Tandem occlusions (TOs)-concurrent extracranial large artery steno-occlusion and intracranial artery occlusion-represent a challenging clinical predicament. Stroke due to TOs is associated with high mortality and morbidity. Because of increased clot burden compared with single occlusions and impaired anterograde flow, intravenous thrombolysis may be less effective, and outcomes are poor without timely intervention. Endovascular thrombectomy (EVT) has become the cornerstone of intracranial revascularization, but the optimal management of the extracranial carotid lesion remains undefined. Evidence from observational studies and early-phase randomized controlled trials (RCTs) is mixed. Currently, no standardized treatment approach is widely accepted, and practice patterns are guided by personal preference and expert opinion. Ongoing RCTs seek to determine whether there is an optimal approach to EVT in the setting of TO with respect to (a) technique and (b) the order of treatment. Even on completion of active RCTs, a dearth of evidence will remain on the optimal antithrombotic therapy, exact device selection, and EVT in dissection-associated TOs and posterior circulation TOs. In the present narrative review, we critically appraise the literature on the endovascular management of TOs and offer considerations for practice that may help to reduce the burden of tandem occlusion strokes.

Abstract Background and aims The burden of young adult stroke (YAS) is increasing and existing research efforts are often fragmented, lack the inclusion of lower resourced settings, and are rarely tailored to the distinct aetiologies and life-stage priorities of young adults. The Global Young Adult Stroke Research Alliance aims to maximise impact of research in the area by maximising the relevance, quality and support for YAS research as well as the capacity of those doing the research. We aimed to develop a prioritised list of actions to achieve these objectives. Methods The multinational and multidisciplinary founding committee of the Global YAS Research Alliance identified the potential actions using Value Focused Thinking. Members of the Global YAS Research Alliance met to discuss and rank the actions in order of priority. Data were analysed using the graph theory based ranking approach to identify a prioritised list of actions for the Alliance. Results Researchers, multidisciplinary clinicians and people with lived experience of stroke met in-person (Helsinki 2025) or online (June 2025). Thirty-four attendees anonymously ranked the objectives producing. The top 3 ranked objective included: Conclusions Global collaborative effort is needed to maximise the impact of young adult stroke research to support better outcomes and prevention. Current top-ranked priorities include consensus of research priorities, characterising unmet need and recommendations for outcome measurement. Conflict of interest ERM declares equity in Hydro Functional Pty Ltd and has received Honoraria from Methinks, Moleac, and a CIHR 2024 Catalyst Grant #SCT-191292. The remaining authors have nothing to disclose.

Abstract Background and aims Idiopathic isolated extra-cranial internal carotid artery vasospasm (iiecICAV) is a rare syndrome marked by spontaneous, segmental, and reversible vasoconstriction of the cervical ICA. Additional clinical, imaging, and laboratory data are needed to refine diagnosis and guide treatment. Methods We report five new cases of iiecICAV and conducted a PRISMA-compliant systematic review using PubMed, Google Scholar, and Web of Science (keywords: “carotid” AND “vasospasm” OR “spasm” OR “vasoconstriction” OR “constriction”). Forty cases were identified; protocol registered in PROSPERO (CRD42024605271). Results Among 45 cases (65% female), median age at symptom onset was 27 years (Interquartile Range-IQR: 16). Disease remained unilateral in 18%; others had bilateral or alternating vasospasms. Median follow-up was 2 years (IQR: 4), with a median of 5 recurrences (IQR: 14). Good functional outcome (modified Rankin Scale <3) was achieved in 90%. Medical therapies including antiplatelets (81%), anticoagulants (47%), glucocorticoids (27%), calcium channel blockers (66%) did not significantly alter recurrence or outcome. Invasive treatments were used in 60%, including ICA stenting (11), intra-arterial vasodilators (6), angioplasty (4), and stellate ganglion blockade (5). Recurrences ceased in 6 of 11 patients after ICA bifurcation stenting. In five patients with continued attacks, vasoconstriction occurred in the unstented subpetrosal ICA; targeted stenting in three led to complete resolution. Conclusions iiecICAV is a rare cause of ischemic stroke in young individuals. Despite varied treatment strategies, outcomes are generally favorable. Targeted stenting may reduce recurrence in anatomically specific cases Conflict of interest Ezgi Yilmaz: Nothing to disclose; Aneesh B. Singhal: Nothing to disclose; Okan Sokmen: Nothing to disclose, Emrah Aytac: Nothing to disclose, Hasan Huseyin Kozak: Nothing to disclose, Eylem Ozaydın Goksu: Nothing to disclose , Sinan Balcı: Nothing to disclose, Anil Arat: Nothing to disclose, Ethem Murat Arsava: Nothing to disclose, Mehmet Akif Topcuoglu: Nothing to disclose Topcuoglu1

