🧠 Subarachnoid Hemorrhage (SAH): The Thunderclap Headache You Can’t Miss on the USMLE
Subarachnoid hemorrhage is a neurological emergency caused by arterial bleeding into the subarachnoid space, most commonly due to ruptured berry aneurysms. The USMLE loves this diagnosis because it’s life-threatening but classically described.
USMLE Buzzword: "Worst headache of life" + neck stiffness + photophobia = SAH
🧬 Pathophysiology
Rupture of aneurysm (e.g. circle of Willis) → arterial blood in subarachnoid space
↑ intracranial pressure → headache, vomiting, altered consciousness
Risk of vasospasm, rebleeding, hydrocephalus
🔍 Classic Symptoms
| Symptom | Description |
|---|---|
| Thunderclap headache | Sudden onset, maximal intensity at onset |
| Neck stiffness | Due to meningeal irritation |
| Photophobia | Sensitivity to light |
| Nausea/vomiting | Common with increased ICP |
| Seizure or LOC | May occur with severe bleeds |
| Focal neurologic signs | Due to vasospasm or large aneurysm |
🧪 Diagnostic Workup
| Step | Test | Findings |
|---|---|---|
| 1 | Non-contrast CT head | Hyperdensity in sulci or cisterns |
| 2 | Lumbar puncture | Xanthochromia, elevated opening pressure |
| 3 | CT angiography | Aneurysm localization for repair |
🧠 Always do LP if CT is negative but suspicion remains high
💊 Management Strategy
| Phase | Management |
|---|---|
| Acute | Airway support, control BP <160 mmHg, reverse anticoagulants |
| Prevent rebleed | Neurosurgical clipping or endovascular coiling |
| Prevent vasospasm | Administer nimodipine for 21 days |
| Monitor | ICU care, serial neuro checks, manage hydrocephalus |
📚 Sample USMLE Vignette
A 45-year-old woman with hypertension develops sudden, severe headache and photophobia. CT shows blood in basal cisterns. What’s the next step?
✅ Answer: Neurosurgery consult for aneurysm repair
📲 Call to Action
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