A 56-year-old lady presented 3 days following the acute onset of a severe, occipital headache on examination a right homonymous hemianopia was detected. CT imaging showed bilateral intracerebral haematomas in the left tempero-parietal and right occipital lobes. Admission imaging also demonstrated subarachnoid blood in over the right superior cerebral convexities. MR imaging revealed a shallow subdural haemorrhage. Angiography, revealed diffuse changes of alternating constriction and dilatation in arteries of the anterior and posterior circulation. The clinical presentation was consistent with reversible cerebral vasoconstriction syndrome The resolution of the angiographic abnormalities on a follow-up study after an interval of 8 weeks, supported this diagnosis. Our patient presented with recurrent thunderclap headache, a characteristic presentation of the reversible cerebral vasoconstriction syndrome. Angiographic abnormalities in this condition resemble those of CNS vasculitis. In our patient, neuroimaging revealed a multifocal distribution of haemorrhages in the intracerebral, subarachnoid, and subdural compartments. In the published literature cortical subarachnoid haemorrhage is the most frequent haemorrhagic manifestation of this condition, followed by intracerebral haemorrhage. Subdural haemorrhage is a less well reported manifestation occurring in just 2% of patients in the largest case series of reversible cerebral vasoconstriction to date. An awareness of the multiple haemorrhagic presentations of reversible cerebral vasoconstriction syndrome may aid in earlier recognition of this syndrome.
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