Reversible Cerebral Vasoconstriction Syndrome Secondary to Paroxetine and Opioid Use in a Middle-Aged Woman: A Case Report

Reversible cerebral vasoconstriction syndrome (RCVS) is a condition that usually presents with recurrent thunderclap headaches, focal neurological deficits, and seizures, secondary to transient cerebral vascular spasms. Although the mechanism is not well understood, medications that modulate serotonergic activity, such as selective serotonin reuptake inhibitors (SSRIs), may induce RCVS. In this case, we present a 39-year-old female patient with thunderclap headaches and a multitude of neurological deficits, including vision loss and musculoskeletal weakness. Her medical history is significant for depression, migraines, and opioid-use disorder in remission, treated with paroxetine and mirtazapine, sumatriptan, and buprenorphine-naloxone, respectively. The diagnosis of RCVS was supported by imaging that demonstrated multiple acute cerebral infarcts and stenoses. The patient spent a total of eight days as an inpatient, and during that time, her symptoms showed gradual improvement. RCVS is a rare condition that should be considered in a patient with risk factors for whom high-acuity diagnoses such as subarachnoid hemorrhage have been ruled out.