A case of reversible cerebral vasoconstriction syndrome presenting with recurrent bath-related thunderclap headaches with blood pressure surges

Abstract

A 44-year-old woman presented with thunderclap headaches, triggered by bathing, which were accompanied by blood pressure surges. She had experienced these same episodes for 5 consecutive days before admission to our department. While no focal neurological signs were noted, her brain magnetic resonance imaging (MRI) revealed high intensity lesions in the bilateral occipital lobes and the left frontal lobe on both T2-weighted images and flair images. Furthermore, her brain MRA showed multifocal arterial constrictions, which suggested reversible cerebral vasoconstriction syndrome (RCVS) accompanied by posterior reversible encephalopathy syndrome (PRES). Intravenous calcium blocker infusion, which was followed by oral administration for 3 months, prevented further thunderclap headaches and blood pressure surges. The MRI on hospital day 13 revealed no abnormalities associated with PRES, while the multifocal arterial constrictions persisted. Although the exact mechanism of RCVS is poorly understood, aberrant central sympathetic activity triggered by bathing could play a key role in triggering thunderclap headaches and blood pressure surges.Key words: thunderclap headache, reversible cerebral vasoconstriction syndrome, posterior reversible encephalopathy syndrome, bath-related headache, blood pressure surge (Jpn J Stroke 37: 31-35, 2015)