Que - 25 year old male presented to emergency department with sudden onset of 10/10 headache with some photophobia and neck stiffness. He was afebrile. He had some neck stiffness and prefered dark room, otherwise examination was unremarkable. You suspected SAH and arrange CT scan which was unremarkable. What is your next management plan?
Ans -
1 - Discharge patient home with simple analgesia
2 - Arrange LP now
3 - Admit patient overnight and arrange LP tomorrow
4 - Arrange MRI
5 - Tell patient that he has migraine and should go home and rest until it settles
Ans -
1 - Discharge patient home with simple analgesia
2 - Arrange LP now
3 - Admit patient overnight and arrange LP tomorrow
4 - Arrange MRI
5 - Tell patient that he has migraine and should go home and rest until it settles
MRI. LP after 12hrs but time frame not given. Also MRI more sensitive??
ReplyDeleteI would go with answer 3, which tells that admit overnight (that would be usually more than 12 hours) and arrange LP tomorrow. Usual practice is to go with answer 3. MRI is usually not available in all hospital. I am not sure whether MRI is more sensitive or not, I think LP after 12 hours would be more sensitive.
ReplyDelete3
ReplyDeleteok. but if it is a SAH, wouldnt it be advantageous to know for sure sooner than later, so that appropriate management can be undertaken, also given that SAH carries a very high mortality rate, even with treatment?
ReplyDeleten I think LP now or MRI now....coz i think its not wise to wait 12hrs...!! Agree with John...!!
ReplyDeleteAnyways...Thanx Bro
Treatment - surgical evacuation will depend up on SAH grading which will be on basis of patient's conscious status (here GCS 15/15 and mass effect on CT scan (here no mass effect. Likelyhood of having moderate or major bleeding in the case is almost 0. We are doing LP to exlcude minor bleeding which will unlikely to require surgery now, but will require observation in hospital.
ReplyDeleteAnother argument is MRI not available in all hospital and all time. (As per my knowledge in South Australian public system, there is only MRI facility avaiable in Royal Adelaide Hospital - which is only available on Mon- Fri). If we will arrange MRI for every normal CT scan MRI will flood out.
About waiting overnight, I think there is no major harm as patient's GCS is 15 and have normal CT scan. Doing LP now has no role - just waste of time and patient will suffer unnecessary as it cannot exclude small SAH.
In current climate, I will go with answer 3.
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ReplyDeleteI'd also like to thank you for the blog!
ReplyDeleteAbout the answer. What about excluding meningitis? Even though the patient is afebrile, he has meningism. I'd go for LP.