Introduction Although Reversible Cerebral Vasoconstriction Syndrome (RCVS) is generally considered a benign condition, it can lead to multiple serious complications, including hemorrhagic or ischemic strokes and Posterior Reversible Encephalopathy Syndrome (PRES). It is both more frequent and morbid in females as compared to males. Patients usually present with a thunderclap headache, and the RCVS2 score aids in the diagnosis based on clinical and imaging‐related factors. In approximately 90‐95% of cases, resolution occurs without medical intervention; however, agents such as nimodipine, verapamil, and milrinone are employed if clinical progression, worsening, or complications are noted. A standard approach remains lacking, particularly in managing complex cases. Case report We report a case of a 42‐year‐old female with uncontrolled type II diabetes mellitus, hypertension, and marijuana use who presented with lower extremities and right arm weakness, facial and tongue numbness that resolved. The initial magnetic resonance imaging (MRI) showed a left parietal lobe acute infarct and edema in the bilateral parietal lobes concerning PRES. Her hospital course was complicated by worsening symptoms, including right upper extremity weakness, aphasia, and confusion. Repeat MRI showed a new stroke in the right parietal lobe and worsening PRES. Her vascular imaging raised suspicion for vasculitis or RCVS. CTAs revealed progressive vasospasm, and an angiogram with vasodilator challenge showed some response, which favored the diagnosis of RCVS. Despite treatment, she later developed papilledema and occipital lobe strokes. Serial transcranial dopplers were obtained to assess the degree of fluctuating vasospasm. The patient was treated with intra‐arterial nicardipine and milrinone, followed by a course of intravenous milrinone. Due to persistent vasospasm, oral nimodipine, then oral sildenafil, was initiated. The patient was ultimately discharged on verapamil. Conclusion RCVS is a rare but life‐threatening disease associated with rapid neurological decline and poor outcomes. Standard therapy with calcium channel blockers may be insufficient in severe cases, highlighting the need for consideration of alternative agents like sildenafil. Early recognition of risk factors, including substance use and certain prescription medications, coupled with timely escalation of care, is critical to improving prognosis and guiding future therapeutic approaches.
Asmar et al. (Sat,) studied this question.