# A nurse is assessing a 52-year-old patient who was admitted with a sudden onset of severe headache. Which assessment finding would be most indicative of a ruptured cerebral aneurysm?

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## 문제

A nurse is assessing a 52-year-old patient who was admitted with a sudden onset of severe headache. Which assessment finding would be most indicative of a ruptured cerebral aneurysm?

## 보기

1. Gradual onset of confusion over several hours
2. Nuchal rigidity with positive Kernig's sign **✔ 정답**
3. Unilateral facial drooping with slurred speech
4. Progressive weakness in bilateral lower extremities

**정답: 2**

## 해설

Nuchal rigidity with positive Kernig's sign indicates meningeal irritation from subarachnoid hemorrhage, which is the classic presentation of ruptured cerebral aneurysm. Other options describe gradual or focal neurological symptoms not specific to aneurysmal rupture.

## 심화 해설

Clinical Reasoning: Recognizing Meningeal Irritation in Subarachnoid Hemorrhage

When a patient presents with a sudden, severe "thunderclap" headache, a ruptured cerebral aneurysm leading to subarachnoid hemorrhage (SAH) must be at the top of the differential diagnosis. The key to answering this question lies in understanding the pathophysiology of blood entering the subarachnoid space.

Following aneurysm rupture, blood is released under high pressure into the cerebrospinal fluid (CSF) within the subarachnoid space. This blood acts as a potent chemical irritant to the meninges, the protective layers covering the brain and spinal cord. The resulting inflammatory response, a form of chemical meningitis, leads to the classic clinical syndrome of meningismus, or meningeal irritation.

Why Nuchal Rigidity and Kernig's Sign Are Correct

Option 2, nuchal rigidity (neck stiffness) with a positive Kernig's sign, is the most indicative finding. These are objective, physical examination signs of meningeal inflammation. Nuchal rigidity occurs because the inflamed meninges and spinal nerve roots are highly sensitive to stretching; flexing the patient's neck causes pain and reflexive muscle spasm. A positive Kernig's sign—pain and resistance in the hamstrings when the examiner attempts to extend the patient's knee with the hip flexed at 90 degrees—occurs for the same reason: stretching the irritated nerve roots and meninges of the lumbar spine.

The provided literature supports the clinical significance of these signs. A case report on a pediatric patient with a severe headache explicitly notes that a positive Kernig sign was a key physical finding that prompted urgent neuroimaging to rule out intracranial pathology, including a CNS infection [2]. While that specific case was ultimately diagnosed as sinusitis, the clinical decision-making pathway is identical: a positive Kernig sign in the setting of a severe headache is a red flag for meningeal irritation, which in the context of a sudden-onset headache is most commonly caused by SAH. Furthermore, a review of CNS infections confirms that clinical profiles of patients with meningeal inflammation are characterized by these classic signs, which are assessed to differentiate various intracranial pathologies . Neuroimaging studies are then used to confirm the presence of blood or infection, but the bedside assessment of meningeal signs is the critical first step in narrowing the differential .

Why the Other Options Are Incorrect

- Option 1: Gradual onset of confusion over several hours. A ruptured aneurysm causes a hyperacute, instantaneous headache, not a gradual process. Gradual confusion suggests a metabolic encephalopathy, a slowly expanding mass, or an infection, not the explosive onset of an SAH.

- Option 3: Unilateral facial drooping with slurred speech. This is a classic presentation of an acute ischemic stroke affecting the middle cerebral artery territory. While a large SAH can cause focal deficits due to vasospasm or an expanding hematoma, the most immediate and direct sign of the hemorrhage itself is meningeal irritation, not a focal cranial nerve deficit.

- Option 4: Progressive weakness in bilateral lower extremities. This pattern suggests a spinal cord pathology, such as a compressive lesion or transverse myelitis, or a parasagittal brain lesion. It is not characteristic of the diffuse meningeal irritation caused by blood in the subarachnoid space.References (research sources)

- [2]Diagnosis of Acute Isolated Sphenoid Sinusitis Based on a Positive Kernig Sign in a Pediatric Patient.Research articleYamamoto H, Ihara T. (2025) · DOI: 10.7759/cureus.93291

## 임상 시나리오

Assessing for Meningeal Irritation in Suspected SAHRapid recognition of nuchal rigidity and Kernig's sign
A thunderclap headache is a red flag for subarachnoid hemorrhage (SAH). Blood in the subarachnoid space acts as a chemical irritant, causing meningismus.

Assess for nuchal rigidity by gently flexing the neck. A positive finding is stiffness and pain. Next, test for Kernig's sign: with the hip flexed to 90 degrees, attempt to extend the knee. Pain and resistance confirm meningeal irritation.

CautionDo not rely on CT alone; a negative scan within the first 6 hours still requires a lumbar puncture to rule out xanthochromia. Avoid performing lumbar puncture if there are signs of increased intracranial pressure without prior imaging.

## 핵심 개념

- **Nuchal Rigidity** — Neck stiffness and pain upon passive flexion due to meningeal inflammation; a classic sign of meningitis and subarachnoid hemorrhage.
- **Kernig's Sign** — Pain and resistance in the hamstrings when extending the knee with the hip flexed at 90 degrees, indicating meningeal irritation.
- **Subarachnoid Hemorrhage (SAH)** — Bleeding into the subarachnoid space, often from a ruptured aneurysm, presenting with a sudden, severe 'thunderclap' headache.
- **Meningismus** — The clinical syndrome of meningeal irritation (headache, photophobia, nuchal rigidity) caused by blood or infection in the subarachnoid space.
- **Thunderclap Headache** — A sudden, severe headache reaching maximum intensity within seconds; the hallmark symptom of a ruptured cerebral aneurysm.

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