Severe Reversible Cerebral Vasospasm Syndrome Successfully Treated with Balloon Angioplasty and Intra-Arterial Nicardipine Infusion: A Case Report

Objective: Reversible cerebral vasospasm syndrome (RCVS) is characterized by multiple reversible convulsions of the cerebral arteries, accompanied by recurrent, thunderclap-like headaches. The prognosis of most patients is favorable; however, extensive cerebral infarction may result in significant disability or mortality in approximately 5% of cases. Endovascular treatment may be a therapeutic option for patients who do not respond to medical therapy. However, there is a paucity of detailed studies addressing this procedure. Case Presentation: A 33-year-old woman presented with severe headache and elevated blood pressure during parturition, resulting in a decreased level of consciousness for 2 days postpartum. Head imaging revealed an intracerebral hemorrhage in the right caudate head nucleus and severe multiple stenoses of the cerebral vessels, leading to a diagnosis of RCVS. Despite treatment with verapamil and magnesium, complete paralysis of both lower limbs, the right upper limb, and aphasia developed on postpartum day 8 (day P8). Nicardipine was injected into the bilateral internal carotid arteries (ICAs) and vertebral arteries, and balloon angioplasty was performed at the tips of the bilateral ICA. Symptoms recurred, and the same nicardipine injection was administered on days P9 and P10. Vasoconstriction gradually improved, no major cerebral infarction occurred, and the patient was able to walk (modified Rankin Scale score, 1) by day P90. Conclusion: Despite medical treatment, there are cases of extensive cerebral infarction due to strong vasoconstriction, and the postpartum period is a risk factor. Endovascular treatment is an effective option for severe RCVS.