Subarachnoid Hemorrhage: Recognizing Symptoms and Understanding Warning Signs

Subarachnoid hemorrhage (SAH) is a life-threatening form of stroke that occurs when bleeding happens in the space between the brain and the surrounding membrane. Early detection and prompt medical intervention are crucial for improving outcomes. While some patients may experience subtle warning signs, most present with sudden and severe symptoms. This article outlines the key clinical features of SAH, including early indicators, primary manifestations, and associated neurological deficits.

Common Symptoms of Subarachnoid Hemorrhage

The hallmark symptom of subarachnoid hemorrhage is a sudden, intense headache—often described as "the worst headache of my life." This abrupt onset headache typically peaks within seconds to minutes and differs significantly from any previous headaches the individual may have experienced. In younger and middle-aged adults, headache is the dominant presenting feature. However, in older patients, headache may be less prominent, occurring in only about 50% of cases. The pain is usually localized to the frontal or occipital regions and can persist for up to one to two weeks before gradually subsiding.

Nausea and Vomiting: A Frequent Companion Symptom

Alongside severe headache, many patients experience nausea and repeated vomiting. This reaction is primarily triggered by the presence of blood irritating the meninges—the protective layers surrounding the brain. Unlike typical gastrointestinal upset, this vomiting is sudden, forceful, and not related to food intake. Its occurrence alongside a thunderclap headache should raise immediate suspicion of a neurological emergency such as SAH.

Neck Stiffness and Meningeal Irritation

One of the most telling physical signs of subarachnoid hemorrhage is nuchal rigidity, or neck stiffness. This results from blood entering the subarachnoid space and irritating the meninges, leading the body to reflexively resist neck flexion. In addition to neck stiffness, clinicians often assess for positive Brudzinski's and Kernig's signs—classic neurological markers of meningeal irritation. These signs typically remain present throughout the acute phase, lasting approximately three to four weeks, and gradually resolve as the blood is reabsorbed by the body.

Altered Mental Status: A Sign of Severe Bleeding

Impaired consciousness—including confusion, drowsiness, or even loss of consciousness—is a red flag indicating a more extensive hemorrhage. When a patient presents with altered mental status, it suggests increased intracranial pressure or significant disruption of brain function due to the bleed. This condition demands urgent evaluation, often involving neuroimaging such as CT angiography or cerebral angiogram, to identify the source of bleeding—most commonly a ruptured aneurysm—and initiate timely treatment, which may include surgical clipping or endovascular coiling.

Focal Neurological Deficits Based on Bleed Location

Depending on the region of the brain affected, subarachnoid hemorrhage can lead to specific neurological impairments. For example, if the bleeding involves the motor cortex, patients may develop hemiparesis—weakness or paralysis on one side of the body. Involvement of the frontal lobes can result in cognitive changes, personality shifts, or psychiatric-like symptoms such as agitation or apathy. These focal signs help clinicians localize the area of injury and guide further diagnostic and therapeutic strategies.