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Objective: Factors predicting poor outcome in RCVS are not fully identified.Methods: We retrospectively analyzed clinical, imaging and angiography data in 162 RCVS patients. Uni- and multi-variable analysis were performed to identify predictors of persistent (non-transient) clinical worsening, radiological worsening, early angiographic progression, and poor discharge outcome (modified Rankin Scale score 4-6).Results: The mean age was 44±13 years, 78% women. Persistent clinical worsening occurred in 14% at 6.6±4.1 days after symptom onset; radiological worsening in 27% (mainly new infarcts), and angiographic progression in 15%. Clinical worsening correlated with angiographic progression and new non-hemorrhagic lesions. Age and gender did not independently predict any type of worsening. Infarction on baseline imaging predicted poor outcome. Prior serotonergic antidepressant use predicted clinical and angiographic worsening but not poor outcome. Intra-arterial vasodilator therapy independently predicted clinical worsening and poor discharge outcome but was offered to more severe cases. Glucocorticoid treatment was an independent predictor of clinical worsening (OR 10.2, 95% CI 3.3-31.6) as well as imaging and angiographic worsening and poor discharge outcome. Of N=23 with clinical worsening, 17 received glucocorticoids (15 within prior 2 days - FIGURE). There were no significant differences in baseline brain lesions and angiographic abnormalities between glucocorticoid-treated and untreated patients. Clinical worsening occurred in 37% of 46 treated vs. 5% of 116 not treated (p<0.001); discharge mRS 4-6 occurred in 47% treated vs. 17% not-treated, and 61% of treated patients developed new brain lesions.Conclusion: Worsening in RCVS can be predicted from certain baseline features. Empiric glucocorticoids "until vasculitis is ruled out" is best avoided esp. since RCVS can be accurately diagnosed upon admission using our recent criteria.