This is a 60-year-old male with a history of subarachnoid hemorrhage seven years ago due to a Right Pcomm artery aneurysm rupture which was secured with coil embolization; with a 2mm residual neck and coil compaction found on follow-up angiogram. He was then lost to follow-up. He presented with one week of severe headache and three days of nausea and vomiting, and non-contrast head CT revealed an intraparenchymal hemorrhage in the R middle cranial fossa near the coiled aneurysm. He was transferred to another hospital, remaining awake, alert, and at his neurological baseline, and with a stable repeat NCHCT on arrival. Shortly after returning to his room, he became unresponsive, bradycardic, and hypertensive to SBP 240s with bilaterally fixed and dilated pupils, mouth foaming, and minimal movement to noxious stimuli in the extremities. STAT NCHCT revealed a new 9mm acute R frontotemporal SDH with 1cm R-to-L midline shift, uncal herniation, effacement of basal cisterns, and mass effect on the brainstem, along with new SAH and IVH. SBP was controlled to 140s; 250 ml 3% saline bolus and 1g/kg mannitol were administered. The patient was taken to OR for emergent R hemicraniectomy followed by DSA with coiling of the R Pcomm aneurysm.