Hemorrhagic stroke physical examination

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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]

Physical examination

Thalamic haemorrhage

downward gaze (paralysis of upward gaze) small pupils (lack of light pupillary response) depressed consciousness apathy hypersomnolence disorientation visual hallucinations aphasia impairment of verbal memory visuospatial dysfunction

• Thalamic strokes can also present with behavioural patterns depending on the four main arterial thalamic territories:
  • anterior: perservations, apathy and amnesia
    • paramedian infarction: disinhibition, personality change and amnesia (severe retrograde and anterograde amnesia)
    • extensive lesions: "thalamic dementia"
  • inferolateral: executive dysfunction and occasionally severe long term disability
  • posterior: no specific behavioural pattern however can include cognitive dysfunction, neglect, aphasia

35 percent of cases, subcortex in 30 percent, cerebellum in 16 percent, thalamus in 15 percent, and pons in 5 to 12 percent

Locations	Physical examination
Putamenal hemorrhage (35%)	Hemiplegia Hemisensory loss Homonymous hemianopsia Gaze palsy Stupor Coma
Thalamic hemorrhage (15%)	Downward gaze (paralysis of upward gaze) Small pupils (lack of light pupillary response) Depressed consciousness Apathy Hypersomnolence Disorientation Visual hallucinations Aphasia Impairment of verbal memory Visuospatial dysfunction
Pontine hemorrhage (5-12%)	Decreased level of consciousness (most common) Long tract signs including tetra paresis Cranial nerve palsies Seizures Cheyne-Stokes respiration
Cerebellar hemorrhage (16%)	Small bleeds Ataxia Nystagmus Larger bleeds Impair consciousness Obstructive hydrocephalus (obstruct the fourth ventricle)
Lobar hemorrhage	Acute neurological deterioration Decreased GCS
Subarachnoid haemorrhage (SAH)	Focal neurological deficits often present either at the same time as the headache or soon thereafter

References

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