A 42-year-old woman is brought to the emergency department due to severe headache. Three hours ago, the patient suddenly began experiencing bilateral headache, which rapidly worsened in severity. She also has had neck pain and an episode of vomiting. The patient has had no prior headaches, and medical history is significant for hypertension. She works in a day care. Temperature is 38.3 C (100.9 F), blood pressure is 154/92 mm Hg, and pulse is 102/min. Oxygen saturation is 98% on room air. On physical examination, the patient appears in obvious discomfort and keeps her eyes closed. She follows simple instructions, and there is no focal weakness or numbness. Funduscopy shows no papilledema. There is increased resistance to passive neck flexion, and it also elicits pain. Which of the following is the best next step in management of this patient?

Question

A 42-year-old woman is brought to the emergency department due to severe headache.  Three hours ago, the patient suddenly began experiencing bilateral headache, which rapidly worsened in severity.  She also has had neck pain and an episode of vomiting.  The patient has had no prior headaches, and medical history is significant for hypertension.  She works in a day care.  Temperature is 38.3 C (100.9 F), blood pressure is 154/92 mm Hg, and pulse is 102/min.  Oxygen saturation is 98% on room air.  On physical examination, the patient appears in obvious discomfort and keeps her eyes closed.  She follows simple instructions, and there is no focal weakness or numbness.  Funduscopy shows no papilledema.  There is increased resistance to passive neck flexion, and it also elicits pain.  Which of the following is the best next step in management of this patient?

Quizplus · Accepted Answer

Subarachnoid hemorrhage (SAH) usually results from rupture of a saccular aneurysm and classically presents with a sudden-onset, severe headache, often called a thunderclap headache. The location of the headache can be highly variable, but it is commonly accompanied by vomiting and photophobia, and some patients may experience a brief loss of consciousness. Neck pain (or stiffness) and low-grade fever are also common due to blood-induced meningeal irritation. SAH is associated with high morbidity and mortality, and recognition is complicated by a wide range of clinical presentations. Although nearly 20% of patients die before reaching the hospital, approximately 40% present in a normal state of alertness without any neurologic deficit. Noncontrast CT scan of the brain is the initial diagnostic step of choice as it has high sensitivity for detecting blood pooling in the basal cisterns or sulci of the subarachnoid space. blood pooling If CT scan is unremarkable and there is still reasonable suspicion for SAH, lumbar puncture is performed to evaluate for red blood cells or xanthochromia. Xanthochromia is a pink or yellow tint of the cerebral spinal fluid (CSF) caused by hemoglobin degradation products (eg, bilirubin) that appear as soon as 2 hours following a subarachnoid bleed and persist in the CSF for weeks. (Choice A) Administration of 100% oxygen is appropriate therapy for a cluster headache, which presents as a unilateral, severe headache that is usually accompanied by signs of parasympathetic hyperactivity (eg, ptosis, miosis, nasal congestion) on the ipsilateral side. (Choice B) Cervical spine x-ray is appropriate to evaluate for fracture following cervical spine trauma, but it is not indicated for spontaneous onset of severe headache. (Choice D) Although meningitis presents with fever, neck stiffness, and severe headache, the dramatic onset and rapidly progressive severity of symptoms in this patient make SAH more likely, and given the high mortality associated with unrecognized SAH, a CT scan (which is less invasive and can generally be performed more rapidly than lumbar puncture) is the best next step. If the CT scan is negative, lumbar puncture (which would evaluate for xanthochromia and meningitis) should be considered. Meningitis patients often have high-grade fever and chills and appear ill. (Choice E) Sumatriptan can be helpful for migraine headaches. Migraines are often accompanied by nausea and photophobia, but they also typically have a prodrome and are not associated with fever. Educational objective: Subarachnoid hemorrhage typically presents with a sudden-onset, severe headache that may be accompanied by vomiting, neck stiffness, fever, and loss of consciousness. CT scan of the brain is the best initial diagnostic step. References: Clinical decision rules to rule out subarachnoid hemorrhage for acute headache. (http://www.ncbi.nlm.nih.gov/pubmed/24065011) Initial misdiagnosis and outcome after subarachnoid hemorrhage. (http://www.ncbi.nlm.nih.gov/pubmed/14970066)

A 42-Year-Old Woman Is Brought to the Emergency Department Due