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Subarachnoid hemorrhage after negative CT — USMLE Step 3 MCQ

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HardEmergency MedicineSubarachnoid hemorrhage after negative CTUSMLE Step 3

A 62-year-old man has sudden severe headache during intercourse. Blood pressure is 178/96 mm Hg. Neurologic examination is normal. Noncontrast head CT performed 3 hours after onset is negative. Because suspicion remains high, lumbar puncture shows xanthochromia and elevated red blood cells that do not clear between tubes. Which of the following is the most appropriate next step in management?

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Correct answer: E — CT angiography and neurosurgical consultation

Thunderclap headache with xanthochromia indicates subarachnoid hemorrhage despite negative CT. Vascular imaging and neurosurgical consultation are required.

Reference: American Heart Association/American Stroke Association subarachnoid hemorrhage guidance