Purpose: Population level tracking of post-stroke functional outcomes is critical to guide interventions that reduce the burden of stroke-related disability. However, functional outcomes are often missing or documented in unstructured notes. We developed a natural language processing (NLP) model that reads electronic health records (EHR) notes to automatically determine the modified Rankin Scale (mRS). Method: We included consecutive patients (⩾18 years) with acute stroke admitted to our center (2015–2024). mRS scores were obtained from the Get With the Guidelines registry and clinical notes (if documented), and used as the gold standard to compare against NLP-generated scores. We used text-based features from notes, along with age, sex, discharge status, and outpatient follow-up to train a logistic regression for prediction of good (0–2) versus poor (3–6) mRS, and a linear regression for the full range of mRS scores. The models were trained for prediction of mRS at hospital discharge and post-discharge. The models were externally validated in a dataset of patients with brain injuries from a different healthcare center. Findings: We included 5307 patients, 5006 in train and test and 301 in validation; average age was 69 (SD 15) and 65 (SD 17) years, respectively; 47% female. The logistic regression achieved an area under the receiver operating curve (AUROC) of 0.94 [CI 0.93–0.95] (test) and 0.94 [0.91–0.96] (validation), and the linear model a root mean squared error (RMSE) of 0.91 [0.87–0.94] (test) and 1.17 [1.06–1.28] (validation). Discussion and Conclusion: The NLP-based model is suitable for use in large-scale phenotyping of stroke functional outcomes and population health research.

Background and objectives Although left atrial appendage closure (LAAC) is performed in patients with non-valvular atrial fibrillation (NVAF) at increased risk of intracranial haemorrhage (ICH), outcome data are scarce. We assessed the detailed neurological indications for LAAC and outcomes after LAAC in high ICH risk patients.Methods Study population included consecutive patients with NVAF who underwent LAAC in a single hospital network between January 2015 and October 2021 because of prior ICH or the presence of high ICH risk imaging markers on brain MRI (cerebral microbleeds (CMBs)). Primary safety and efficacy outcome measures were the occurrence of ICH and thromboembolic events, respectively, after LAAC.Results Among 146 patients with NVAF who underwent LAAC for high ICH risk, 122 had a history of ICH, while 24 presented with high ICH risk imaging markers only. Mean age was 75.7±7.61, 42 (28.8%) were women. Mean CHA2DS2-VASc score was 5.23±1.52. Of 122 patients with ICH history, 58 (47.5%) had intraparenchymal haemorrhage (IPH), 40 (32.8%) had traumatic ICH (T-ICH) and 18 (14.7%) had non-traumatic subdural haemorrhage. Of 85 patients with brain MRIs including necessary sequences, 43 (50.6%) were related to cerebral amyloid angiopathy and 37 (43.5%) to hypertensive microangiopathy. While 70% of patients were discharged on oral anticoagulants (OAC), 92% were not taking OAC at 1 year. Over 2.12 years mean follow-up, one patient had recurrent non-traumatic IPH (incidence rate (IR) 0.32 per 100 patient-years), five had T-ICH (IR 1.61 per 100 patient-years) and six had an ischaemic stroke (IR 1.94 per 100 patient-years).Conclusions Among patients with NVAF at high ICH risk, LAAC demonstrated a low risk of recurrent ICH or ischaemic stroke compared with previously published data. LAAC in high ICH risk populations should be considered in clinical practice per FDA approval and recent guidelines.

