Hemorrhagic Manifestations of Reversible Cerebral Vasoconstriction Syndrome: Frequency, Features, and Risk Factors

Background And Purpose: Reversible cerebral vasoconstriction syndrome (RCVS), characterized by severe headaches and reversible constriction of cerebral arteries, may be associated with ischemic and hemorrhagic strokes. The aim of this study was to describe the frequency, patterns, and risk factors of intracranial hemorrhages in RCVS.

Methods: We analyzed prospective data on 89 consecutive patients with RCVS, of which 8 were postpartum and 46 used vasoactive substances. Standard bivariate and multivariate statistical tests were applied to compare patients with and without hemorrhage.

Results: Thirty patients (34%), of which 5 were postpartum and 12 used vasoactive substances, developed at least 1 type of intracranial hemorrhage, including cortical subarachnoid (n = 27), intracerebral (n = 11), and subdural hemorrhage (n=2). Patients with hemorrhage had an older age (46.6 versus 41.6 years, P = 0.049) and were more frequently females (90% versus 51%, P = 0.0017) or were migrainers (43% versus 19%, P = 0.022) than those without hemorrhage. Multivariate testing identified 2 independent risk factors of hemorrhage in RCVS: female gender (OR, 4.05; 95% CI, 1.46 to 11.2) and migraine (OR, 2.34; 95% CI, 1.06 to 5.18). Patients with hemorrhage had a greater risk of persistent focal deficits (30% versus 2%, P = 0.0002), cerebral infarction (13% versus 2%, P = 0.039), posterior reversible encephalopathy syndrome (17% versus 3%, P = 0.041) at the acute stage, and of inability to resume normal activities at 6 months (27% versus 0%, P < 0.0001).

Conclusions: In RCVS, women and migrainers seem to be at higher risk of intracranial hemorrhage. Overall, intracranial hemorrhages are frequent in RCVS and are associated with a more severe clinical spectrum.