Reversible Postpartum Cerebral Vasoconstriction Syndrome

I read with great interest the article “Fulminant Postpartum Cerebral Vasoconstriction Syndrome” by Fugate et al.¹ As a headache specialist who is starting to diagnose reversible cerebral vasoconstriction syndrome (RCVS) in a larger number of my patients who present with recurrent thunderclap headaches, I feel it is very important to understand the natural history of this newly recognized condition. There are data to suggest that RCVS may not be a self-limited syndrome but may persist for a year or more in certain individuals;² now we have the article by Fugate et al¹ that suggests the syndrome may even lead to death. As the 4 presented cases seem to be outliers, I was wondering whether the authors could determine any predisposing factors for fulminant postpartum RCVS? As migraine appears to be a risk factor for this condition,³ I note that only 1 patient was known to have a history of migraine. Did any further investigation determine whether the other patients had a migraine history? In those with migraine, did any have active migraine during their pregnancy especially frequent attacks in their third trimester? Is it possible that active migraine during pregnancy could predispose to the development of RCVS, and frequent migraine around the time of delivery could lead to fulminant postpartum RCVS? In regard to procedures at the time of delivery, if epidurals were completed, is it possible that a resulting state of intracranial hypotension from a cerebrospinal fluid leak could have in some manner reduced the threshold for excessive arterial vasoconstriction and fatal RCVS? The article did not state whether brain magnetic resonance imaging with gadolinium was completed in all patients, but if these studies were done, did any patients demonstrate the neuroimaging findings (pachymeningeal enhancement or tonsillar descent) suggestive of a postprocedural cerebrospinal fluid leak?