Post-concussion syndrome (PCS) is a recognized condition characterized by a range of persistent physical, cognitive, and emotional symptoms following traumatic brain injury (TBI)1-3. However, accurately diagnosing and managing PCS can be challenging due to overlapping symptomatology and the absence of definitive diagnostic marker1-3.
Reversible cerebral vasoconstriction syndrome (RCVS) is a rare but significant cerebrovascular disorder characterized by transient constriction of cerebral arteries, which can lead to a range of symptoms, from mild headaches to sudden and severe headaches, focal neurological deficits, and, in some cases, ischemic or hemorrhagic strokes4-6. While RCVS and PCS are distinct clinical entities, their symptomatology can overlap, making accurate diagnosis and appropriate management crucial.
The purpose of this case report is to underscore the significance of brain imaging studies in addressing persistent headaches in collision sports. The study protocol was approved by the Institutional Review Board of Myongji Hospital (No. MJH 2023-12-019). Written informed consent and permission to publish the clinical images were obtained from the patient.
A 30-year-old male rugby player presented to the outpatient clinic with recurrent headaches that had occurred since a collision during a game four weeks ago. He has been actively playing rugby since middle school and currently holds the number 8 position in a professional team. Prior to the outpatient visit, the patient had already undergone a non-contrast brain computed tomography (CT) at a local hospital, which did not reveal any evidence of bleeding or abnormalities. However, due to the persistence of headaches, the patient visited our outpatient clinic for further management. When the patient presented to the outpatient clinic, the initial suspicion was PCS, and the examination was initiated accordingly. The headache was described as having a pulsating quality and worsened after engaging in physical activity, running, or Valsalva maneuver, but improved with rest. Sport Concussion Assessment Tool, 5th edition (SCAT5) from the British Journal of Sports Medicine was conducted (Table 1). The patient reported experiencing headaches and showed impairments in both immediate memory and delayed recall domains on assessment, with no other neurological abnormalities observed. However, in order to differentiate any underlying structural issues in the brain, magnetic resonance imaging (MRI) and magnetic resonance angiography (MRA) were conducted (Fig. 1). In the MRI scan, no remarkable findings were observed; however, MRA images revealed multifocal luminal irregularities in the bilateral A2, M2, and basilar arteries. These findings confirmed the presence of RCVS.
Table 1 . Sport Concussion Assessment Tool, 5th edition (SCAT5)
| Domain | Score |
|---|---|
| Total number of symptoms (of 22) | 1 |
| Symptom severity score (of 132) | 4 |
| Orientation (of 5) | 5 |
| Immediate memory | 23 of 30 |
| Concentration (of 5) | 5 |
| Neurologic screen | Normal |
| Balance examination (of 30) | 30 |
| Delayed recall | 7 of 10 |
Fig. 1. Brain magnetic resonance angiography (MRA) images. On the brain MRA image, multifocal mild luminal irregularities (arrows) are observed in both A2 segments, both M2 segments, and the basilar artery region. (A) The right M2 and both A2 segments. (B) The left M2 segment. (C) The basilar artery.
In patients with RCVS, a thunderclap headache is typically experienced, and imaging studies reveal segmental vasoconstriction of cerebral arteries. While there can be variations from case to case, a thunderclap headache may be absent in up to 15% of RCVS patients6.
In the case of this patient, recurrent headaches occurring after trauma and mild impairment of memory were the presenting symptoms. However, the headache pattern did not resemble a thunderclap headache, and the initial brain CT scan did not show any specific findings suggestive of intracranial bleeding or structural issues causing the headache, making it challenging to suspect an organic etiology. Although there were no apparent neurological deficits, the presence of recurring headaches that commenced following the trauma, and their correlation with triggers such as the Valsalva maneuver or exercise, served as indicative markers of secondary headaches7. Eventually, confirmation of RCVS was achieved only after obtaining brain MRA images, highlighting a potential case that could have been misdiagnosed as PCS.
In the case of RCVS, nimodipine or verapamil can be used to address vasoconstriction of cerebral arteries8. Since there is no well-established definitive treatment, symptomatic management is employed, similar to PCS3-5. While most RCVS patients tend to recover without deficits, severe vasoconstriction or, albeit rare, stroke can lead to significant complications9,10. Therefore, patients showing abnormalities in vascular structure should not be overlooked, and follow-up vascular imaging is necessary.
Given that there is no objective diagnostic tool for diagnosing PCS, it can be easily overdiagnosed, especially in under-evaluated sports-related injury patients, particularly in collision sports such as rugby. In patients experiencing posttraumatic headaches in sports, non-contrast brain CT and diffusion MRI images are commonly obtained, but angiography is often omitted. However, when patients present with recurring headaches and signs indicative of vascular or structural disease, such as those triggered by exercise, considering angiography becomes crucial.
No potential conflict of interest relevant to this article was reported.
Conceptualization, Supervision: YKK. Data curation, Formal analysis: JCS. Writing–original draft: JCS. Writing–review & editing: YKK, JCS.
