Reversible Cerebral Vasoconstriction Syndrome Presenting with Hemorrhage and Delayed Cerebral Abscess: A Rare Clinical Progression

Abstract

We present the case of a 32-year-old woman who developed recurrent thunderclap headaches, initially misattributed to migraine, ultimately diagnosed as reversible cerebral vasoconstriction syndrome (RCVS) based on multifocal arterial narrowing and clinical presentation. Her course was complicated by right occipital intracerebral hemorrhage (ICH) and later by formation of a cerebral abscess at the prior hemorrhagic site. Cultures revealed methicillin-sensitive Staphylococcus aureus without a clear systemic infectious source; dermatologic seeding was suspected. This case highlights two uncommon features: an RCVS-related ICH complicated by abscess formation and the absence of typical infectious risk factors. The pathophysiology was hypothesized to involve hematogenous spread in the context of transient blood-brain barrier disruption following hemorrhage. While RCVS typically has favorable outcomes, this case underscores the importance of maintaining a broad differential diagnosis in patients with evolving symptoms and neuroimaging findings. To our knowledge, this represents a rare instance of spontaneous abscess development at the site of RCVS-related hemorrhage in an immunocompetent individual.