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Investigate the CSF in a patient with sudden headache and a normal CT brain scan
  1. J. van Gijn*,
  2. G.J.E. Rinkel
  1. *Professor of Neurology and
  2. Professor of Neurology & Haemorrhagic Cerebrovascular Disease, Department of Neurology, room G03.228, University Medical Centre, Heidelberglaan 100, 3584 CX Utrecht, the Netherlands; E-mail: *j.vangijn{at} and †g.j.e.rinkel{at}


So there you are, in the emergency department, on a night shift. You have just seen a young woman with an unremarkable past medical history who had come to hospital because of an excruciating headache. The pain had come on in seconds, or at most two minutes, about three hours beforehand, while she was clearing the kitchen. Even though the examination was normal you have ordered a CT scan, as you are well aware that it can take 6 h or more for neck stiffness to develop after subarachnoid haemorrhage (SAH). To your surprise there is no evidence of subarachnoid blood or other abnormality on any of the CT slices; the radiology resident has the same opinion. Since you may now be feeling a little nonplussed, if only briefly, the next section is meant to help you get quickly back on your feet again.


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