History

  • Sudden and maximal in onset
  • Compared to previous headaches
  • Family history of aneurysm
  • Associated Symptoms
    • Photophobia
    • Visual Changes
    • Neck Stiffness

Exam

  • Full neuro examination
    • Cranial nerves
    • Visual fields
    • Speech
    • Cerebellar (finger-nose)
    • Motor
    • Sensation
    • Gait

Testing Plan

  • Non-contrast head CT
    • Excellent sensitivity <6 hours from onset
  • Lumbar puncture
    • >100 RBCs in tube 4
      • Can be difficult to interpret after a traumatic lumbar puncture
    • Xanthochromia

Treatment Plan

  • Prevent rebleeding
    • Keep SBP <140
      • Nicardipine
    • Reverse any anticoagulants
      • Vitamin K
      • Prothrombin complex concentrate
      • Fresh frozen plasma
  • Prevent vasospasm
    • Nimodipine PO
  • Prevent delayed ischemia
    • Avoid hyperthermia
    • Avoid hyper/hypoglycemia
  • Prevent seizures
    • Levetiracetam (aka Keppra)

Additional Reading