Background and objectives The most common cause of convexity subarachnoid hemorrhage (cSAH) in younger patients (younger than 60 years) is reversible cerebral vasoconstriction syndrome (RCVS). Evidence on the long-term outcomes of future vascular events and functional outcome after cSAH due to RCVS is limited. We aimed to assess the rates and baseline predictors of our primary outcomes (cSAH, intracerebral hemorrhage (ICH), and ischemic stroke), functional outcome, and mortality after cSAH attributed to RCVS. Methods Individual patient data pooled analysis in patients with cSAH attributed to RCVS. A systematic literature search was conducted in PubMed and EMBASE. Two independent reviewers screened studies and extracted data. Quality assessment was assessed using the Newcastle-Ottawa Scale. Early events during the accepted time frame of an RCVS episode (<3 months) were classified as progression rather than recurrence. Follow-up was truncated at 5 years. Primary outcomes were recurrent cSAH, ICH, and ischemic stroke. Secondary outcomes were mortality and functional status measured by modified Rankin Score (mRS). Results We identified 21 eligible cohorts finally including 138 patients from 9 collaborative centers, which provided individual patient data. The mean age was 49.3 +/- 12.1 years, and 110 (79.7%) were female. During a mean follow-up of 1.8 years, annual rates were cSAH recurrence 0.81% (95% CI 0.1-2.91), ICH 0.81% (95% CI 0.1-2.91), and ischemic stroke 0.81% (95% CI 0.1-2.91). Progression during the initial episode (shortly after admission) occurred in 10 patients for cSAH, 2 for ICH, and 8 for ischemic stroke, respectively. Of 106 patients (76.8%) with available outcome data, 100 (94.3%) achieve a mRS of <= 1 at follow-up, indicating no significant disability. Two patients died (annual rate 0.5%, 95% CI 0.09-2.9): one within 10 days and the other within 2 months of the cSAH. Discussion Our data suggest a favorable prognosis for most patients after RCVS-associated cSAH with low rates of recurrent events and a high proportion achieving functional independence. Major limitations include retrospective data collection and potential selection bias from centers providing individual patient data. Nevertheless, these findings provide prognostic information to inform clinical practice.

BACKGROUND:Time-to-treatment goals for acute ischemic stroke (AIS) have substantially improved outcomes, yet similar metrics have not been studied in patients with intracerebral hemorrhage (ICH), where mortality rates are much higher. METHODS:Multicenter, observational retrospective study of patients with ICH and AIS between January 1, 2017, and December 31, 2022, in 11 comprehensive stroke centers across the United States participating in Get With The Guidelines. We included patients with ICH who received antihypertensive therapy and anticoagulation reversal, and patients with AIS requiring intravenous thrombolytic and mechanical thrombectomy. The coprimary outcomes included (1) time-to-treatment and (2) the percentage of patients meeting current national time interval goals. Multivariable logistic regression models controlling for age, sex, race and ethnicity, time to arrival, National Institutes of Health Stroke Scale score, arrival systolic blood pressure, and admission international normalized ratio were constructed to assess the likelihood of patients with ICH being treated within goal compared with patients with AIS. Multivariable logistic regression models were constructed to assess the impact of treatment time on mortality or discharge disposition in patients with ICH. RESULTS:A total of 28 180 patients were identified, of which 7003 patients were included: n=1972 ICH (mean age, 67; 43% female) and n=5031 AIS (mean age, 69; 49% female). The median door-to-first medication was 52 (28-157) minutes for patients with ICH and 42 (30-63) minutes for patients with AIS (P<0.001). Fifty-three percent of patients with ICH received antihypertensive medications in ≤60 minutes from arrival compared with 74% of patients with AIS who received intravenous thrombolytic ≤60 minutes (P<0.001). Thirty-seven percent of patients with ICH received anticoagulation reversal ≤90 minutes from arrival compared with 47% of patients with AIS with door-to-puncture times ≤90 minutes (P<0.001). The adjusted odds of timely treatment in patients with ICH compared with patients with AIS are less than three-fourths (adjusted odds ratio, 0.74 [95% CI, 0.61-0.89]; P<0.01). Patients with ICH who received antihypertensive treatment ≤60 minutes from arrival had a higher likelihood of discharge to home or acute rehab unit (adjusted odds ratio, 7.48 [95% CI, 1.99-28.09]; P<0.01) compared with those treated in >60 minutes. CONCLUSIONS:Time-to-treatment for patients with ICH is significantly longer than for patients with AIS. Faster antihypertensive treatment times are associated with better discharge outcomes in patients with ICH.

