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Subarachnoid hemorrhage — ABIM Board MCQ

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HardNeurologySubarachnoid hemorrhageABIM Board

A 49-year-old develops a sudden maximal-at-onset headache with vomiting and neck stiffness. Noncontrast head CT performed 14 hours after onset is negative, but clinical suspicion for subarachnoid hemorrhage remains high. What should be done next?

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Correct answer: D — Perform lumbar puncture for subarachnoid blood products

The best answer is “Perform lumbar puncture for subarachnoid blood products”. CT sensitivity declines with time after symptom onset. A delayed negative scan does not safely exclude subarachnoid hemorrhage in a classic high-risk presentation, so lumbar puncture for red cells and xanthochromia remains appropriate when no contraindication exists. Unrelated biomarkers and vascular screening cannot replace definitive evaluation, and discharge risks rebleeding.

Reference: 2023 AHA/ASA Aneurysmal Subarachnoid Hemorrhage Guideline: https://professional.heart.org/en/guidelines-statements/2023-guideline-for-the-management-of-patients-with-aneurysmal-subarachnoidstr0000000000000436