Three years of RCVS and PRES cases at a single comprehensive stroke center: observations on clinical presentation, headache features, triggers, and management
- 1Department of Neurology, University of California, Davis
- 2Department of Neurology, Barrow Neurological Institute, St. Joseph’s Hospital and Medical Center
- 3Creighton University
Abstract
Introduction: Reversible cerebral vasoconstriction syndrome (RCVS) and posterior reversible encephalopathy syndrome (PRES) are rare neurovascular disorders requiring further investigation into their characteristics.
Methods: We retrospectively reviewed and compared inpatient RCVS and PRES cases over a 3-year period, collecting data on demographics, medical history (including migraine), clinical presentation, diagnostics (urine drug screening and imaging), length of stay, time to diagnosis, suspected triggers (including substances), complications, and treatment.
Results: The sample consisted of 21 PRES and 9 RCVS cases ( n = 30). Migraine ( n = 5/9, 56%) and chronic pain ( n = 4/9, 44%) were the predominant comorbidities in the RCVS group, whereas hypertension ( n = 17/21, 81%) and chronic kidney disease ( n = 8/21, 38%) were the predominant comorbidities in the PRES group. All individuals with RCVS presented with headache ( n = 9/9, 100%), specifically thunderclap headache ( n = 8/9, 89%), followed by headache that was different from their usual migraine, positional headache, and new migraine. PRES commonly presented with altered mental status ( n = 15/21, 71%) and focal neurologic deficits ( n = 10/21, 48%). Initial neurologic examination findings demonstrated a similar pattern, with altered mental status ( n = 18/21, 86%) being common in PRES. Urine drug screening was completed for the majority of the RCVS group ( n = 6/9, 67%) and half of the PRES group ( n = 11/21, 52%). Of those tested in the RCVS group, n = 4/6 (67%) were positive for THC. The primary imaging modality was a CT angiogram (CTA) for RCVS ( n = 9/9, 100%) and magnetic resonance imaging (MRI) for PRES ( n = 18/21, 86%). Patients with PRES had a shorter median time to diagnosis (1 day [IQR 1–2] vs. 3 days [IQR 2–4] for RCVS) and a longer median length of stay (5 days [IQR 3–9] vs. 1 day [IQR 1–2] for RCVS). The most common physician-identified triggers were THC for RCVS ( n = 7/9, 78%) and hypertension for PRES ( n = 15/21, 71%). For PRES, the most common complications were seizures ( n = 10/21, 48%) and respiratory failure ( n = 4/21, 19%), while there were no complications in the RCVS group. The majority of patients with RCVS were treated with verapamil ( n = 8/9, 89% of the RCVS group). For PRES, treatment with blood pressure control ( n = 20/21, 95%) and antiseizure medication ( n = 7/21, 33%) was most common.
Discussion: RCVS cases were more frequent in individuals with migraine presenting with thunderclap headache, with THC as the primary identified trigger. PRES cases were characterized by altered mental status, a hypertension trigger, faster diagnosis, longer lengths of stay, and more complications.
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BibTeX
@article{ahmad2026three,
title = {{Three years of RCVS and PRES cases at a single comprehensive stroke center: observations on clinical presentation, headache features, triggers, and management}},
author = {Sarah R. Ahmad and Sai Alekha Challa and Lauren Suh and Supreet Kaur},
journal = {Frontiers in Neurology},
year = {2026},
month = nov,
doi = {10.3389/fneur.2026.1870218},
url = {https://www.frontiersin.org/articles/10.3389/fneur.2026.1870218/full},
note = {CC BY 4.0},
}
RIS
TY - JOUR
TI - Three years of RCVS and PRES cases at a single comprehensive stroke center: observations on clinical presentation, headache features, triggers, and management
AU - Sarah R. Ahmad
AU - Sai Alekha Challa
AU - Lauren Suh
AU - Supreet Kaur
PY - 2026
DA - 2026/11/02
JO - Frontiers in Neurology
DO - 10.3389/fneur.2026.1870218
UR - https://www.frontiersin.org/articles/10.3389/fneur.2026.1870218/full
AB - Introduction: Reversible cerebral vasoconstriction syndrome (RCVS) and posterior reversible encephalopathy syndrome (PRES) are rare neurovascular disorders requiring further investigation into their characteristics. Methods: We retrospectively reviewed and compared inpatient RCVS and PRES cases over a 3-year period, collecting data on demographics, medical history (including migraine), clinical presentation, diagnostics (urine drug screening and imaging), length of stay, time to diagnosis, suspected triggers (including substances), complications, and treatment. Results: The sample consisted of 21 PRES and 9 RCVS cases ( n = 30). Migraine ( n = 5/9, 56%) and chronic pain ( n = 4/9, 44%) were the predominant comorbidities in the RCVS group, whereas hypertension ( n = 17/21, 81%) and chronic kidney disease ( n = 8/21, 38%) were the predominant comorbidities in the PRES group. All individuals with RCVS presented with headache ( n = 9/9, 100%), specifically thunderclap headache ( n = 8/9, 89%), followed by headache that was different from their usual migraine, positional headache, and new migraine. PRES commonly presented with altered mental status ( n = 15/21, 71%) and focal neurologic deficits ( n = 10/21, 48%). Initial neurologic examination findings demonstrated a similar pattern, with altered mental status ( n = 18/21, 86%) being common in PRES. Urine drug screening was completed for the majority of the RCVS group ( n = 6/9, 67%) and half of the PRES group ( n = 11/21, 52%). Of those tested in the RCVS group, n = 4/6 (67%) were positive for THC. The primary imaging modality was a CT angiogram (CTA) for RCVS ( n = 9/9, 100%) and magnetic resonance imaging (MRI) for PRES ( n = 18/21, 86%). Patients with PRES had a shorter median time to diagnosis (1 day [IQR 1–2] vs. 3 days [IQR 2–4] for RCVS) and a longer median length of stay (5 days [IQR 3–9] vs. 1 day [IQR 1–2] for RCVS). The most common physician-identified triggers were THC for RCVS ( n = 7/9, 78%) and hypertension for PRES ( n = 15/21, 71%). For PRES, the most common complications were seizures ( n = 10/21, 48%) and respiratory failure ( n = 4/21, 19%), while there were no complications in the RCVS group. The majority of patients with RCVS were treated with verapamil ( n = 8/9, 89% of the RCVS group). For PRES, treatment with blood pressure control ( n = 20/21, 95%) and antiseizure medication ( n = 7/21, 33%) was most common. Discussion: RCVS cases were more frequent in individuals with migraine presenting with thunderclap headache, with THC as the primary identified trigger. PRES cases were characterized by altered mental status, a hypertension trigger, faster diagnosis, longer lengths of stay, and more complications.
SN - 1664-2295
ER -