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CT angiography of the head and neck
0%
0/7
Lumbar puncture
Lumbar puncture and administration of vancomycin, ceftriaxone, and ampicillin
43%
3/7
MRI of the brain
29%
2/7
No further evaluation
Select Answer to see Preferred Response
This patient is presenting with a headache concerning for subarachnoid hemorrhage, and has a normal head CT within 6 hours of symptom onset. This is sufficient to rule out subarachnoid hemorrhage, and no further evaluation is necessary.A subarachnoid hemorrhage typically presents with a sudden onset and severe "thunderclap" headache. Any patient with such a pattern of headache should immediately have a head CT performed to rule out an intracranial bleed. Head CT will show extravasated blood which appears as a hyperattenuating substance in the normally CSF-filled subarachnoid space. For patients presenting within 6 hours of symptoms onset, a non-contrast CT scan of the head is sufficient to rule out subarachnoid hemorrhage. Perry et. al examined the utility of CT imaging to rule out subarachnoid hemorrhage in patients presenting to the emergency department with headache. They found that in patients presenting within 6 hours of symptoms onset, the sensitivity of non-contrast head CT for the detection of subarachnoid hemorrhage was 100%. Therefore, head CT obtained within this window can safely rule out subarachnoid hemorrhage.Incorrect Answers:Answer 1: CT angiography of the head and neck may be utilized to visualize CNS vasculature or search for an aneurysm if a non-contrast CT scan of the head reveals subarachnoid blood. However, it is not an appropriate initial screening study and is not necessary for this patient with a normal non-contrast CT scan.Answer 2: Lumbar puncture is sometimes utilized to evaluate for blood in the CSF or xanthochromia in patients with suspected subarachnoid hemorrhage. However, because this patient had a non-contrast head CT within 6 hours of symptom onset, subarachnoid hemorrhage can be safely ruled out and lumbar puncture is not necessary.Answer 3: Lumbar puncture and administration of vancomycin, ceftriaxone, and ampicillin after head CT would be appropriate if meningitis were suspected. However, this patient's history and presentation do not suggest meningitis or other CNS infection as a cause of his symptoms. Answer 4: MRI of the brain may be appropriate to better characterize a mass or demyelinating lesions visualized on non-contrast CT. However, it is not utilized to rule out subarachnoid hemorrhage. Bullet Summary:Non-contrast CT scan of the head can safely rule out subarachnoid hemorrhage when obtained within 6 hours of symptom onset.
4.2
(12)
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