with or without neurological deficits, is characterized by vasoconstriction of cerebral arteries which often resolves within three months and may be associated with stroke. Previous case reports examining neuropsychological profiles of RCVS patients demonstrated stroke-specific and/or diffuse global impairments that often exceed impairment expected post-acute phase of clinical stroke and possibly suggest residual deficits related to RCVS alone (Perdices & Herkes, 2018). Method The present case is a 36-year-old right-handed African-American male who sustained a left thalamic hemorrhage with extension into the ventricular system following marijuana use. Cerebral angiogram was suggestive of RCVS. The Montreal Cognitive Assessment (MoCA), Western Aphasia Battery (WAB), Repeatable Battery for the Assessment of Neuropsychological Status- Update (RBANS), and Peabody Picture Vocabulary Teat- 4th edition (PPVT-4) were administered at bedside. Results Neuropsychological testing was abnormal with severe global impairments on tasks requiring attention and processing speed, visuospatial abilities, immediate and delayed memory, and executive functioning. The patient’s expressive speech was characterized by fluent output with pronounced provoked and unprovoked phonemic and semantic paraphasias. Additionally, he evidenced confabulatory responses during memory testing and lost mental set during tasks requiring simultaneous attention. Conclusions Considering the patients clear sensorium at the time of the evaluation, these deficits extend beyond what would be expected by a single thalamic lesion and implicate more generalized cerebral dysfunction secondary to his RCVS. Consistent with previous case studies, this case demonstrates how RCVS may confound and contribute to neurocognitive deficits even after hemorrhagic stroke.

Preeclampsia and Cerebrovascular Disease.

Preeclampsia and Cerebrovascular Disease.

Reversible cerebral vasoconstriction syndrome (RCVS) in the context of aseptic meningitis in a twenty eight year-old postpartum female

Reversible cerebral vasoconstriction syndrome (RCVS) is an uncommon pathology that typically presents with a severe thunderclap headache in middle-aged postpartum females. Our patient was a twenty eight year-old Caucasian female seven months postpartum who presented with a ten day history of severe frontal headaches, myalgia, nausea, and anorexia without fevers. She then developed severe left hemiplegia, dysarthria, and paresthesias. Initial cerebrospinal fluid was significant for lymphocytepredominant pleocytosis, and acyclovir, vancomycin, and doxycycline were started for empiric meningitis. Cultures and marker were pan-negative for viral, bacterial, fungal, and autoimmune etiology. A computed tomography head scan was suggestive of distal right internal carotid artery atherosclerosis and ectasia, highly unusual for a woman of this age with no cardiovascular risk factors. Her hospital course was characterized by insomnia, delirium, worsening overnight headaches, and unusual bradycardic episodes. A computed tomography angiogram confirmed right internal carotid artery and middle cerebral artery M1 and M2 segment narrowing, suggestive of RCVS. A follow-up cerebral arteriogram highlighted right middle cerebral artery M1 segment tapering, confirming this diagnosis. We suspect an additional diagnosis of aseptic meningitis, due to her cerebrospinal fluid findings, which likely exacerbated her clinical presentation. Her refractory headaches eventually improved spontaneously. This presentation of reversible cerebral vasoconstriction syndrome in the context of a late post-partum onset and aseptic meningitis is the first such case to be documented, and we hope to shed some light on this unusual and uncommon disease, as well as some avenues for future research.

Reversible Cerebral Vasoconstriction Syndrome: Recognition and Treatment.

Reversible cerebral vasoconstriction syndrome (RCVS) is a rare but increasingly recognized disorder with over 500 cases published in the literature. The condition is characterized by recurrent severe thunderclap headaches with or without other neurological symptoms and diffuse segmental narrowing of the cerebral arteries which is reversible within 3months. RCVS may occur spontaneously but in over 50% of cases, it is associated with various other conditions, including vasoactive medications or illicit drugs and the post-partum state. One third to a half of cases develop hemorrhagic or ischemic brain lesions or a combination of both. Posterior reversible encephalopathy syndrome (PRES) often occurs in association with RCVS and the conditions are likely to share a common pathophysiology. The pathogenesis of RCVS remains uncertain but autonomic dysregulation, oxidative stress, and genetic predisposition are postulated. Significant differential diagnoses include subarachnoid hemorrhage (SAH) due to aneurysmal rupture, cervical artery dissection, and primary angiitis of the central nervous system (PACNS). Although there is no proven treatment, calcium channel antagonists including nimodipine and verapamil have been administered with reported reduction of headache intensity but without effect on the time course of cerebral vasoconstriction. Glucocorticoids have been reported as an independent predictor of worse outcome and should be avoided. The cornerstone of RCVS management remains largely supportive with bed rest and analgesics and removal of precipitating factors. Invasive neurointerventional techniques should be reserved for severe deteriorating cases. The condition is usually benign and self-limited and the majority of patients have a favorable outcome but around 5-10% are left with permanent neurological deficits and rare cases may die. This review details the importance of the early recognition of this increasingly described condition and current treatment recommendations.

