MEDizzy - A 36-year-old woman arrives in the emergency room

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Combined Neurology

A 36-year-old woman arrives in the emergency room complaining of severe headache that has lasted for several days. She has a past medical history of migraine headaches but states that her present headache is different in quality as well as duration. She has had several self- limiting transient headaches over the past week, but 3 days prior to her arrival today she experienced a sudden sharp severe headache. The headache was more intense on the right side and radiated over the entire cranium. Although the headache is now less severe, it still persists. On physical exam the patient is afebrile with a normal blood pressure. She has no sinus tenderness. She denies any photophobia. Her cranial nerve exam is unremarkable. A funduscopic exam reveals mild papilledema. She has mild to moderate nuchal rigidity. The remainder of her neurologic and mental status exam is unremarkable. The patient described has a non contrast head CT, which is unremarkable. Which of the following studies would be most appropriate?

ExplanationC. Lumbar puncture should be performed in patients whose clinical presentation suggests a subarachnoid hemorrhage and whose CT scan is negative, equivocal, or technically inadequate. The CSF pressure should always be measured. High intracranial pressure is an important clue in the occasional patient with cerebral venous sinus thrombosis or pseudotumor cerebri. After an aneurysmal hemorrhage, erythrocytes rapidly disseminate throughout the subarachnoid space. Released hemoglobin is metabolized to the pigmented oxyhemoglobin, which is reddish-pink in color. This process results in xanthochromia. The presence of xanthochromia is the primary criterion for a diagnosis of a subarachnoid hemorrhage in patients with a negative CT scan.