Presentation
Female patient with past history of migraine headache. Had a severe attack of migraine two days ago. Today she presented to ER with severe thunderclap headache and vomiting. No ilicit drug use. Not pregnant. CT scan of the brain revealed left frontal parenchymal hematoma and bilateral frontal subarachnoid hemorrhage. CT angiography to rule out aneurysm or vascular malformation.
Patient Data
CT cerebral angiography shows diffuse attenuation (spastic) and beading of all intracranial arteries.
No evidence of cerebral vascular aneurysms or vascular malformation.
Normal CT venography. No venous thrombosis.
Left frontal parenchymal hematoma and bilateral subarachnoid hemorrhage.
Case Discussion
In our Patient with sudden onset of thunderclap headaches and vomiting. CT shows a nontraumatic left frontal lobar hemorrhage and bilateral frontal convxity subarachnoid hemorrhage.
CT angiogram shows no aneurysms or vascular malformations. Yet, the typical appearance of diffuse attenuation and beading of all intracranial vessels was consistent with reversible vasoconstriction syndrome. The patient had laboratory work up for vasculitis markers which were all negative. No specific precipitating factors such as pregnancy or labor or illicit drugs. Migraine may be the contributing factor in this case.
Reversible cerebral vasoconstriction syndrome (RCVS) is a group of conditions with a common clinical and radiologic presentation. It is characterized by thunderclap headache and reversible vasoconstriction of the cerebral arteries.
The findings on imaging consist of either direct visualization of the vascular narrowings and/or complication(s) related to vascular narrowings such as:
convexity non-aneurysmal subarachnoid hemorrhage
lobar hemorrhage
watershed infarct
vasogenic edema
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