JP, a healthy 54-year-old woman, was running with friends when she experienced a sudden, severe headache; vomiting; left-sided hemiplegia; and a decreased level of consciousness. After she arrived at the hospital, her condition continued to deteriorate. She became less responsive, had difficulty maintaining an airway, and required intubation. Neurologically, her pupils were equal but sluggishly reactive to light; she had no cough reflex, a weak gag response, and withdrew only to noxious stimuli. Initial vital signs included a heart rate of 41 beats/min and a blood pressure of 200/96 mm Hg.

A 12-lead electrocardiogram revealed a type I second-degree heart block with no ST changes or Q waves. Computed tomography (CT) of the head showed a large subarachnoid hemorrhage (SAH) and intraparenchymal blood. Despite clinical and CT findings, no aneurysm was detected by emergent cerebral angiography. Although this result...

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