Question of the Week # 211

211 )  A 42 year old woman in otherwise good health presents to the Emergency room for severe headache. She has history of migraines in the past for which she uses sumatriptan at the onset of Headache and usually, she has relief. Though this is not the worst headache of her life, she says that it is very severe and is upset that the headache did not resolve even after injecting herself  with a triptan. She denies any fever.  Her physical and neurological examination is benign. There is no neck stiffness.  A computed tomography (CT) scan of the head is obtained, which did not reveal any abnormalities. A subsequent  lumbar puncture reveals bloody fluid. The specimen was transported to the lab for further evaluation. It was processed in the laboratory 12 hours later and the report indicates “Xanthochromia” Which of the following most likely explains  the CSF findings?

A) Status migranosus

B) Meningitis

C) Sub-arachnoid Hemorrhage

D) Sentinel bleed

E) Delay in CSF processing

10 Responses

  1. C

  2. C…….

  3. C

  4. E…… Correction of before answer….It was processed in the laboratory 12 hours later and the report indicates “Xanthochromia

  5. eee

  6. E. more than 12h…

  7. C

  8. The time interval between the onset of symptoms of SAH and CSF specimen collection should be 12 hours. If it was around that time, the CSF was collected and then showed xanthochromia then it’s SAH. Any delay in the diagnosis can be fatal and moreover, Xanthochromia and spectrophotometry remain reliable ways to detect SAH several days after the onset of headache! So, this patient with a headache which is severe and xanthochromia on diagnosis is SAH until proven otherwise. Refer to Neurosurgery as soon as possible!

    Answer C

  9. Pseudo-xanthochromia can result from in vitro hemolysis of CSF containing 1,000 × 106 erythrocytes/liter for >=12 hours at ambient temperature.3 Differentiation of subarachnoid hemorrhage from traumatic LP is also possible with D-dimer assay.8
    In this patient, bloody tap and become xanthochromia after 12 hrs.
    The answer mostly likely
    E:)

  10. A CSF sample with delayed process >12hrs is not going to tell you it’s SAH or traumatic tap, because red cell from traumatic tap will turn in yellow as well. Plus, this patient’s clinical presentation does not look like SAH at all.

    It is E

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