A 13 yo male presents to the ED with vomiting and is minimally responsive.  Per the patient's mother he was lifting weights when he suddenly didn't feel well.  He then had LOC and she observed seizure-like activity.  CT head is shown below.  What's the diagnosis?  Scroll down for answer.

Answer:  Subarachnoid hemorrhage (SAH) 

• Less common in children, but still high on the differential diagnosis of sudden, severe headache
• Primary causes are AVMs and aneuyrsms, other causes include neoplasm, infection, hemophilia, sickle cell and stimulant drug use (cocaine, amphetamines)
• Common presentation: sudden headache, nausea/vomiting, LOC, seizure, cranial nerve palsy (seizure and cranial nerve palsy more common in children)
• SAH of posterior circulation and internal carotid artery aneurysms are more common in children (present earlier in life)
• CT angiogram is used for diagnosis of etiology of SAH
• In consultation with hematology, provide disease specific care for patients with underlying coagulopathy (hemophilia) or sickle cell disease
• Management similar to in adults, see Back to Basics: Subarachnoid Hemorrhage Management
• Treat aggressively.  Even with severe bleeds and dramatic presentations, children tend to have faborable outcomes

Garg, K. (2014). Pediatric intracranial aneurysms--our experience and review of literature. Child's Nervous System, 30(5), 873-83.

Getzoff, M., & Goldstein, B. (1999). Spontaneous subarachnoid hemorrhage in children. Pediatrics in Review, 20(12).