Nimodipine-refractory reversible cerebral vasoconstriction syndrome treated effectively with verapamil

Abstract

Reversible cerebral vasoconstriction syndrome (RCVS) is characterized by recurrent thunderclap headache and reversible multifocal vasoconstrictions of the cerebral arteries. There are no treatment guidelines despite its potential for precarious outcomes. A 52-year-old woman with recurrent episodes of severe headache was diagnosed with RCVS and treated with oral nimodipine, which has been widely used for RCVS. However, her vessel status worsened despite treatment for several days and only improved after administration of intra-arterial (IA) and per os (PO) verapamil, which has been used to reverse vasoconstrictions in variant angina. Based on this case and literatures, we propose an alternative strategy using verapamil. The presence of a vascular reaction after an IA verapamil challenge during initial digital subtraction angiography can diagnose RCVS while also serving as an emergent treatment. Based on the response to IA verapamil, PO verapamil can be prescribed if there are no contraindications or side effects.