A patient arrives complaining of an acute onset of a headache, which she describes as “the worst headache l’ve ever had”. On exam, meningeal signs are found. The clinican believes the probability of this being a subarachnoid bleed to be approximately 37% based on the evidence
Based on the scenario described, where a patient presents with an acute onset of a severe headache—often referred to as a “thunderclap headache” or the “worst headache I’ve ever had”—and exhibits meningeal signs, there is a significant concern for a subarachnoid hemorrhage (SAH).
Key Points to Consider:
Symptoms: The patient’s description of the headache and the presence of meningeal signs (e.g., neck stiffness, photophobia) are classic indicators of potential meningeal irritation, often seen in cases of SAH.
Probability Assessment: The clinician estimates a 37% probability of a subarachnoid bleed. This percentage reflects a clinical judgment based on presenting symptoms, history, and possibly preliminary imaging or assessments.
Diagnostic Approach:
Immediate Evaluation: A non-contrast CT scan of the head is often the first imaging modality used to assess for SAH, as it is rapid and highly sensitive in the acute setting.
Lumbar Puncture: If the CT is negative but suspicion remains high, a lumbar puncture may be performed to assess for xanthochromia (yellowish discoloration of the cerebrospinal fluid), which indicates the presence of blood.
Treatment Considerations: If SAH is confirmed, urgent management may include neurosurgical intervention, such as clipping or coiling of an aneurysm, if one is found, along with supportive care and monitoring for complications.
Importance of Follow-Up: Given the significant risk associated with SAH, timely intervention and close follow-up are crucial to prevent serious morbidity or mortality.
In summary, the combination of the acute severe headache and meningeal signs strongly raises the suspicion for a subarachnoid hemorrhage, necessitating urgent diagnostic evaluation and potential intervention.