Reversible Cerebral Vasoconstriction Syndrome with Spontaneous Spinal Subdural Hemorrhage—a Perplexing Conundrum!!!

A middle aged lady presented with thunderclap headache and vomiting without any deficits on examination. Her cerebral imaging including MR and CT angiogram were normal but lumbar puncture (LP) revealed uniformly blood stained CSF suggestive of SAH. Subsequent spine imaging revealed spontaneous spinal subdural hemorrhages (SSDH) in the dorsal and lumbosacral cord. Coagulopathy and other essential work up was normal. Digital subtraction angiography (DSA) done 3 weeks into ictus revealed extensive cerebral vasospasm with sausage like beaded appearance akin to reversible cerebral vasoconstriction syndrome (RCVS) with normal spinal vasculature. She was treated with Nimodipine for 6 weeks. Her headache improved without any recurrence. Repeat DSA and spine imaging was normal with resolution of both vasospasm and SSDH. Establishing the inciting event in this patient with 2 obvious pathologies, SSDH and possible RCVS, is a perplexing task and forms the central idea of discussion. We made an attempt to resolve this chicken egg paradox, ie, SSDH leading to intracranial vasospasm vs RCVS leading SSDH, by providing rational arguments for both the clinical scenarios. We would also like to highlight the necessity of spinal imaging in patients with thunderclap headache.