Symptoms and Clinical Features of Traumatic Subarachnoid Hemorrhage After Head Injury

Understanding Traumatic Subarachnoid Hemorrhage

Subarachnoid hemorrhage following a head injury, also known as traumatic subarachnoid hemorrhage (tSAH), occurs when bleeding from brain trauma extends into the subarachnoid space—the area between the brain and the thin tissues that cover it. This condition is a serious neurological emergency and can lead to life-threatening complications if not promptly diagnosed and managed. It typically results from direct brain trauma such as falls, accidents, or blunt force impacts to the head.

Common Symptoms Following Head Trauma

Initial signs related to head injury often appear immediately after the impact. These include localized pain at the site of injury, swelling or bruising on the scalp, dizziness, confusion, and mild disorientation. In some cases, patients may experience brief loss of consciousness or feel lightheaded shortly after the incident. While these symptoms might initially seem minor, they can be early indicators of more severe underlying brain damage, especially when they progress or worsen over time.

Key Signs of Subarachnoid Bleeding

One of the hallmark features of tSAH is the sudden onset of an extremely severe headache, often described by patients as "the worst headache of my life." This headache typically develops rapidly during or right after physical activity and tends to intensify progressively. It may affect the entire head or be concentrated in one area, and in some cases, radiates to the upper neck, causing stiffness and discomfort.

Additional neurological symptoms frequently accompany the headache. These include nausea, vomiting, sensitivity to light (photophobia), and blurred vision. Some individuals may also report vertigo or difficulty maintaining balance. The presence of these symptoms should prompt immediate medical evaluation, as they suggest possible bleeding within the central nervous system.

Neurological and Cognitive Complications

A significant number of patients—approximately 25%—develop mental status changes or altered consciousness. These can range from mild confusion and restlessness to severe agitation, delirium, hallucinations, or even coma. Older adults are particularly vulnerable to atypical presentations, where cognitive disturbances may overshadow classic symptoms like headache or neck stiffness.

In more severe cases, the accumulation of blood in the subarachnoid space can trigger cerebral vasospasm, a dangerous narrowing of brain arteries that reduces blood flow and increases the risk of stroke. This complication may result in focal neurological deficits such as facial drooping, slurred speech (aphasia), partial paralysis (hemiparesis), sensory loss, or oculomotor nerve palsy leading to double vision or drooping eyelids.

Seizures and Increased Intracranial Pressure

Although less common, some patients may experience seizure activity—either partial or generalized—due to irritation of the brain tissue by blood products. Additionally, rising intracranial pressure can lead to papilledema (swelling of the optic disc), retinal hemorrhages, or subhyaloid bleeding visible during eye examination, all of which are critical diagnostic clues for clinicians.

Physical Examination Findings

During clinical assessment, healthcare providers often detect meningeal signs such as nuchal rigidity (stiff neck), Brudzinski's sign, or Kernig's sign—indicative of irritation in the meninges surrounding the brain and spinal cord. These physical findings, combined with a history of recent head trauma, strongly support the diagnosis of subarachnoid hemorrhage.

Potential for Severe Outcomes

It's important to note that traumatic subarachnoid hemorrhage does not occur in isolation. Many patients have concomitant brain injuries such as contusions, diffuse axonal injury, or skull fractures. In critical cases, extensive bleeding can lead to brain herniation, respiratory failure, or cardiovascular instability, all of which pose immediate threats to life. Early imaging—typically via non-contrast CT scan—is essential for rapid confirmation and timely intervention.

Given the variability in symptom presentation, especially among elderly patients who may lack typical warning signs, a high index of clinical suspicion is crucial. Prompt recognition and treatment significantly improve outcomes and reduce the risk of long-term disability or death.