Reversible cerebral vasoconstriction syndrome (RCVS) in the context of aseptic meningitis in a twenty eight year-old postpartum female

Abstract

Reversible cerebral vasoconstriction syndrome (RCVS) is an uncommon pathology that typically presents with a severe thunderclap headache in middle-aged postpartum females. Our patient was a twenty eight year-old Caucasian female seven months postpartum who presented with a ten day history of severe frontal headaches, myalgia, nausea, and anorexia without fevers. She then developed severe left hemiplegia, dysarthria, and paresthesias. Initial cerebrospinal fluid was significant for lymphocytepredominant pleocytosis, and acyclovir, vancomycin, and doxycycline were started for empiric meningitis. Cultures and marker were pan-negative for viral, bacterial, fungal, and autoimmune etiology. A computed tomography head scan was suggestive of distal right internal carotid artery atherosclerosis and ectasia, highly unusual for a woman of this age with no cardiovascular risk factors. Her hospital course was characterized by insomnia, delirium, worsening overnight headaches, and unusual bradycardic episodes. A computed tomography angiogram confirmed right internal carotid artery and middle cerebral artery M1 and M2 segment narrowing, suggestive of RCVS. A follow-up cerebral arteriogram highlighted right middle cerebral artery M1 segment tapering, confirming this diagnosis. We suspect an additional diagnosis of aseptic meningitis, due to her cerebrospinal fluid findings, which likely exacerbated her clinical presentation. Her refractory headaches eventually improved spontaneously. This presentation of reversible cerebral vasoconstriction syndrome in the context of a late post-partum onset and aseptic meningitis is the first such case to be documented, and we hope to shed some light on this unusual and uncommon disease, as well as some avenues for future research.