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Acute severe headache with normal CT after 12 hours — SCE Acute Medicine MCQ

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ModerateAcute Neurological PresentationsAcute severe headache with normal CT after 12 hoursSCE Acute Medicine

A 45-year-old woman is assessed on the acute medical unit. She has thunderclap headache and vomiting. CT head performed 18 hours after onset is reported normal, and examination shows neck stiffness. Initial assessment includes relevant observations, bedside tests and urgent blood results. What is the most appropriate investigation?

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Correct answer: B — Lumbar puncture after cranial imaging

Lumbar puncture after cranial imaging is the best answer because LP is needed when CT is negative beyond the early high-sensitivity window and suspicion of SAH persists. Urgent upper gastrointestinal endoscopy is plausible, but it is less appropriate for the physiology or timing described in this stem. The other distractors either fit a neighbouring presentation, delay definitive treatment, or miss the key immediate risk. Clinical pearl: Timing of CT matters in SAH exclusion.

Reference: NICE NG228