Does a patient with sudden onset, severe bilateral temporal headache, neck pain, chills, nausea, and a pain score of maximum intensity require a computed tomography (CT) scan with or without contrast?

From the Guidelines

A CT scan without contrast is recommended initially for this patient presenting with a sudden-onset, severe headache (10/10 pain) accompanied by neck pain, chills, and nausea. This clinical picture raises concern for potentially serious conditions such as subarachnoid hemorrhage, meningitis, or other intracranial pathologies. According to the 2023 guideline for the management of patients with aneurysmal subarachnoid hemorrhage, a non-contrast CT should be performed first as it can quickly identify acute bleeding, mass effect, or hydrocephalus 1. The Ottawa SAH Rule, as outlined in the guideline, suggests that patients with new severe nontraumatic headache reaching maximum intensity within 1 hour, accompanied by neck pain or stiffness, require additional investigation for SAH 1.

The patient's symptoms, including neck pain and a "thunderclap headache", meet the criteria for further investigation. If the non-contrast CT is negative but clinical suspicion remains high for subarachnoid hemorrhage, a lumbar puncture may be warranted, especially if the patient presents more than 6 hours after the onset of symptoms 1. Contrast-enhanced CT would only be indicated if there is suspicion of infection, inflammation, or tumor after the initial non-contrast study. The abrupt onset of this severe headache is particularly concerning and requires urgent evaluation to rule out life-threatening conditions. While waiting for imaging, the patient should receive appropriate pain management and anti-emetics as needed, and vital signs should be closely monitored for signs of increased intracranial pressure or infection.

Key points to consider in the management of this patient include:

• The high sensitivity and specificity of non-contrast CT in detecting SAH, especially when performed within 6 hours of symptom onset 1
• The importance of considering the patient's clinical presentation and risk factors for SAH, such as age and neck pain or stiffness 1
• The potential need for further imaging, such as lumbar puncture or contrast-enhanced CT, if the initial non-contrast CT is negative but clinical suspicion remains high for SAH 1.

From the Research

Diagnostic Approach

The patient's symptoms, including a sudden onset of severe headache, neck pain, chills, and nausea, suggest a potential subarachnoid hemorrhage. To diagnose this condition, a computed tomography (CT) scan is often used. The key consideration is whether to use a CT scan with or without contrast.

CT Scan Without Contrast

• A non-contrast CT scan is commonly used to rule out subarachnoid hemorrhage, as it can quickly identify blood in the subarachnoid space 2.
• The diagnostic accuracy of non-contrast CT is probably very high, but the clinical impact of relying solely on this test has not been fully evaluated 2.
• A study found that non-contrast CT had a sensitivity of 93% for detecting spontaneous subarachnoid hemorrhage, but this may not be sufficient to rule out the condition in all cases 3.

CT Scan With Contrast

• While a non-contrast CT is often the initial choice, a CT scan with contrast may be necessary in some cases to further evaluate the patient's condition.
• However, the provided studies do not specifically address the use of contrast-enhanced CT scans for diagnosing subarachnoid hemorrhage.

Clinical Considerations

• The patient's symptoms, including severe headache and neck pain, suggest a high suspicion for subarachnoid hemorrhage, and a CT scan without contrast is a reasonable initial step 3, 4.
• If the non-contrast CT is negative, further evaluation with lumbar puncture or other imaging modalities may be necessary to rule out subarachnoid hemorrhage 2, 3.