47W is brought to the ED 1 h after the sudden onset of HA.

She says that she was walking from

work to her car when she felt an explosion in her head causing her to fall to the ground. She is
not sure if she lost consciousness. Since then, she has had a severe HA characterized by double
vision and throbbing pain exacerbated by head movement. She has HTN treated with atenolol.
She has smoked two packs of cigarettes daily for 20 y. Her P is 80/min, R are 16/min, and BP is
148/82 mm Hg. Examination shows L ptosis. The L pupil is 6.5 mm, and the R pupil is 4.5 mm.
Upward gaze and adduction of the L eye are limited. A CT scan of the head shows diffuse
subarachnoid blood. A LP yields grossly bloody CSF.