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Initial angiographic imaging may be normal in the first 4 to 5 days of symptoms, which may be due to early involvement of small peripheral arterioles with progression proximally over time to involve the medium and larger arteries that are more easily visualized on imaging. Vascular imaging demonstrates segmental narrowing in multiple intracranial vessels. Subarachnoid or lobar hemorrhage, infarcts, and cerebral edema can occur with RCVS. Associated neurological deficits may or may not be present. Reversible cerebrovascular vasoconstriction syndromes are a group of conditions characterized by multifocal vascular narrowing and a clinical presentation of a sudden, severe headache. MR angiogram demonstrated multifocal segmental arterial narrowing involving the posterior cerebral arteries and superior cerebellar arteries, as well as the middle cerebral arteries ( Fig. Magnetic resonance imaging (MRI) brain revealed a focal acute infarct in the right cerebellar hemisphere and focal cortical edema along the right frontal convexity ( Fig.
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He received normal saline bolus, morphine, and divalproex sodium, which improved his pain to 5/10. He had no lateralizing symptoms or cerebellar signs on physical examination. He presented to the pediatric ED with a severe (10/10) bandlike headache described as the worst of his life. The headache improved but persisted, and 6 days after the initial ingestion, worsened with the development of nausea and vomiting. The following day, he again presented for headache to his pediatrician who diagnosed him with migraines and started prochlorperazine and diclofenac. Computed tomography head only showed sinus opacification, and he was discharged home on antibiotics for presumed sinusitis. After reading an article on the Internet about a case of thunderclap headache after ingestion of these peppers, he became concerned and presented to the emergency department (ED). His blood pressure at home was elevated at 167/95. Two days later, he developed an acute headache during football practice, which did not improve with acetaminophen. A 15-year-old healthy male ingested a Carolina Reaper pepper on a dare.