Delayed Progression of Cerebral Infarction Despite Neurological Improvement in Unilateral Reversible Cerebral Vasoconstriction

Previous literatures describing cerebral infarction in Reversible Cerebral Vasoconstriction Syndrome (RCVS) have not address the temporal change of cerebral ischemia in relation to clinical symptoms. A 54-year-old man presented with altered consciousness, aphasia and right hemiparesis. Initially, CT angiography showed diffuse narrowing of left Middle Cerebral Artery (MCA) without any diffusion restriction on brain MRI. Two days after onset, he recovered consciousness and follow-up MRI revealed diffusion restrictions at left frontal and temporal cortices. Five days after onset, aphasia and right hemiparesis improved and MR angiography revealed the restoration of left MCA despite extended lesion at left temporal cortex on T2-weighted MRI. We report the case of a patient with unilateral RCVS who showed initial clinical-MRI mismatch with delayed ischemic change on diffusion-weighted MRI followed by progression of infarction despite neurological improvement. We suggest early augmentation of cerebral blood flow be required in this case.