Medical Case Details:
A 34-year-old male with no known comorbidities presented to the emergency department with sudden onset severe headache of two hours duration. He described it as the “worst headache of my life,” with pain reaching maximum intensity within seconds while straining during weightlifting at the gym.
The headache was occipital in location, non-throbbing, and associated with nausea and one episode of vomiting. Initially, there was no photophobia, but photophobia and neck stiffness developed within the next 30 minutes. There was no history of fever, loss of consciousness, focal neurological deficits, migraines, or similar previous episodes.
Family history revealed that his father had an intracranial aneurysm requiring surgery at the age of 52 years. The patient was not on any medications and had no known drug allergies.
On examination, he was alert and oriented with a GCS of 15/15. Blood pressure was 158/96 mmHg, pulse rate was 92/min, temperature was 37.1°C, and oxygen saturation was 99% on room air. Neck rigidity was present, along with positive Kernig’s and Brudzinski’s signs. Fundoscopy showed no papilledema, and cranial nerve, motor, and sensory examinations were normal.
Non-contrast CT brain performed within three hours of symptom onset did not reveal obvious hemorrhage. Lumbar puncture done six hours later showed xanthochromia, non-clearing RBCs between tube 1 and tube 4, and elevated opening pressure of 28 cmH?O. CBC, renal function tests, liver function tests, and coagulation profile were within normal limits.
A diagnosis of subarachnoid hemorrhage secondary to suspected ruptured intracranial aneurysm was considered. The patient was managed with bed rest, head elevation, IV nimodipine for vasospasm prophylaxis, and IV labetalol for blood pressure control.