An otherwise healthy 42-year-old male is evaluated in the emergency department for sudden, severe head pain. He states the pain began abruptly 2 hours ago during a high-intensity workout and describes it as unlike any headache he has ever experienced. Associated symptoms include marked nausea and sensitivity to light. Vital signs show a blood pressure of 165/95 mmHg, a heart rate of 92/min, and a temperature of 37.1°C (98.8°F). Neurologic examination is nonfocal, but there is noticeable resistance to neck flexion. Arrange the following diagnostic interventions in the correct chronological sequence for working up this patient's likely diagnosis, from first to last.
- 1Non-contrast computed tomography of the head
- 2Lumbar puncture to evaluate for xanthochromia
- 3Cerebral angiography
Answer
The correct sequence is: Non-contrast computed tomography of the head, followed by Lumbar puncture to evaluate for xanthochromia, followed by Cerebral angiography.
The patient's presentation is highly suspicious for an acute subarachnoid hemorrhage. The standard diagnostic sequence begins with a non-contrast CT scan of the head due to its speed and high sensitivity for detecting acute blood. If the CT is negative but clinical suspicion remains, a lumbar puncture is the mandatory next step to look for xanthochromia or elevated red blood cells. Finally, once a subarachnoid hemorrhage is radiographically or biochemically confirmed, cerebral angiography is performed to identify the source of the bleed.
Step-by-Step Solution
Key Concept
Diagnostic sequencing for suspected subarachnoid hemorrhage
Estimated Time:45s