A postpartum woman with recurrent headaches and transient neurological deficits: a case report

Reversible cerebral vasoconstriction syndrome (RCVS) is an under-recognized clinical entity characterized by transient segmental vasoconstriction of cerebral arteries. It commonly presents with thunderclap headaches and can mimic other acute neurological conditions, often delaying diagnosis. Known risk factors include the female sex, postpartum state and exposure to vasoactive substances. We report the case of a 26-year-old, white woman presenting ten days postpartum with severe, recurrent headaches. Her medical history included opioid maintenance therapy and past cocaine use. Initial laboratory findings, magnetic resonance imaging (MRI) and transcranial duplex sonography (TCD) were unremarkable leading to the assumption of a multifactorial etiology of the headaches. However, 11–12 days after symptom onset, the development of new focal neurological deficits prompted repeat imaging (MRI and TCD), finally revealing basal cerebral arteries vasoconstriction and increased flow velocity consistent with RCVS. Treatment with nimodipine resulted in rapid clinical and sonographic improvement, with complete resolution of symptoms and vascular findings at 1-month follow-up. This case underlines the diagnostic challenges of RCVS. Clinicians should maintain a high index of suspicion for RCVS in patients presenting with acute-onset headaches and risk profiles, even in the absence of early imaging abnormalities. Early recognition and targeted treatment may improve outcomes in this potentially reversible condition.