Subarachnoid hemorrhage physical examination
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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-In-Chief: Cafer Zorkun, M.D., Ph.D. [2]
Overview
In a patient with thunderclap headache, none of the signs mentioned are helpful in confirming or ruling out hemorrhage, although a seizure makes bleeding from an aneurysm more likely. Physical examination should include vital sign, level of consciousness (Glasgow Coma Scale (GCS)) eye examination, and neurologic examination.[1][2][3][4]
Physical Examination
In a patient with thunderclap headache, none of the signs mentioned are helpful in confirming or ruling out hemorrhage, although a seizure makes bleeding from an aneurysm more likely.
Physical examination should include:[1][2][3][4]
- Vital signs
- Level of consciousness (Glasgow Coma Scale (GCS))
- Eye examination
- Neurologic examination
Vital Signs
As a result of the bleeding
- Mild to moderate blood pressure (BP) elevation
- Temperature elevation (secondary to chemical meningitis after the fourth day following bleeding).
- Tachycardia (several days after the occurrence of a hemorrhage)
Level of consciousness
Level of consciousness (Glasgow Coma Scale (GCS))
Eyes
Funduscopic examination may reveal:
- Papilledema
- Subhyaloid retinal hemorrhage (small round hemorrhagenear the optic nerve head)
- Other retinal hemorrhages
Oculomotor nerve abnormalities (affected eye looking downward and outward, pupil widened and less responsive to light) may indicate a bleed at the posterior inferior cerebellar artery.
Neurologic
Focal neurologic findings
Bleeding into the subarachnoid space may occur as a result of injury or trauma. SAH in a trauma patient is often detected when a patient who has been involved in an accident becomes less responsive or develops hemiparesis or changed pupillary reflexes, and Glasgow Coma Score calculations deteriorate. Headache is not necessarily present.
Focal neurologic findings may include:[5][6]
- Cranial nerve palsies
- Amnesia
- Oculomotor nerve palsy with or without ipsilateral mydriasis, which results from rupture of a posterior communicating artery aneurysm.
- Abducens nerve palsy is usually due to increased ICP rather than a true localizing sign
- Monocular vision loss can be caused by an ophthalmic artery aneurysm compressing the ipsilateral optic nerve
- Hemiparesis results from middle cerebral artery (MCA) aneurysm, ischemia or hypoperfusion in the vascular territory, or intracerebral clot
- Aphasia
- Hemineglect
- Leg monoparesis or paraparesis with or without akinetic mutism/abulia points to anterior communicating aneurysm rupture
Level of severity of neurological deficit (National Institutes of Health Stroke Scale (NIHSS))
| Aneurysm locations | Focal neurologic findings |
|---|---|
| Posterior communicating artery aneurysm |
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| Middle cerebral artery (MCA) aneurysm | |
| Anterior communicating artery aneurysm |
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| Ophthalmic artery aneurysm |
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References
- ↑ 1.0 1.1 Bos MJ, Koudstaal PJ, Hofman A, Breteler MM (2007). "Decreased glomerular filtration rate is a risk factor for hemorrhagic but not for ischemic stroke: the Rotterdam Study". Stroke. 38 (12): 3127–32. doi:10.1161/STROKEAHA.107.489807. PMID 17962600.
- ↑ 2.0 2.1 Hackam DG, Mrkobrada M (2012). "Selective serotonin reuptake inhibitors and brain hemorrhage: a meta-analysis". Neurology. 79 (18): 1862–5. doi:10.1212/WNL.0b013e318271f848. PMID 23077009. Review in: Evid Based Ment Health. 2013 May;16(2):54
- ↑ 3.0 3.1 Qureshi AI, Tuhrim S, Broderick JP, Batjer HH, Hondo H, Hanley DF (2001). "Spontaneous intracerebral hemorrhage". N Engl J Med. 344 (19): 1450–60. doi:10.1056/NEJM200105103441907. PMID 11346811.
- ↑ 4.0 4.1 Fisher CM (1971). "Pathological observations in hypertensive cerebral hemorrhage". J Neuropathol Exp Neurol. 30 (3): 536–50. PMID 4105427.
- ↑ Byrd DM, Prusoff WH (1975). "Multiplicity reactivation of 5-iodouracil-substituted, nonviable bacteriophage T4td8". Antimicrob Agents Chemother. 8 (5): 558–63. PMC 429421. PMID 1108777.
- ↑ Suarez JI, Tarr RW, Selman WR (2006). "Aneurysmal subarachnoid hemorrhage". N Engl J Med. 354 (4): 387–96. doi:10.1056/NEJMra052732. PMID 16436770.