Reversible cerebral vasoconstriction syndrome (RCVS) is a clinical-radiologic condition characterized by recurrent thunderclap headaches and reversible segmental vasoconstriction of the cerebral arteries and largely affects women of middle age [1], [2], [3], [4]. Although self-limiting, RCVS can lead to severe complications, including ischemic stroke, intracerebral hemorrhage (ICH subarachnoid hemorrhage (SAH), seizures, and cerebral edema, which are associated with disability, long-term neurological deficits, or death, with poor outcomes occurring in 8–13 % of cases and mortality rates ranging from 2 % to 7 % [4], [5], [6], [7]. Despite these risks, factors predicting who develops severe complications and poor clinical outcomes in RCVS remain incompletely understood.

Advanced age and female sex have been disproportionately linked to greater clinical and radiographic severity, as well as poorer outcomes [1], [8], while other studies have identified seizure disorders [4], [9], reversible cerebral edema [4], [6], radiological infarction [5], [7], atrial fibrillation [4], and chronic kidney disease [4] as markers of increased morbidity. Additionally, glucocorticoid treatment has been correlated with clinical, imaging, and angiographic worsening, along with unfavorable discharge outcomes [2], [5]. The role of vasoactive medications such as serotonergic antidepressants in RCVS progression may worsen vasospasm in setting of aneurysmal SAH, however, their role remains uncertain [5], [10].

Despite these reported risk factors, most RCVS studies focus primarily on common triggers, including vasoactive substances (cannabis, Selective Serotonin Reuptake Inhibitors (SSRIs), nasal decongestants) and postpartum status [3], [11], [12], [13], [14], [15], [16]. While these studies document the transient nature and potential for recovery, less attention has been given to characterizing the subgroup of patients who experience persistent neurological deficits, serious complications, or long-term morbidity. By better characterizing this subgroup through an investigation of clinical and demographic factors associated with poor outcomes in RCVS at a Comprehensive Stroke Center (CSC) in Colorado, this study aims to improve the gap in the literature by describing the risk factors and pathophysiological mechanisms driving severe RCVS complications.