Background and Purpose: Cerebral venous thrombosis (CVT) requires acute anticoagulation. Heparin is commonly used but specific recommendations on intensity and timing are lacking. We sought to characterize practicepattern variation in the use of unfractionated heparin (UFH) for acute CVT treatment across multiple centers. Methods: This was a two-center retrospective study performed at Yale New Haven Hospital and Massachusetts General Hospital. Adult patients with CVT between 2013 and 2021 initially managed with parenteral anticoagulation and without endovascular therapy were included. The co-primary objectives were variation in UFH dosing and time to therapeutic anticoagulation by dosing intensity. Dosing intensity was defined as high intensity (>= 12 units/kg/hr) or low intensity (<12 units/kg/hr), with or without initial boluses. Results: Seventy-two patients were included; 62 patients (86 %) received initial anticoagulation with UFH. The median initial UFH rate was 12 (IQR 11-14) units/kg/hr and 17 (27 %) patients received initial boluses (77 units/kg, IQR 40-80). Time to therapeutic anticoagulation was 11 (IQR 6-21) hours with high intensity UFH with a bolus (n = 13) and was 27 h (IQR 20-29) with low intensity UFH with a bolus (n = 4), while time to therapeutic anticoagulation was 30 (IQR 13-35) and 30 (IQR 23-39) hours with high (n = 21) and low intensity (n = 18) UFH without a bolus, respectively. Initial boluses reduced time to therapeutic anticoagulation overall (20 vs 30 h, p = 0.003). Conclusions: Practice-pattern variation in UFH dosing leads to delays in time to therapeutic anticoagulation for CVT. Bolus dosing and high intensity UFH likely reduces the time to therapeutic anticoagulation.

Background One third of all patients with acute ischemic strokes have a pre-existing disability. Patients with pre-existing disabilities have historically been excluded from landmark clinical trials of acute stroke interventions, leading to ongoing controversy about the risks and benefits of acute stroke interventions such as endovascular thrombectomy (EVT). To address this controversy, we compared long-term outcomes and end-of-life care in large vessel occlusion (LVO) patients with moderate-to-severe baseline disability treated with EVT versus medical management alone. Methods Patients who presented with an LVO to our comprehensive stroke center between January 2017 and December 2020 were retrospectively identified from a prospectively maintained database. Moderate-to-severe baseline disability was defined as a pre-stroke modified Rankin Scale (mRS) of 3-5. Delta mRS was defined as the difference between the 90-day and baseline mRS. Logistic and ordinal regressions were performed to evaluate the relationships between EVT and outcomes. An analysis of rates and reasons for transitions to comfort care was also performed, where applicable. Results A total of 175/1008 (17%) LVO patients with moderate-to-severe baseline disability were identified. The median age was 82 (IQR 70-89), and 59% were female. Thirty-two patients (18%) with moderate-to-severe baseline disability were treated with EVT. EVT was independently associated with improved delta mRS (B=-1.048; 95%CI=-1.777,-0.318; p=0.005) accounting for age and NIHSS. However, EVT did not reduce the odds of transitioning to comfort care (aOR=0.794; 95%CI=0.347,1.818; p=0.585) accounting for age and NIHSS. Seventy-six (43%) patients were transitioned to comfort care during their hospitalization. Of the 99 who were not transitioned to comfort care, 18 were treated with EVT, and EVT was independently associated with improved delta mRS (B=-2.794; 95%CI=-4.002,-1.586; p<0.0001). The median time from presentation to transition to comfort care was 2 days (IQR 1-7) in the non-EVT group, compared to 7 (IQR 4-11) in the EVT group (H(1)=5.46, p=0.019). The primary reasons for transitions to comfort care were poor perceived prognosis and medical complications. Conclusions Among patients with moderate-to-severe baseline disability, EVT is associated with less post-stroke accumulated disability without limiting transitions to comfort care. EVT is compatible with goal-concordant care and should not be routinely withheld because of baseline disability alone.

