Hemorrhagic stroke physical examination

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AHA/ASA Guidelines for the Management of Spontaneous Intracerebral Hemorrhage (2015) Management of ICH
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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]

Physical examination

Physical examination should include:

• Vital signs
• Level of consciousness (Glasgow Coma Scale (GCS))
• Level of severity of neurological deficit (National Institutes of Health Stroke Scale (NIHSS))

Physical examination of patients with Intracerebral hemorrhage is usually varies based on the location of the bleeding.

Locations	Physical examination
Putamenal hemorrhage	Hemiplegia Hemisensory loss Homonymous hemianopsia Gaze palsy Stupor Coma
Thalamic hemorrhage	General signs: 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
	Behavioural patterns based 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
Pontine hemorrhage	Decreased level of consciousness (most common) Long tract signs including tetraparesis Cranial nerve palsies Seizures Cheyne-Stokes respiration
Cerebellar hemorrhage	Small bleeds Ataxia Nystagmus Larger bleeds Impair consciousness Obstructive hydrocephalus (obstruct the fourth ventricle)
Lobar hemorrhage	The signs vary depending on the location of the hemorrhage: Acute neurological deterioration Decreased GCS Seizure Contralateral homonymous hemianopsia (occipital hemorrhage) Contralateral plegia/paresis of the leg with relative sparing of the arm (frontal hemorrhage)

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