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Diagnosis of reversible cerebral vasoconstriction syndrome (RCVS) is currently based on luminographic findings of vasoconstriction. In addition to vasoconstriction, the blood–brain barrier (BBB) breakdown has been postulated as a central mechanism of RCVS. Our aim was to document BBB breakdown in patients with RCVS and its role for the pathophysiology‐based diagnosis of RCVS.

We prospectively recruited 72 consecutive patients with thunderclap headache who did not have aneurysmal subarachnoid hemorrhage from April 2015 to July 2016 at the Samsung Medical Center. Based on the International Classification of Headache Disorders–3 beta criteria and neuroimaging, patients were classified as having RCVS (n = 41; “definite” in 29 imaging‐proven patients and “probable” in 12 imaging‐negative patients), other secondary causes (n = 7), and thunderclap headache of …