From the Guidelines
The most appropriate next step for this 30-year-old female with severe headache for 10 hours accompanied by nausea and vomiting and a normal CT is to perform a lumbar puncture to rule out subarachnoid hemorrhage (SAH), as recommended by the American Heart Association/American Stroke Association guidelines 1. This approach is based on the high level of suspicion for SAH in patients with acute onset of severe headache, and the fact that a normal CT scan does not completely rule out SAH, especially if the scan is performed more than 3 days after the onset of symptoms 1.
- The clinical presentation of severe headache, nausea, and vomiting is consistent with SAH, which is a medical emergency that requires prompt diagnosis and treatment.
- The guidelines recommend a high level of suspicion for SAH in patients with acute onset of severe headache, and suggest that a lumbar puncture should be performed if the CT scan is nondiagnostic 1.
- The patient's symptoms and normal CT scan results do not necessarily rule out SAH, and further evaluation with a lumbar puncture is necessary to confirm or exclude the diagnosis.
- If the lumbar puncture is negative, other causes of headache such as migraine or tension headache can be considered, and treatment can be tailored accordingly.
- It is essential to prioritize the diagnosis of SAH due to its high morbidity and mortality, and the potential for severe consequences if left untreated 1.
From the Research
Severe Headache Evaluation
The patient's symptoms of a severe headache for 10 hours, accompanied by nausea and vomiting, and a normal computed tomography (CT) scan, require further evaluation to rule out subarachnoid hemorrhage (SAH).
- The decision to perform a lumbar puncture (LP) is a crucial step in the diagnosis of SAH, as it can help detect the presence of blood in the cerebrospinal fluid 2, 3.
- Studies have shown that LP can be a safe and effective procedure in patients with suspected SAH, even if the CT scan is negative 4.
- The diagnostic yield of LP in CT-negative patients with suspected SAH is significant, with a pooled proportion of 0.383 (0.077,0.756) for LP+ investigations 3.
Lumbar Puncture Considerations
When considering LP, it is essential to weigh the benefits and risks of the procedure.
- The probability of SAH above which emergency clinicians should perform a LP is 1.0% 2.
- LP-verified SAH patients exhibit a lower rate of delayed ischemic neurological deficits, but no difference in rebleeding rate, compared to CT-verified cohort 5.
- The presence of underlying vascular pathology, such as aneurysm or arteriovenous malformation (AVM), is less common in LP-verified SAH patients, but still occurs in one out of five patients 5.
Next Steps
Based on the evidence, the most appropriate next step for the 30-year-old female patient would be to consider a lumbar puncture to rule out SAH, given the severity and duration of her headache, and the normal CT scan result.
- The decision to perform LP should be made in consultation with the patient, taking into account the potential benefits and risks of the procedure 2.
- Further evaluation, including radiological examinations such as CT angiography (CTA) and digital subtraction angiography (DSA), may be necessary to determine the underlying cause of the SAH, if diagnosed 5.