Reversible cerebral vasoconstriction syndrome

ABSTRACTReversible cerebral vasoconstriction syndrome (RCVS) is a relatively rare, non-progressive angiopathy frequently heralded by severe thunderclap headache. It is characterised by vasoconstriction of cerebral arteries which usually resolves within three months of onset. Transient focal neurological signs may occur, and persistent deficits associated with haemorrhagic comorbidities have been reported in a small percentage of individuals. In this paper we report the case of RH, a 36-year-old woman who presented at a university teaching hospital in Sydney with a clinical history and radiological evidence consistent with RCVS. There were no haemorrhagic events during the course of her illness, and vasoconstriction resolved within a few days, following treatment with verapamil. Neuropsychological evaluation 16 months later revealed significant deficits in autobiographical memory, verbal and non-verbal new learning and active delayed recall, cognitive flexibility, abstraction and (to a lesser extent) immediate attention span and information processing speed. RH’s case was unusual because the “trigger” for RCVS (Ear, Nose and Throat surgery) has not been previously reported, and because despite there being no haemorrhagic complications during the course of RCVS and no subsequent radiological abnormalities, she had significant cognitive impairment. To date, persistent neuropsychological deficits have not been recognised as a feature of RCVS.

Cerebral Sinus Thrombosis: A Rare but Fatal Complication of Inflammatory Bowel Disease

Inflammatory bowel disease (IBD) is an idiopathic autoimmune disease. Extra intestinal manifestation of IBD has been reported to be 25 to 35%. There is a well-known risk of thrombosis in patients with IBD. It rarely involves cerebral vasculature in the form of arterial stroke or venous sinus thrombosis. This case is about 35 yrs old male who was a known case of ulcerative colitis for the last 10 years. He presented with history of severe thunderclap headache for the last few hours along with vomiting. He also had three episodes of seizure, generalized tonic clonic in nature. The examination does not show any focal asymmetry except mild drowsiness. His CT brain showed Focal cortical and subcortical area in the left posterior parietal region displaying multiple foci of hyper density with perifocal edema. CT venogram showed an intraluminal filling defect in the superior sagittal sinus suggestive of venous sinus thrombosis. Conclusion: Cerebral venous sinus thrombosis are considered as one of the rare but fatal complication of inflammatory bowel disease. It must be considered in all those with inflammatory bowel disease wherein absence of any other vascular risk factor patient presents with acute severe headache and focal or diffuse neurological symptoms including seizure

Reversible cerebral vasoconstriction syndrome.

Reversible cerebral vasoconstriction syndrome (RCVS) is a clinical-radiological syndrome characterised by severe thunderclap headaches with or without other neurological symptoms and multifocal constriction of cerebral arteries that usually resolves spontaneously within 3 months. Most patients recover completely, but up to 10% have a permanent neurological disability and some even die. Previously RCVS has been described in many clinical contexts and under different names with the term RCVS first being suggested in 2007 to unify the group. The condition may be spontaneous, but in up to 60% of cases it is secondary to another cause, including vasoactive substances (medications and illicit drugs), blood products and the post-partum state. It is believed to have a similar pathophysiological mechanism to the posterior reversible encephalopathy syndrome (PRES), and both can occur in similar clinical contexts and are frequently associated. Treatment options include calcium channel antagonists. RCVS occurs in a broad range of clinical situations making it an increasingly recognised condition about which doctors in various specialties need to be aware.

The distribution of subarachnoid and intraventricular hemorrhage on computed tomography suggests the location of an idiosyncratic vascular lesion

The incidence of aneurysmal subarachnoid hemorrhage (SAH) associated with intraventricular hemorrhage (IVH) varies. In general, the anterior communicating artery and posterior circulation aneurysms cause such IVHs. A 48-year-old man visited the Neurosurgical Department for the evaluation of a severe thunderclap headache that had awakened him from sleep. Brain computed tomography revealed diffuse, but asymmetric, SAH. Digital subtraction cerebral angiography (DSA) showed multiple vascular lesions, including an obvious saccular aneurysm on the left anterior choroidal artery. After surgical clipping, rebleeding was noted, and repeat DSA demonstrated that the bleeding site was on the right posterior cerebral artery. The distribution of SAH associated with the preserved Liliequist membrane may suggest the origin of the bleeding. Treatment of the correct bleeding site is effective for preventing rebleeding.

