Reversible Cerebral Vasoconstriction Syndrome: An Underdiagnosed Neurological Condition Masquerading as Acute Stroke in the Emergency Department

Reversible cerebral vasoconstriction syndrome (RCVS) is a syndrome of cerebrovascular dysregulation.It is marked by sudden-onset, severe headaches that occur over a period of days, which are a result of widespread cerebral vasoconstriction.Structural neuroimaging is frequently unremarkable, especially in the early stages.Reversible cerebral vasoconstriction syndrome is benign and self-limiting, however, it can rarely lead to severe complications such as ischaemic stroke, subarachnoid or other intra-cerebral haemorrhage, and posterior reversible encephalopathy syndrome (PRES).We describe the case of a 60-year-old female who presented with headache, vomiting, slurred speech, and hemiparesis.Clinical neurological assessment in the Emergency Department (ED) revealed an National Institute of Health Stroke Scale (NIHSS) of 7. A magnetic resonance (MR) diffusion-weighted scan with an extended angiogram was suggestive of spasm over the right middle cerebral artery (MCA), with no evidence of acute infarct or haematoma.The patient was treated successfully with tapering doses of nimodipine and other supportive measures, with progressive neurological improvement over a period of 5 days, finally being discharged from the hospital on day 7.In our opinion, this case bears clinical significance because RCVS is rare and often underdiagnosed.It is also very similar descriptively to the often-encountered PRES, but different in terms of cerebrovascular dysregulatory mechanisms.In our report, we have taken the opportunity to describe the current accepted emergency care treatment modalities of this relatively uncommon condition, with recent evidence-based guidelines and a review of the literature.