Severe Headache, Bloody CSF, Normal CT!

[thamerdoha]

36 years old man, presented to the ER complaining of severe headache for 1 day, on Examination he has Temp of 103 F, nuchal rigidity and photophobia, His CT is normal, LP shows CSF with 55 WBCs and 50 000 RBCs
what the most appropriate next step in the management ?

a - Ceftriaxone and Vancomycin
b - angiography
c - repeat CT scan
d - give Nimodipine and do embolization
e - give Nimodipine and do surgical clipping

[usmlekzz]

I think, its subarachnoid hemorrhage case .
In acute setting, CT might be normal

So, I am confused between last 2 answers..
I'll go for D....

[A.D.A.M]

mmm it's really confusing... I mean D or E

but I tend to say D... Embolization

[cool_atomic]

ruptured aneurysm- SAH. give nimodipine and do surgical clipping: E)

embolization would kill him..... the whole reason we give nimodipine is to prevent post-rupture vasospasm.... and if we'd embolize the vessel, what's the point in giving nimodipine?

[Kais_MD]

Originally Posted by cool_atomic

ruptured aneurysm- SAH. give nimodipine and do surgical clipping: E)

embolization would kill him..... the whole reason we give nimodipine is to prevent post-rupture vasospasm.... and if we'd embolize the vessel, what's the point in giving nimodipine?

its acutally nimodipine and emoblization..MTB and world has embolization superior to surgical clipping because of the risk factors you are taking with a craniotomy to do a surgicall clipping..So with these two choices you choose embolization...

[cool_atomic]

Originally Posted by Kais_MD

its acutally nimodipine and emoblization..MTB and world has embolization superior to surgical clipping because of the risk factors you are taking with a craniotomy to do a surgicall clipping..So with these two choices you choose embolization...

so wouldn't embolization cut off the supply distal to the bleed? considering the aneurysm is at the circle of willis anteriorly, would it not cut off the blood supply to the eye, for example?

[Waseem Akhtar]

Originally Posted by cool_atomic

so wouldn't embolization cut off the supply distal to the bleed? considering the aneurysm is at the circle of willis anteriorly, would it not cut off the blood supply to the eye, for example?

E is the answer I think.because its probably SAH and i've myself seen a case in ER with such presentation. Surgical Clipping is the standard Rx for SAH.

[USMLE2011m]

May we know the real answer please

[Kais_MD]

Originally Posted by cool_atomic

so wouldn't embolization cut off the supply distal to the bleed? considering the aneurysm is at the circle of willis anteriorly, would it not cut off the blood supply to the eye, for example?

i understand it makes sense that way but the embolization is done near the bleed...and mtb neuro under SAH and Kaplan has embolization superior in therapy to surgical clipping because of the complication it causes...So fischer said it lol

[cool_atomic]

Originally Posted by Kais_MD

i understand it makes sense that way but the embolization is done near the bleed...and mtb neuro under SAH and Kaplan has embolization superior in therapy to surgical clipping because of the complication it causes...So fischer said it lol

just checked kaplan: IM neurology: CVA chapter:
It says, give nimodipine first, then Surgical clipping OR embolization, but does not describe which one is superior.
Looks like the forum admins can help us here!

[Kais_MD]

Originally Posted by cool_atomic

just checked kaplan: IM neurology: CVA chapter:
It says, give nimodipine first, then Surgical clipping OR embolization, but does not describe which one is superior.
Looks like the forum admins can help us here!

Page 283 of MTB under treatment. 1 is nimodipine and then both embolization and surgical clipping is mentioned..and it finishes off with Embolization is superior to surgical clipping in terms of survival and complications.

[thamerdoha]

the answer is "D" : Nimodipine and Embolization
lets go back to the case , this pt presented with sever headache , sings of meningeal irritation , normal CT and CSF with high RBCs and few WBCs

so differential diagnosis :
SAH
Meningitis

for meningitis , its excluded because the CSF shows normal ratio of WBCs to RBCs which is 1 : 500-1000 .. so 50 000 / 500 , 50 000 / 1000
the WBC will range from 50 - 100 so 55 is a normal ratio which goes with SAH

for SAH : CT scan without contrast has 5 % of false negative
so do LP with normal CT scan , if the CSF shows high RBCs but with normal ratio of WBC to RBCs as i mentioned above this goes with SAH

for the management of SAH :
Embolization : is to use a catheter to clog up the site of bleeding under interventional neuroradiologist by using a platinum wire into the site of hemorrhage

Surgical clipping is also used but it has complications and mortality

now embolization is superior to surgical clipping , choose embolization if answers contain both , if embolization is not mention , surgical clipping would be the correct answer

source : MTB - CK step 2