Clinical Practice and Cases in Emergency Medicine

Introduction: Radiologically negative subarachnoid hemorrhage (SAH) has a low incidence and is associated with good clinical outcomes. 

Case Report: We present the case of a 44-year-old male with new-onset headaches, which began one week prior while bike riding. At an outside hospital, he had normal computed tomography head and angiogram. He declined a lumbar puncture. Over the following week, the headache was persistent. He lacked meningeal signs. Repeat studies were normal. Lumbar puncture was positive for xanthochromia. 

Conclusion: Radiologically negative SAH should be included in the differential diagnosis of patients presenting with unremitting headache in the setting of recent exercise, despite negative imaging, and meningeal signs.