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Subarachnoid hemorrhage (SAH) is a life-threatening neurological emergency characterized by bleeding into the subarachnoid space between the brain and skull. Most cases result from rupture of cerebral aneurysms, though trauma, arteriovenous malformations, and other vascular abnormalities can also cause SAH.
When blood enters the subarachnoid space, it triggers acute inflammation and disrupts normal cerebrospinal fluid circulation, leading to increased intracranial pressure. The presence of blood products causes cerebral vasospasm, typically occurring 3-14 days post-hemorrhage, which can result in delayed cerebral ischemia and secondary brain injury.
Patients typically present with sudden onset of severe headache described as 'the worst headache of my life,' often accompanied by nausea, vomiting, photophobia, and altered mental status. Immediate CT imaging without contrast is the initial diagnostic test, while lumbar puncture may be needed if CT is negative but clinical suspicion remains high, and CT angiography helps identify the bleeding source for surgical planning.