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Reversible cerebral vasoconstriction syndrome — SCE Neurology MCQ

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HardHeadacheReversible cerebral vasoconstriction syndromeSCE Neurology

Five days after delivery, a woman has three thunderclap headaches over 48 hours. She recently restarted sertraline and has taken pseudoephedrine. CT shows a small convexity subarachnoid haemorrhage; CT angiography shows multifocal segmental narrowing in several cerebral arteries. Which diagnosis best integrates the pattern?

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Correct answer: C — Reversible cerebral vasoconstriction syndrome

Recurrent thunderclap headaches, the postpartum state, exposure to vasoactive drugs, convexity subarachnoid blood and multifocal arterial narrowing form a characteristic RCVS phenotype. Aneurysmal haemorrhage more often produces basal cisternal blood and does not explain repeated attacks before the bleed; primary CNS vasculitis usually has a more progressive headache and neurological course rather than recurrent thunderclaps. PRES can overlap with RCVS but would require its own oedema pattern. Venous thrombosis is an important postpartum differential, although the arterial beading and trigger profile favour RCVS. Vasoactive triggers should be withdrawn and neurovascular specialist management arranged.

Reference: NHS Scotland Right Decisions, Headache in pregnancy: https://www.rightdecisions.scot.nhs.uk/media/fjifaee2/2023-02-21-headache-in-pregnancy.pdf