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

As a result of the bleeding

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]

Level of severity of neurological deficit (National Institutes of Health Stroke Scale (NIHSS))

Aneurysm locations Focal neurologic findings
Posterior communicating artery aneurysm
Middle cerebral artery (MCA) aneurysm
Anterior communicating artery aneurysm
Ophthalmic artery aneurysm

References

  1. 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. PMID 17962600. doi:10.1161/STROKEAHA.107.489807. 
  2. 2.0 2.1 Hackam DG, Mrkobrada M (2012). "Selective serotonin reuptake inhibitors and brain hemorrhage: a meta-analysis.". Neurology. 79 (18): 1862–5. PMID 23077009. doi:10.1212/WNL.0b013e318271f848.  Review in: Evid Based Ment Health. 2013 May;16(2):54
  3. 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. PMID 11346811. doi:10.1056/NEJM200105103441907. 
  4. 4.0 4.1 Fisher CM (1971). "Pathological observations in hypertensive cerebral hemorrhage.". J Neuropathol Exp Neurol. 30 (3): 536–50. PMID 4105427. 
  5. Byrd DM, Prusoff WH (1975). "Multiplicity reactivation of 5-iodouracil-substituted, nonviable bacteriophage T4td8.". Antimicrob Agents Chemother. 8 (5): 558–63. PMC 429421Freely accessible. PMID 1108777. 
  6. Suarez JI, Tarr RW, Selman WR (2006). "Aneurysmal subarachnoid hemorrhage.". N Engl J Med. 354 (4): 387–96. PMID 16436770. doi:10.1056/NEJMra052732. 

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