Reversible cerebral vasoconstriction syndrome: rare or underrecognized in children?

Reversible cerebral vasoconstriction syndrome (RCVS) is a clinicoradiological diagnosis comprising 'thunderclap' headaches and reversible segmental vasoconstriction of cerebral arteries, occasionally complicated by ischaemic or haemorrhagic stroke. We report a case of RCVS in a 13-year-old male with severe thunderclap headaches and no focal neurological signs. Brain imaging showed multiple posterior circulation infarcts; cerebral computed tomography, magnetic resonance imaging, and catheter angiography showed multifocal irregularity and narrowing, but in different arterial segments. Laboratory studies did not support a diagnosis of vasculitis. Symptoms resolved over 3 weeks; magnetic resonance angiography 3 months later was normal and remained so after 2 years. We highlight the typical clinical features of RCVS in this case and suggest that the diagnosis should be considered in children with thunderclap headaches or stroke syndromes where headache is a prominent feature, especially if cerebrovascular imaging studies appear to be evolving or discrepant.

Transient Charles Bonnet syndrome in a patient with reversible cerebral vasoconstriction syndrome

Charles Bonnet syndrome (CBS) was first described by a Swiss philosopher named Charles Bonnet in 1760. For a long time, this syndrome was considered to be rare; however, in 1996, Teunisse et al. [1] reported psychopathological characteristics of 60 patients with CBS and questioned the rarity of CBS. CBS is diagnosed if the following criteria are fulfilled: (a) the presence of formed and complex, persistent, or repetitive visual hallucinations; (b) full or partial retention of insight; (c) the absence of delusions; (d) and the absence of hallucinations in other modalities [2]. Reversible cerebral vasoconstriction syndrome (RCVS) is a disorder characterized with reversible segmental and multifocal vasoconstriction of cerebral arteries and severe headaches with or without focal neurological deficits or seizures. Calabrese et al. described the following features for RCVS: (a) transfemoral angiography or indirect [computed tomography (CT) or magnetic resonance (MR)) angiography showing segmental cerebral artery vasoconstriction; (b) no evidence for aneurysmal subarachnoid hemorrhage; (c) normal or near-normal findings for cerebrospinal fluid analysis (protein level \80 mg/dL, white blood cell count\10 cells/lL, normal glucose level); (d) severe, acute headache with or without additional neurological signs or symptoms; and (e) the diagnosis cannot be confirmed until reversibility of the angiographic abnormalities is documented within 12 weeks after onset and if death occurs before the follow-up examinations are completed, the autopsy rules out conditions such as vasculitis, intracranial atherosclerosis, and aneurysmal subarachnoid hemorrhage, which can also manifest with headache and stroke [3]. Here, we report transient visual hallucinations resembling the ones in CBS in a patient with RCVS. A 64-year-old woman experienced severe thunderclap headache when she was skiing. CT and MR imaging (MRI) of her brain performed at that time revealed no abnormality. MRI and magnetic resonance angiography (MRA) conducted about 3 weeks later revealed convexity subarachnoid hemorrhage in the right frontal lobe and multiple segmental cerebral artery vasoconstrictions (Fig. 1). Her blood pressure was 130/96 mmHg, her body temperature was 36.2 C, and she was alert. She had no visual loss but experienced formed and complex visual hallucination such as ‘‘people walking down the street’’ or ‘‘people acting in a theater’’ only when she closed her eyes, and she had full retention of insight. Her visual hallucinations began about 3 weeks after the onset of headache, and lasted for about a week. 99mTc-ECD single-photon emission computed tomography showed diminished blood flow in both the occipital lobes (Fig. 2). Her headache eventually resolved without any neurological deficit. MRA performed at about 5 weeks after the onset of headache showed more cerebral artery vasoconstrictions, but the vasoconstrictions resolved 2 weeks after that, and the patient was diagnosed with RCVS. Y. Yagi (&) Y. Watanabe H. Yokote T. Amino T. Kamata Department of Neurology, Musashino Red Cross Hospital, Kyonancho 1-26-1, Musashino, Tokyo 180-8610, Japan e-mail: yyagi-tmd@umin.ac.jp