Background and Purpose:Informed consent (IC) practices for endovascular thrombectomy (EVT) in acute stroke are not well elucidated. We investigated the roles and specialties of those obtaining EVT IC, aiming to provide insights for enhancing the process. Methods:We conducted a survey from July- December 2023 among acute stroke care clinicians. Utilizing Qualtrics, we disseminated a questionnaire through various national and international online platforms. This analysis summarizes the characteristics of individuals who obtain IC at respondents' institution. Results:Among 168 respondents, 71% were staff physicians, 70% practiced in the US and 70% worked at academic centers. Neurology (77%) was the most common specialty obtaining EVT IC, followed by neurosurgery (41%), radiology (30%) and emergency medicine (EM) (10%). Staff physicians were the most frequently involved (61%), followed by fellows (43%), residents (48%) and advanced practice providers (APPs) (36%). Comparatvely, non-US institutions were more likely to utilize neurologists alone (50% vs 31%, P = 0.016) and staff physicians (76% vs 54%, P = 0.008), while US institutions more often utilized neurosurgeons (51% vs 18%, P < 0.001), APPs (43% vs 18%, P = 0.002) and residents (56% vs 28%, P = 0.001). Non-academic institutions used EM (25% vs 5%, P < 0.001) and APPs (50% vs 31%, P = 0.031), while academic institutions commonly utilized neurosurgeons (48% vs 18%, P = 0.001), residents (59% vs 13%, P < 0.001) and fellows (52% vs 18%, P < 0.001). Conclusion:Neurologists and staff physicians are the primary providers obtaining EVT IC, with variations based on region and institution type. Future efforts to optimize the IC process should integrate various specialties and be widely adaptable.

BackgroundThe occurrence of acute ischaemic stroke (AIS) while using oral anticoagulants (OAC) is an increasingly recognised problem among nonvalvular atrial fibrillation (NVAF) patients. We aimed to elucidate the potential role of left atrial appendage closure (LAAC) for stroke prevention in patients with AIS despite OAC use (AIS-despite-OAC).MethodsWe retrospectively collected baseline and follow-up data from consecutive NVAF patients who had AIS-despite-OAC and subsequently underwent endovascular LAAC, between January 2015 and October 2021. The primary outcome measure was the occurrence of AIS after LAAC, and the safety outcome was symptomatic intracerebral haemorrhage (ICH).Results29 patients had LAAC specifically because of AIS-despite-OAC. The mean age at the time of the procedure was 73.4±8.7, 13 were female (44.82%). The mean CHA2DS2-VASc score was 5.96±1.32, with an expected AIS risk of 8.44 per 100 patient-years. 14 patients (48%) had two or more past AIS-despite-OAC. After LAAC, 27 patients (93.10%) were discharged on OAC which was discontinued in 17 (58.62%) after transoesophageal echocardiogram at 6 weeks. Over a mean of 1.75±1.0 years follow-up after LAAC, one patient had an AIS (incidence rate (IR) 1.97 per 100 patient-years). One patient with severe cerebral microangiopathy had a small ICH while on direct OAC and antiplatelet 647 days after LAAC.ConclusionsLAAC in AIS-despite-OAC patients demonstrated a low annual AIS recurrence rate in our cohort (1.97%) compared with the expected IR based on their CHA2DS2-VASc scores (8.44%) and to recent large series of AIS-despite-OAC patients treated with OAC/aspirin only (5.3%–8.9%). These hypothesis-generating findings support randomised trials of LAAC in AIS-despite-OAC patients.

Introduction The mantra “time is brain” cannot be overstated for patients suffering from acute ischemic stroke. This is especially true for those with large vessel occlusions (LVOs) requiring transfer to an endovascular thrombectomy (EVT) capable center. We sought to evaluate the spoke hospital door in–door out (DIDO) times for patients transferred to our hub center for EVT. Methods Individuals who first presented with LVO to a spoke hospital and were then transferred to the hub for EVT were retrospectively identified from a prospectively maintained database from January 2019 to November 2022. DIDO was defined as the time between spoke hospital door in arrival and door out exit. Baseline characteristics, treatments, and outcomes were compared, dichotomizing DIDO at 90 minutes based in the American Heart Association goal for DIDO ≤90 minutes for 50% of transfers. Multivariable regression analyses were performed for determinants of the 90-day ordinal modified Rankin Scale (mRS) and DIDO. Results We identified 194 patients transferred for EVT with available DIDO. The median age was 67 years (IQR 57–80), and 46% were female. The median National Institutes of Health Stroke Scale (NIHSS) was 16 (10–20), 50% were treated with intravenous thrombolysis at a spoke, and TICI 2B-3 reperfusion was achieved in 87% at the hub. The median DIDO was 120 minutes (97–149), with DIDO ≤90 minutes achieved in 18%. DIDO was a significant determinant of 90-day ordinal mRS ( B = 0.007, 95% CI = 0.001–0.012, p = 0.013), even when accounting for the last known well-to-spoke door in, spoke door out-to-hub arrival, hub arrival-to-puncture, puncture-to-first pass, age, NIHSS, intravenous thrombolysis, TICI 2B-3, and symptomatic intracranial hemorrhage. Importantly, determinants of DIDO included Black race or Hispanic ethnicity ( B = 0.918, 95% CI = 0.010–1.826, p = 0.048), atrial fibrillation or heart failure ( B = 0.793, 95% CI = 0.257–1.329, p = 0.004), and basilar LVO location ( B = 2.528, 95% CI = 1.154–3.901, p < 0.001). Conclusion Spoke DIDO was the most important period of time for long-term outcomes of LVO stroke patients treated with EVT. Targets were identified to reduce DIDO and improve patient outcomes.

