Three years of RCVS and PRES cases at a single comprehensive stroke center: observations on clinical presentation, headache features, triggers, and management

Abstract Background Reversible cerebral vasoconstriction syndrome (RCVS) and posterior reversible encephalopathy syndrome (PRES) are related but distinct neurovascular disorders with unanswered questions regarding etiologies, relationship to migraine and substances, and optimal management. Methods We retrospectively reviewed inpatient RCVS and PRES cases, identified by ICD-10 code, at our center over three years. We collected demographics, medical history (including migraine), presenting symptoms (especially headache features), neurologic exam findings, diagnostics (urine drug screen, imaging modality for diagnosis), time to diagnosis, etiology (including substances), complications, length of stay, and treatment. Statistical analyses compared RCVS only, PRES only, and RCVS and PRES groups. Results Among 33 analyzed charts, PRES was the most common diagnosis (63.6%), followed by RCVS (27.3%) and both (9.1%). Migraine and chronic pain predominated in the RCVS group; hypertension and chronic kidney disease in the PRES group. All individuals with RCVS presented with headache, most commonly thunderclap (followed by migraine different from usual, positional headache, and new onset migraine), often with a normal exam. PRES commonly presented as altered mental status with focal neurologic deficits and faster diagnosis albeit longer length of stay. Initial imaging was CT angiography for RCVS and MRI for PRES; confirmatory DSAs were uncommon. Marijuana was the most common suspected etiology for the RCVS group, while hypertension was the more common etiology in the PRES group. Complications were rare in the RCVS group but more common in the PRES group (primarily seizures). Finally, RCVS was predominantly treated with verapamil, and PRES with blood pressure control and antiseizure medication. However, no RCVS patients were given a specific duration for which to continue treatment. Conclusions We found that RCVS cases often had co-morbid migraine and THC as a suspected etiology, and typically presented with thunderclap headache. PRES presented with altered mental status and focal deficits with faster diagnosis compared to RCVS but longer length of stay, and more complications. Optimal management of RCVS, particularly duration of treatment and management of potentially triggering medications requires further study.