A 38-year-old woman comes to the emergency department due to severe headache. An hour ago, she experienced a sudden, explosive headache followed by a brief loss of consciousness. Since regaining consciousness spontaneously, she has had persistent global headache and nausea. Head movement or bright light worsens the pain. Temperature is 37.2 C (99 F), blood pressure is 142/90 mm Hg, and pulse is 98/min. The patient is somnolent but easily rouses to voice. She is well oriented to time, place, and person. There is increased resistance to neck flexion, which elicits pain. The pupils are equal and reactive to light. Deep tendon reflexes and sensory examination are normal. Brain imaging would most likely reveal which of the following?

Question

A 38-year-old woman comes to the emergency department due to severe headache.  An hour ago, she experienced a sudden, explosive headache followed by a brief loss of consciousness.  Since regaining consciousness spontaneously, she has had persistent global headache and nausea.  Head movement or bright light worsens the pain.  Temperature is 37.2 C (99 F), blood pressure is 142/90 mm Hg, and pulse is 98/min.  The patient is somnolent but easily rouses to voice.  She is well oriented to time, place, and person.  There is increased resistance to neck flexion, which elicits pain.  The pupils are equal and reactive to light.  Deep tendon reflexes and sensory examination are normal.  Brain imaging would most likely reveal which of the following?

Quizplus · Accepted Answer

11ec160b_39dd_79c8_9249_a37b35085da0_MD0001_00 This patient with a sudden-onset, explosive headache (ie, thunderclap headache), brief loss of consciousness, and signs of meningeal irritation (eg, neck stiffness, pain) likely has a subarachnoid hemorrhage (SAH). SAH usually results from the spontaneous rupture of a saccular (berry) aneurysm. These aneurysms most commonly develop at branch points of the anterior, middle, or posterior cerebral arteries in patients with a genetic predisposition (eg, family history, autosomal dominant polycystic kidney disease, Ehlers-Danlos syndrome). Blood empties into the subarachnoid space and pools in the cerebral sulci and basal cisterns, which is the diagnostic finding of SAH on CT scan. Blood in direct contact with the pia mater triggers severe headache and meningeal irritation. Nausea, photophobia, and transient loss of consciousness are also common. Many patients appear neurologically intact at presentation; however, progressively deteriorating mental status (eg, somnolence) is typical. In addition, SAH commonly triggers delayed cerebral vasospasm (eg, 4 days after initial bleeding) resulting in stroke with focal neurologic deficits. (Choice B) Diffuse cerebral edema can result from too-rapid correction of hypernatremia. The drop in serum osmolarity stimulates water flow into brain cells, which can increase intracranial pressure to cause impaired cerebral perfusion and eventual brain herniation. (Choice C) Intracerebral hemorrhage usually results from the rupture of small arteries in the pons, thalamus, or basal ganglia, commonly in the setting of underlying hypertensive vasculopathy. The hemorrhage occurs within the brain parenchyma, with patients usually experiencing focal neurologic deficits. Severe headache is sometimes present, but meningeal signs are not expected. (Choices D and E) Plaque rupture and thrombosis of a large cerebral artery (eg, anterior cerebral artery) and embolization of thrombus (eg, cardioembolic thrombus due to atrial fibrillation) are common mechanisms of ischemic stroke. Patients usually have focal neurologic deficits without headache or meningeal signs. Educational objective: Sudden-onset, severe headache with signs of meningeal irritation (eg, neck pain, stiffness) should raise suspicion for subarachnoid hemorrhage (SAH). SAH usually results from rupture of a saccular (berry) aneurysm, and it is recognized on CT scan by blood pooling in the cerebral sulci and basal cisterns.

A 38-Year-Old Woman Comes to the Emergency Department Due to Severe