Quick answer
How should I present a subarachnoid hemorrhage case on rounds?
Open with the sudden, maximal-at-onset headache and its trigger, since the onset pattern is what separates this from a routine headache. Give the meningeal signs and vitals, then the CT findings and the specific aneurysm on angiography before naming aneurysmal subarachnoid hemorrhage as your diagnosis. End with blood-pressure control, vasospasm prevention, and the urgent need to secure the aneurysm.
Before you speak
Define the moment and the information you actually have
An emergency-department presentation immediately after CT and CT angiography confirm the bleed and its source.
The on-call neurosurgery and neurocritical-care team deciding on blood-pressure targets and aneurysm-securing timing.
History, vital signs, a focused neuro and meningeal exam, non-contrast CT, and CT angiography. A lumbar puncture and a full cerebrovascular risk-factor panel are not supplied.
About 90 seconds
Fictional training case: The presentation is locked to the simulated patient JSON. It names important unknowns instead of inventing an examination, vital signs, allergies, or tests.
Complete spoken example
First, read it once without stopping
The paragraph breaks show the clinical shape. In a real presentation, pause briefly between ideas rather than announcing the headings.
Ms. Baker is a 52-year-old woman with hypertension and a heavy smoking history who presents with a sudden, explosive headache reaching maximum intensity while straining three hours ago.
She describes it as being struck in the back of the head and rates it 10 out of 10, with two episodes of vomiting, photophobia, and brief confusion. She is terrified because her mother died of a brain aneurysm.
Her history includes hypertension, treated with lisinopril but taken inconsistently, and a 30-pack-year smoking history; she continues to smoke and works as a retail supervisor.
Her vitals showed a heart rate of 94, blood pressure 185 over 104, and temperature 37. She is lethargic but oriented, with marked nuchal rigidity and positive Kernig and Brudzinski signs. Non-contrast CT shows subarachnoid blood filling the basal cisterns and both Sylvian fissures, and CT angiography confirms a 7 millimeter anterior communicating artery aneurysm with an irregular bleb.
My leading diagnosis is aneurysmal subarachnoid hemorrhage from a ruptured anterior communicating artery aneurysm, based on the thunderclap onset, meningeal signs, and the CT and CT angiography findings together.
I would admit her to neurocritical care, control blood pressure with a continuous IV infusion to reduce rebleeding risk before the aneurysm is secured, and start oral nimodipine to reduce the risk of delayed vasospasm. I would obtain urgent neurosurgical and interventional-neuroradiology consultation for coiling or clipping within 24 hours, watching closely for any decline in consciousness that could signal rebleeding.
Build the presentation
Give every sentence one job
A presentation is a compressed clinical argument, not a chart read aloud. These six moves keep the facts connected to your reasoning.
Opening one-liner
Make the thunderclap onset audible immediately
“Ms. Baker is a 52-year-old woman with hypertension and a heavy smoking history who presents with a sudden, explosive headache reaching maximum intensity while straining three hours ago.”
Why it belongs: The instantaneous, maximal-at-onset quality and the straining trigger are the features that separate a thunderclap headache from a routine one and demand urgent imaging.
This is a 52-year-old with a bad headache since this morning.
Ms. Baker is a 52-year-old woman who presents with a sudden, explosive headache reaching maximum intensity while straining three hours ago.
Why: Describing the onset pattern, not just severity, is what should trigger urgent evaluation for hemorrhage.
History of present illness
Give the meningeal and family-history features
“She describes it as being struck in the back of the head and rates it 10 out of 10, with two episodes of vomiting, photophobia, and brief confusion. She is terrified because her mother died of a brain aneurysm.”
Why it belongs: Vomiting, photophobia, and confusion support meningeal irritation and raised intracranial pressure, and the family history of aneurysm is a genuine risk factor worth naming.
She has a severe headache with some nausea.
She describes the headache as instantaneous and 10 out of 10, with vomiting, photophobia, and brief confusion.
