Question of the Week # 210

210 )  A 42 year old woman in otherwise good health presents to the Emergency room for sudden onset of severe headache 2 hour ago. She has no previous history of headache or migraine . Upon arrival in the ER, she described her headache as “10 out of 10” in severity. She thinks this is the worst headache of her life. She denies any fever or visual problems or drug abuse.  Her physical and neurological examination is benign. There is no neck stiffness at this time.  A computed tomography (CT) scan of the head is obtained, which did not reveal any abnormalities. A subsequent  lumbar puncture reveals bloody fluid which shows decreasing red color in subsequent collection tubes. The last collection tube shows red fluid but much decreased color as opposed to the first collection tube. Which of the following is the most appropriate management decision?

A) Repeat Lumbar Puncture at a different site

B) Immediate CSF centrifugation

C) Neurosurgery evaluation

D) Re-assurance and analgesic therapy

E) Subcutaneous Sumatriptan

8 Responses

  1. D

  2. BBB … otherwise if the last tube test showed no blood then that would mean its def. SAH & call the neurosurgeon

    • Ans B=A traumatic or bloody tap is defined as the presence of blood in the CSF that comes from venous blood as the tap is being performed. When blood is in the CSF it is important to distinguish between a bloody tap and a subarachnoid hemorrhage. This can be done by comparing the 1st tube vs. the 3rd tube of CSF. With a bloody tap there is clearing of the CSF. When the CSF is centrifuged the supernatant fluid is also clear. When a subarachnoid hemorrhage has occurred there isn’t any clearing from the 1st to the 3rd tube. Within 2-4 hours of the hemorrhage, the red blood cells will start to lysis which colors the supernatant CSF pink for the first 2-10 hours then the fluid will turn yellow. This xanthrochroma will be at a maximum 48 hours after the hemorrhage and can persist for 2-4 weeks.

  3. B)

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