Subarachnoid hemorrhage physical examination
Subarachnoid Hemorrhage Microchapters
AHA/ASA Guidelines for the Management of Aneurysmal Subarachnoid Hemorrhage (2012)
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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.
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.
- Vital signs
- Level of consciousness (Glasgow Coma Scale (GCS))
- Eye examination
- Neurologic examination
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))
Funduscopic examination may reveal:
- Subhyaloid retinal hemorrhage (small round hemorrhagenear the optic nerve head)
- Other retinal hemorrhages
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.
- Cranial nerve palsies
- 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
- 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|
|Middle cerebral artery (MCA) aneurysm|
|Anterior communicating artery aneurysm|
|Ophthalmic artery aneurysm||
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