RCVS is a disorder characterized by transient vasoconstriction of the cerebral arteries that resolves spontaneously. It can present with various neurological symptoms and can cause acute ischemic infarcts. Several drugs have been reported as potential RCVS triggers. Axitinib, a tyrosine kinase inhibitor that inhibits angiogenesis, is often combined with pembrolizumab, an immune checkpoint inhibitor, for treating renal cell carcinoma.  Here, we report a case of RCVS potentially associated with Axitinib and Pembrolizumab therapy. 

A 57-year-old man with a history of hypertension, clear cell renal cell carcinoma, and chronic kidney disease presented to the emergency department with double vision, confusion, and bilateral lower extremity weakness. After his cancer diagnosis, the patient was initiated on neoadjuvant therapy with Axitinib and pembrolizumab. He soon developed severe hypertension with systolic blood pressure exceeding 200 mmHg, leading to its discontinuation a week before this presentation. The brain MRI showed bilateral watershed infracts. Both CT angiogram and MR angiogram (MRA) of the head showed diffusely severe stenosis of the intracranial arteries. The MRA of the neck was unremarkable, as was the vasculitis work-up. The patient was discharged on anti-platelets with plans for outpatient neurology follow-up.

Eighteen months after his initial presentation, a repeat CTA of the head during an unrelated admission revealed that the previously stenosed intracranial vessels were now patent.