General

Case Study - Sudden on-set of worst headache ever

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3 Sep 2016 - General
 

A young women, with no previous medical or surgical history, no on any medication, was attending casualty department due to sudden onset of headache in the morning. She had the epsiode of sudden onset, the worst ever headache, "thunderclap" in nature, rate 10/10, after she ate her breakfast in the morning. There were no visual symptoms or any prodromal symptoms precede the headache. The headcahe was associated with nausea feeling, but no vomiting. There were no photophobia, bo neck stiffness, no fever. The headache was slowly improved over the day, but never fully recover. Patient was mentioning about having a lot of stressful events recently. The vital signs (respiratory rate, oxygen saturation, blood pressure, pulse and temperature) were satisfactory. Neurology examination (plus all other examination), were normal. b-HCG, and other blood tests were normal. What is your differential diagnosis ?? What are the important investigation you wish to do next??? 

Thanks for all the opinions, it is great to have some variety of opinions towards the management of this case. Yes, we should not be performing a lumbar puncture prior to imaging. This patient did had a CT-Brain first which showed no abnormality, prior to a lumbar puncture. A negative Non contrast CT brain and negative lumbar puncture would likely to rule out subarachnoid haemorrhage if both tests performed within a few days of onset. But if in doubt, CT angiography or MR angiography should alwa...
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Yes, "thunderclap in nature" headache described as the worst headache of her life would prompt a doctor to suspect subarachnoid hemorrhage (SAH). You Yi Hong Marinelle Castro I agree with your approach to management. A concise and complete neurologic exam would be the first step. Fundoscopy should be done if possible to ...
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You Yi Hong Performing a lumbar puncture without getting an imaging test that will prove the absence of a mass lesion is a dangerous practice. Even if the patient has an atypical presentation (Normal vital signs, normal neurologic exam), it is still safe to rule out any lesion that may potentially cause brain herniation upon lumbar puncture. The reason why I prefer to do a Contrast enhanced MRI with MRA is becaus...
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A negative CT-Brain followed by a negative lumbar puncture should be sufficient to rule out the possibility of subarachnoid haemorrhage. The other possible alternative of non-contrast CT-Brain with CT angiography can rule out subarachnoid haemorrhage with great sensitivity as well. Marinelle Castro Would you considered to perform a lumbar puncture for xantochromia prior to get the MR/CT-angiography. (I know MRI w...
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I understand You Yi Hong . However, if this is my personal patient, I'd still go for a Contrast-enhanced Cranial MRI with MRA because first, the patient presented with atypical features of normal vital signs and normal neurologic exam. If there is a subarachnoid hemorrhage, this can be seen on ophthalmoscopy. Second, my preferred diagnostic modality will rule out all other urgent causes of severe headache. It...
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Yes, Marinelle Castro the most important cause that we need to rule out is subarachnoid haemorrhage or tiny leakage from the aneurysm. The fist investigation will be CT-Brain to rule out haemorrhagic event in the brain. If the CT-Brain is normal, we will proceed to a lumbar puncture (LP), to obtain cerebral spinal fluid (CSF) to check for cell count and differential count, gram staining & microscopy, (rule o...
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The description of a thunderclap headache that's grade 10/10 will always make a healthcare provider consider the possibility of subarachnoid hemorrhage. This is usually seen on a Plain Cranial CT. However, for this case. The patient has neurologic exam with normal vital signs --- which are quite unusual for a subarachnoid hemorrhage even for a grade 1 hunt and hess classification. So instead of doing a CT scan, I'd request for a Cranial MRI with contrast and MRA. This type of exam will r...
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