Subarachnoid Haemorrhage — Xanthochromia
Asked in our material — Test Series · Surgery Part 2 · Q21
Q21. A 48-year-old has a sudden ‘worst headache of my life’ (thunderclap) with neck stiffness and photophobia. A non-contrast CT at 12 hours is reported as normal. What is the next best step to confirm or exclude the diagnosis? [ Single best answer ]
A. Reassure and discharge
B. Start a triptan for migraine
C. MRI of the cervical spine
D. Lumbar puncture looking for xanthochromia
Answer: D. Lumbar puncture looking for xanthochromia
Explanation: A thunderclap headache suggests subarachnoid haemorrhage. CT is very sensitive early but misses some bleeds after 6–12 h, so a normal CT does not exclude SAH; lumbar puncture (ideally >12 h after onset) looking for xanthochromia confirms it, after which CT angiography localises the aneurysm.
Exam Trap: A normal CT does NOT rule out SAH after several hours — do an LP for xanthochromia (bilirubin), which distinguishes true SAH from a traumatic tap.
| Option | Why it is right / wrong |
| A. Reassure and discharge | Discharge risks missing a treatable aneurysmal bleed. |
| B. Start a triptan for migraine | Triptans are wrong — this is not migraine. |
| C. MRI of the cervical spine | Cervical MRI doesn't address a subarachnoid bleed. |
| D. Lumbar puncture looking for xanthochromia | Correct — LP for xanthochromia after a normal early CT. |
Attack Hook: Thunderclap "worst headache of life" + neck stiffness → subarachnoid haemorrhage. CT negative but suspicion high → lumbar puncture for xanthochromia. Commonest cause = ruptured berry aneurysm.
THIS QUESTION WAS ASKED IN UPSC CMS 2026
PAPER 1 · QUESTION 2
Question asked in UPSC CMS 2026
A 42-year-old labourer developed a sudden, severe and persistent headache, accompanied by vomiting and neck pain. He was evaluated at the nearest hospital where an emergency computed tomography was negative for stroke. Which one of the following investigations is best to confirm the diagnosis?
(a) Electroencephalogram
(b) Carotid Doppler
(c) Lumbar puncture after 12 hours
(d) Upper gastrointestinal endoscopy