Coma is an unresponsive state of disordered consciousness characterized by impaired arousal and awareness. The epidemiology and pathophysiology of coma in ischemic stroke has been underexplored. We sought to characterize the incidence and clinical features of coma as a presentation of large vessel occlusion (LVO) stroke. Individuals who presented with LVO were retrospectively identified from July 2018 to December 2020. Coma was defined as an unresponsive state of impaired arousal and awareness, operationalized as a score of 3 on NIHSS item 1a. 28/637 (4.4

Background Multicenter electronic health records can support quality improvement and comparative effectiveness research in stroke. However, limitations of electronic health record–based research include challenges in abstracting key clinical variables, including stroke severity, along with missing data. We developed a natural language processing model that reads electronic health record notes to directly extract the National Institutes of Health Stroke Scale score when documented and predict the score from clinical documentation when missing. Methods and Results The study included notes from patients with acute stroke (aged ≥18 years) admitted to Massachusetts General Hospital (2015–2022). The Massachusetts General Hospital data were divided into training/holdout test (70%/30%) sets. We developed a 2‐stage model to predict the admission National Institutes of Health Stroke Scale, obtained from the GWTG (Get With The Guidelines) stroke registry. We trained a model with the least absolute shrinkage and selection operator. For test notes with documented National Institutes of Health Stroke Scale, scores were extracted using regular expressions (stage 1); when not documented, least absolute shrinkage and selection operator was used for prediction (stage 2). The 2‐stage model was tested on the holdout test set and validated in the Medical Information Mart for Intensive Care (2001–2012) version 1.4, using root mean squared error and Spearman correlation. We included 4163 patients (Massachusetts General Hospital, 3876; Medical Information Mart for Intensive Care, 287); average age, 69 (SD, 15) years; 53% men, and 72% White individuals. The model achieved a root mean squared error of 2.89 (95% CI, 2.62–3.19) and Spearman correlation of 0.92 (95% CI, 0.91–0.93) in the Massachusetts General Hospital test set, and 2.20 (95% CI, 1.69–2.66) and 0.96 (95% CI, 0.94–0.97) in the MIMIC validation set, respectively. Conclusions The automatic natural language processing–based model can enable large‐scale stroke severity phenotyping from the electronic health record and support real‐world quality improvement and comparative effectiveness studies in stroke.

Reversible cerebral vasoconstriction syndrome is a common, increasingly recognized cause of thunderclap headache. Most patients have some type of trigger that precedes the onset (e.g., orgasm, physical exertion, Valsalva maneuvers, exposure to vasoconstrictive medications) followed by multiple short-duration thunderclap headaches that occur over days to weeks. Physical examination is often without focal neurological deficits. Brain computed tomography may be normal, or show a convexal subarachnoid hemorrhage. Angiography shows multifocal areas of cerebral arterial vasoconstriction, although can be normal early in the course. The vasoconstriction is reversible and repeat angiography in three months will show normalization. The clinical outcomes are usually good despite some patients having hemorrhagic or ischemic strokes. Treatment is primarily analgesics and avoidance of triggers. Triptans, steroids and immunosuppressive agents, which are sometimes used if migraine or central nervous system angiitis is suspected, should be avoided. Improved recognition of RCVS will likely lead to earlier diagnosis and minimize potentially harmful empiric treatment strategies.

A 64-year-old woman was evaluated because of a sudden onset of the worst headache of her life. Computed tomography of the head revealed a convexal subarachnoid hemorrhage. A diagnosis was made.