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A 45-year-old lady presented with a sudden severe headache which occurred when she was hanging out the washing to dry. She collapsed in the garden and then recovered and was able to get inside and alert her husband who called an ambulance. She is holding her head and feels ill. Her GCS is now 15. She is taken for a CT scan of her head which is shown below. Her BP is 170/100 mmHg.
It is a sudden severe headache with maximal intensity within 2 minutes but in reality, one would expect seconds and is usually the worst headache ever experienced. Patients describe it as being hit around the head with a cricket bat. It represents sudden arterial bleeding and supposed meningeal irritation. There are a few causes in the differential but a SAH is almost always the first concern.
It has been thought that some patients may have an earlier headache suggesting a SAH prior to the big one. This has been challenged. It is still in the books and whether it is a myth or real is unclear.
The main cause of subarachnoid haemorrhage is a rupture of a berry aneurysm on branches of the circle of Willis. These are often asymptomatic until they rupture.