Background: Reversible cerebral vasoconstriction syndrome (RCVS) is defined clinically by headaches associated sometimes with seizures and neurological deficits, and radiologically with intermittent spasms in cerebral arteries that would resolve in 3 months. It can present with multiple bleeding patterns. Intraventricular hemorrhage (IVH) is a rare presentation for RCVS as there are 4 reported cases. Methods: This is a case report and review of literature. Results: A 36-year-old patient sought medical attention due to the acute onset of thunderclap headache. A computed tomography (CT), and CT angiogram (CTA) of his head and neck were done. It showed large IVH associated with hydrocephalus and no underlying vascular abnormalities. An external ventricular drain was placed and he was on nimodipine. A CTA was done on day 17 because he had acute global aphasia, right hemibody weakness, and right homonomous hemianopia, which showed severe diffuse intracranial stenosis involving the circle of Willis. He was taken to the angiography suite for chemical spasmolysis with verapamil. There was radiographic improvement and clinical resolution. Conclusions: This case highlights the rarity of RCVS presentations and further signifies the utility of intraarterial spasmolytics as an adjunct in the diagnosis of difficult cases. Further retrospective and prospective data are needed.