A patient presents with an abrupt severe headache and neck pain. Suspecting subarachnoid hemorrhage, what is the initial diagnostic workup?

A patient presents with an abrupt severe headache and neck pain. Suspecting subarachnoid hemorrhage, what is the initial diagnostic workup?

• A. MRI Brain
• B. Lumbar Puncture
• C. CT Angiography
• D. Non-contrast CT Head

Answer: (D)

In suspected subarachnoid hemorrhage, the first step is to rapidly confirm or exclude bleeding in the subarachnoid space. A non-contrast CT scan of the head is the best initial test because it can quickly detect acute blood without delaying treatment, and modern scanners are highly sensitive for SAH within the first several hours after onset. If the CT is positive, SAH is confirmed and further vascular imaging is pursued to locate the bleeding source for treatment planning. If the CT is negative but suspicion remains high (for instance, if presentation is later than 6 hours after onset), a lumbar puncture is performed to look for red blood cells or xanthochromia in the CSF, which would indicate hemorrhage. MRI is less ideal in the acute ED setting due to time and sensitivity considerations, and CT angiography is typically used after SAH is confirmed to identify the source (such as an aneurysm).

In suspected subarachnoid hemorrhage, the first step is to rapidly confirm or exclude bleeding in the subarachnoid space. A non-contrast CT scan of the head is the best initial test because it can quickly detect acute blood without delaying treatment, and modern scanners are highly sensitive for SAH within the first several hours after onset. If the CT is positive, SAH is confirmed and further vascular imaging is pursued to locate the bleeding source for treatment planning. If the CT is negative but suspicion remains high (for instance, if presentation is later than 6 hours after onset), a lumbar puncture is performed to look for red blood cells or xanthochromia in the CSF, which would indicate hemorrhage. MRI is less ideal in the acute ED setting due to time and sensitivity considerations, and CT angiography is typically used after SAH is confirmed to identify the source (such as an aneurysm).