Management of Reversible Cerebral Vasoconstriction Syndrome (RCVS) with Leukocytosis

Clinical Features and Diagnosis

Common triggers of RCVS include serotonergic agents, sympathomimetic drugs, marijuana, SSRIs, triptans, and decongestants, according to the American Heart Association guidelines 1
Leukocytosis in RCVS may be a manifestation of the inflammatory response or related to medications used to treat the condition, with a strength of evidence level of moderate 2

Obtain complete blood count to evaluate leukocytosis, and perform inflammatory markers testing (ESR, CRP) to help differentiate from other causes, as recommended by the American Stroke Association 2

Avoid invasive procedures such as central venous catheterization, lumbar puncture, and bronchoscopy during active coagulopathy if present, as advised by the American Society of Hematology 3
Carefully monitor electrolytes and maintain normal ranges if using medications that may affect electrolyte balance, according to the American Society of Hematology guidelines 3

For patients with persistent hypotension, intravenous phenylephrine (1-10 mcg/kg/min) or dopamine (5-15 mcg/kg/min) may be considered, according to the American Heart Association, as published in Circulation 4

The American Heart Association recommends maintaining euvolemia and avoiding prophylactic hemodynamic augmentation, which can cause iatrogenic harm, as stated by the Stroke journal 5
The American Heart Association suggests that for symptomatic vasospasm with neurological deterioration, elevating systolic blood pressure may be reasonable to reduce progression of delayed cerebral ischemia, as stated by the Stroke journal 5
The American Heart Association advises against aggressive blood pressure augmentation as prophylaxis, as stated by the Stroke journal 5
Intra-arterial nimodipine or verapamil can be considered for severe vasospasm with neurological deterioration despite medical management, as stated by the Stroke journal 5
Cerebral angioplasty may be reasonable for severe vasospasm refractory to medical therapy, as stated by the Stroke journal 5