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Aneurysmal subarachnoid haemorrhage — RACP Adult Medicine MCQ

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HardNeurologyAneurysmal subarachnoid haemorrhageRACP Adult Medicine

A 49-year-old has thunderclap headache, neck stiffness and vomiting. Non-contrast CT performed 12 hours after onset shows no haemorrhage and image quality is adequate. Clinical suspicion of subarachnoid haemorrhage remains high. What is the next investigation?

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Correct answer: D — Perform lumbar puncture for xanthochromia after excluding a contraindication, with vascular imaging if subarachnoid haemorrhage is confirmed

The best answer is “Perform lumbar puncture for xanthochromia after excluding a contraindication, with vascular imaging if subarachnoid haemorrhage is confirmed”. CT sensitivity declines as time from onset increases. With persistent classic features and a negative scan beyond the early high-sensitivity window, CSF assessment for xanthochromia remains an accepted next step, followed by angiographic evaluation when haemorrhage is identified. A negative late CT alone does not safely establish migraine.

Reference: Stroke Foundation: Living clinical guidelines for stroke management: https://informme.org.au/guidelines/living-clinical-guidelines-for-stroke-management