Signs and Symptoms of Pediatric Subarachnoid Hemorrhage: What Parents Need to Know

Subarachnoid hemorrhage (SAH) is a serious type of hemorrhagic cerebrovascular event that can affect children, though it is relatively rare in pediatric populations. It occurs when blood leaks into the subarachnoid space—the area between the brain and the tissues that cover it. SAH is categorized into two main types: primary and secondary. Primary subarachnoid hemorrhage, also known as spontaneous SAH, typically results from the rupture of blood vessels on the surface of the brain or at the base of the brain, often due to congenital aneurysms or vascular malformations.

Understanding Primary vs. Secondary Causes

Secondary subarachnoid hemorrhage arises when bleeding originates elsewhere—such as within brain tissue (intracerebral hemorrhage), in the ventricles (intraventricular hemorrhage), or from traumatic injuries like subdural or epidural bleeds—and then spreads into the subarachnoid space. This distinction is crucial for accurate diagnosis and treatment planning. In infants and young children, secondary causes may be linked to birth trauma, coagulation disorders, or head injuries from accidents.

Common Clinical Presentation in Children

The hallmark symptom of subarachnoid hemorrhage in pediatric patients is a sudden, severe headache—often described as "the worst headache ever"—accompanied by nausea and vomiting. However, younger children may not be able to verbalize headache pain, so clinicians must rely on behavioral cues such as irritability, lethargy, or inconsolable crying. Other key signs include:

• Meningeal irritation signs (e.g., neck stiffness, photophobia, positive Brudzinski's or Kernig's sign)
• Sudden loss of consciousness or altered mental status
• Seizures, especially in those with prior epilepsy history
• Vomiting without gastrointestinal cause

Triggers and Risk Factors in Pediatric Cases

While SAH can occur at any age, certain activities may trigger an event in predisposed children. Episodes have been reported during or after intense physical exertion, such as heavy lifting, straining, or vigorous play that involves rapid bending or impact. Surprisingly, some cases occur during sleep, suggesting that hemodynamic changes during rest cycles might contribute to vessel rupture. Additionally, there are documented instances where children remain asymptomatic for years despite underlying vascular anomalies, only presenting symptoms following a catastrophic bleed.

Children with a history of seizures or chronic headaches may be at higher risk, warranting closer neurological monitoring. Genetic conditions like Ehlers-Danlos syndrome, polycystic kidney disease, or connective tissue disorders can also increase vulnerability to vascular fragility and should be considered during evaluation.

Potential Long-Term Complications

Even with prompt medical intervention, pediatric subarachnoid hemorrhage can lead to lasting neurological deficits. The severity of outcomes depends heavily on the rate and volume of bleeding. Possible long-term consequences include:

• Motor impairments, such as hemiparesis or coordination difficulties
• Cranial nerve dysfunction affecting vision, facial movement, or swallowing
• Cognitive delays or learning disabilities
• Post-hemorrhagic hydrocephalus requiring shunt placement

Early detection and management are critical to improving prognosis. Diagnostic tools such as non-contrast CT scans, lumbar puncture (revealing xanthochromia or bloody cerebrospinal fluid), and cerebral angiography play vital roles in confirming the diagnosis and identifying the source of bleeding.

Conclusion: Awareness Saves Lives

Although subarachnoid hemorrhage is uncommon in children, its sudden onset and potentially devastating effects demand awareness among parents, caregivers, and healthcare providers. Recognizing subtle symptoms, understanding risk factors, and seeking immediate care can make a significant difference in recovery outcomes. If your child experiences unexplained neurological symptoms—especially sudden behavioral changes, persistent vomiting, or seizure activity—it's essential to seek emergency evaluation without delay.