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]

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]

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

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 (Glasgow Coma Scale (GCS))

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.

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))

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