Navigating the Diagnostic Maze: A Case Report and Narrative Review of Reversible Cerebral Vasoconstriction Syndrome

Reversible cerebral vasoconstriction syndrome (RCVS) is a condition characterized by thunderclap headaches, which are sudden and severe headaches that peak within a few seconds. These headaches present diagnostic difficulties due to their diversity and low specificity, often leading to misdiagnoses and patient dissatisfaction.

We present the case of a 52-year-old woman with a 10-day history of recurrent thunderclap headaches. Initial imaging revealed no abnormalities, but she experienced further episodes of thunderclap headaches during hospitalization. Subsequent neurovascular imaging revealed multiple intracranial stenoses with a "string of beads" appearance, confirming the diagnosis of reversible cerebral vasoconstriction syndrome. She was treated with nimodipine, and most symptoms had resolved upon discharge, with no recurrence of headache reported during a 3-month follow-up.

Prior reviews on reversible cerebral vasoconstriction syndrome predominantly emphasized isolated symptoms or advanced neuroimaging findings, offering limited applicability in primary care services. More attention should be given to identifying clinical manifestations warranting heightened reversible cerebral vasoconstriction syndrome suspicion.

Early recognition of reversible cerebral vasoconstriction syndrome counts in primary care services. We proposed a revised diagnostic routine that begins with clinical suspicion prompted by typical manifestations, like recurrent thunderclap headaches, female sex, and specific triggers, and recommends advanced neurovascular imaging when accessible. Extreme headache severity or deviation from prior migraine patterns should raise suspicion for reversible cerebral vasoconstriction syndrome, while diagnostic consideration should still remain in patients with transient neurological deficits, seizures, or cerebrovascular events.