Reversible cerebral vasoconstriction syndrome could be linked to Bálint syndrome

The authors report the case of a 67-year-old woman with reversible cerebral vasoconstriction syndrome (RCVS) who manifested symptoms of Bálint syndrome (simultagnosia, optic ataxia, and ocular apraxia) and visual allochiria in which visual stimuli presented to one hemispace are transposed to the opposite side.

This paper introduces RCVS as a novel cerebrovascular etiology of Bálint syndrome. It is also valuable in that it shows excellent diffusion-weighted imaging (DWI) and apparent diffusion coefficient (ADC) imaging at the time of an acute stroke and how they change with time after an acute ischemic event.

The patient initially presented with a thunderclap headache triggered by Valsalva maneuver and subsequently experienced ischemic strokes in multiple vascular territories. The initial MRI showed an acute infarction of the right parietal-occipital region; DWI and ADC maps confirmed restricted diffusion.

Repeat imaging nine days later revealed bilateral parietal-occipital infarctions consistent with the observed clinical syndrome; DWI remained bright although ADC looked less dark and started showing increases in signal intensity.

A negative vasculitis workup, normal cerebrospinal fluid and rapid clinical-neuroimaging improvement with verapamil are additional features supportive of the diagnosis of RCVS.