Why: The specific descriptors carry more diagnostic weight than 'severe' alone.
Relevant background
Name the vascular risk factors
“Her history includes hypertension, treated with lisinopril but taken inconsistently, and a 30-pack-year smoking history; she continues to smoke and works as a retail supervisor.”
Why it belongs: Hypertension and smoking are the two most modifiable risk factors for aneurysm rupture and are relevant to both acute blood-pressure targets and long-term counseling.
She has high blood pressure and smokes.
She has hypertension, taken inconsistently, and a 30-pack-year smoking history, and continues to smoke.
Why: Naming adherence and pack-years gives the listener more to act on than a bare list of conditions.
Objective data
State vitals, the meningeal exam, and the imaging findings
“Her vitals showed a heart rate of 94, blood pressure 185 over 104, and temperature 37. She is lethargic but oriented, with marked nuchal rigidity and positive Kernig and Brudzinski signs. Non-contrast CT shows subarachnoid blood filling the basal cisterns and both Sylvian fissures, and CT angiography confirms a 7 millimeter anterior communicating artery aneurysm with an irregular bleb.”
Why it belongs: The elevated blood pressure needs immediate control, the meningeal signs support the clinical diagnosis, and the CT angiography identifies the exact aneurysm that will need to be secured.
Her CT showed bleeding and a brain aneurysm.
Non-contrast CT shows subarachnoid blood in the basal cisterns and both Sylvian fissures, and CT angiography confirms a 7 millimeter anterior communicating artery aneurysm.
Why: Naming the exact distribution and aneurysm size and location tells the neurosurgical team precisely what they are treating.
Assessment
Commit to the diagnosis and its source
“My leading diagnosis is aneurysmal subarachnoid hemorrhage from a ruptured anterior communicating artery aneurysm, based on the thunderclap onset, meningeal signs, and the CT and CT angiography findings together.”
Why it belongs: The assessment names the specific bleed and its source vessel, connecting the clinical picture directly to the imaging rather than restating the symptoms.
This is a brain bleed from an aneurysm.
My leading diagnosis is aneurysmal subarachnoid hemorrhage from a ruptured anterior communicating artery aneurysm.
Why: Naming the specific vessel matches how the neurosurgical team will discuss securing it.
Plan
Prioritize blood-pressure control and urgent aneurysm securing
“I would admit her to neurocritical care, control blood pressure with a continuous IV infusion to reduce rebleeding risk before the aneurysm is secured, and start oral nimodipine to reduce the risk of delayed vasospasm. I would obtain urgent neurosurgical and interventional-neuroradiology consultation for coiling or clipping within 24 hours, watching closely for any decline in consciousness that could signal rebleeding.”
Why it belongs: Blood-pressure control and urgent aneurysm securing address the immediate rebleeding risk, while starting nimodipine addresses the delayed vasospasm risk that follows in the coming days.
I'll control her blood pressure and get neurosurgery involved.
I would control blood pressure with a continuous infusion, start nimodipine for vasospasm prevention, and get urgent neurosurgical input for securing the aneurysm within 24 hours.
Why: Naming both the immediate and delayed risks shows a more complete management plan.
Do not fill the blanks
Say what has not yet been established
Real presentations often happen before the chart is complete. A brief, explicit limitation is safer and more credible than a polished invention.
Lumbar puncture and CSF analysis
Say: “A lumbar puncture is not part of this simulation and is not needed here since CT already confirmed the hemorrhage; I would only consider it if CT were negative and suspicion remained high.”
Ordering an unnecessary test should not be presented as routine once imaging is diagnostic.
Full cerebrovascular risk-factor panel
Say: “A lipid panel and coagulation studies are not documented in this simulation and would still need to be obtained before any procedural planning.”
Coagulation status matters before any invasive securing procedure.
