An adult hypertensive male presented with sudden onset severe headache and vomiting. On examination, there is marked neck rigidity and no focal neurological deficit was found. The symptoms are most likely due to:
Ans. d. Subarachnoid hemorrhage (Ref: Harrison 19/e p1784, 18/e p2262-2263; Sabiston 19/e p1880-1882: Schwartz 9/e p1534-1536: Bailey 25/e p304)Most likely diagnosis in an adult hypertensive male with sudden onset severe headache, vomiting with marked neck rigidity without focal neurological deficit would be subarachnoid hemorrhage.A patient developed sudden severe headache two hours ago and become unconscious. Upon regaining conscious, patient developed photophobia and neck rigidity. Most probable diagnosis in this case is subarachnoid hemorrhage. NCCT head should be done in this case to confirm the diagnosis.Subarachnoid HemorrhageMC cause: Trauma >Spontaneous rupture of Berry aneurysmQClinical Features:Sudden transient loss of consciousnessQ (occurs in nearly half of the patients)Excruciating severe headacheQ: presenting complaint in 45% of case s (worst headache of patients life) more common upon regaining consciousness when loss of consciousness is associatedNeck stiffness and vomitingQ: are common associationsFocal neurological deficit: uncommon.Sudden headache in the absence of focal neurological deficit is the hallmark of aneurysmal rupture. QAssociated prodromal symptoms (suggest location of progressively enlarging unruptured aneurysm):Third cranial nerve palsvQ: Aneurysm at junction of PCA and ICASixth nerve palsyQ: Aneurysm in cavernous sinusOccipital and posterior cervical pain: Inferior cerebellar artery aneurysmPain in or behind the eyeQ: MCA aneurysmDiagnosis:Noncontrast CT scan: Investigation of choice (Lumbar puncture is not indicated prior to an imaging procedure)CSF picture: Hallmark of aneurysmal rupture is blood in CSF (Xanthochromic spinal fluidQ)Lumbar puncture should be performed if the CT scan fails to establish the diagnosis of SAH and no mass lesion or obstructive hydrocephalus is found to establish the presence of subarachnoid bloodQTreatment:Traumatic subarachnoid hemorrhage is managed conservativelyQ.Prognosis assessed by:Hunt and Hess Scale.WFNS (World Federal of Neurological Scale
Intracerebral parenchymal hemorrhage
Ischemic stroke
Meningitis
Subarachnoid hemorrhage
C.N.S.