Clinical compression
What leads, what stays, and what can wait?
| Source detail | Decision | Reason |
|---|---|---|
| Instantaneous, maximal-at-onset headache while straining | Lead | This onset pattern is the single most important historical clue for subarachnoid hemorrhage. |
| Family history of fatal brain aneurysm | Include | A first-degree relative with a ruptured aneurysm is a genuine risk factor and explains her fear. |
| Retail supervisor occupation | Omit | Occupation does not change the acute neurosurgical management. |
| Inconsistent lisinopril adherence and continued smoking | Include | These modifiable risk factors are relevant to both acute blood-pressure control and future prevention. |
| CT angiography showing a 7 millimeter aneurysm with an irregular bleb | Lead | The irregular bleb suggests a higher rupture and rebleed risk and shapes the urgency of securing it. |
After the presentation
Likely attending questions
Answer the question first, then give the evidence. If the source case does not contain the answer, say what you would verify.
Why not just lower her blood pressure to normal right away?
Blood pressure is lowered to reduce rebleeding risk while preserving enough cerebral perfusion, using a controlled continuous infusion rather than a rapid drop to a normal reading; the exact target should follow local protocol and her clinical trajectory.
Why start nimodipine now if vasospasm is a delayed risk?
Delayed cerebral vasospasm typically develops days after the bleed, and nimodipine is started early and continued for about three weeks because its protective effect depends on being on board before vasospasm develops.
What would make you worry about rebleeding right now?
Any decline in her level of consciousness or a new neurologic deficit would raise urgent concern for rebleeding or hydrocephalus and would need immediate repeat imaging.
Self-check
A 30-second check before you present
- Describe the headache onset as sudden and maximal, not just 'severe.'
- Name the trigger and exact time since onset.
- Report meningeal signs and vitals before the imaging.
- Give the exact CT distribution and the aneurysm's size, location, and shape.
- State the leading diagnosis and its source vessel together.
- Name blood-pressure control and vasospasm prevention as separate priorities.
- State the urgency and timeframe for securing the aneurysm.
- Flag any decline in consciousness as a rebleeding emergency.
Common presentation problems
Repair the habits that make a case hard to follow
Calling this 'the worst headache' without describing the onset speed
Repair: State that it reached maximum intensity instantaneously, which is the key discriminating feature.
Treating blood-pressure control and vasospasm prevention as the same step
Repair: Name them as two separate priorities with different timeframes.
Ordering a lumbar puncture reflexively after a positive CT
Repair: State that LP is reserved for when CT is negative and suspicion remains high.
Delaying neurosurgical consultation while awaiting more tests
Repair: Say that neurosurgery and interventional radiology are contacted urgently once the aneurysm is confirmed.
Frequently asked questions
Oral case presentation questions
Do I need to name coiling versus clipping in the initial presentation?
State that both are being considered by the specialist team; the specific choice depends on aneurysm anatomy and institutional expertise, which are not yet determined at this point in the presentation.
Should I mention the Hunt and Hess or modified Fisher grade?
Yes if your program expects it, since these grades communicate severity concisely to the receiving team; state the exam findings that support the grade rather than the grade alone.
How long should this presentation be?
This worked example targets about 90 seconds. A rapidly declining patient may need an even shorter initial alert, with details filling in as the team assembles.
Practice out loud
Turn the patient encounter into your own presentation
Bedside English lets you interview an AI patient, then practice presenting the collected case to an AI attending and respond to follow-up questions.
Editorial record
Sources, provenance, and review boundary
The patient facts come from simulated case ns_002. Clinical framing and presentation design were checked against the sources below. This page teaches clinical communication and reasoning; it is not medical advice or a local protocol.
- 2023 AHA/ASA Guideline for the Management of Patients With Aneurysmal Subarachnoid HemorrhageAmerican Heart Association / American Stroke Association · accessed 2026-09-03
- Feedback on Oral Presentations during RoundsStanford Medicine · accessed 2026-09-03
- Clinical Teaching Tools: OMP and SNAPPSUCSF Medical Education · accessed 2026-09-03
Published: · Last source, safety, and language review: