Further examination

Neurological examination following intracranial hemorrhage is useful in assessing the level of focal damage to the patient, with serial examinations acting as a monitor of further damage. Grading systems exist for the classification of patients after subarachnoid hemorrhage (see below), but none are specific to intracerebral hematoma. Assessment of these patients includes general, cardiorespiratory, and abdominal examination.

Brainstem function tests

In an unconscious patient requiring respiratory support a limited examination of the brainstem reflexes (corneal, oculocephalic, pupillary reaction) may provide information about the severity and location of hemorrhage and guide early prognosis.

Further neurological examination

Cranial nerve examination is often difficult in these patients, but important diagnostic information can be gained from the presence of a gaze paresis or abnormal eye movements such as nystagmus. Papilledema will not occur with acutely raised intracranial pressure, but acute subhyaloid hemorrhage is present in up to 20 per cent of cases and is pathognomic of subarachnoid hemorrhage.

Increased reflexes, clonus, and extensor plantar responses are common after intracranial hemorrhage with or without raised intracranial pressure; if asymmetrical, they may provide information about the laterality of the lesion. Motor and other long-tract signs are usually contralateral to the side of hemorrhage. Neck stiffness can be detected in an unconscious patient and, although more common in subarachnoid hemorrhage, is not diagnostic.

Grading systems for subarachnoid hemorrhage

There are many grading systems for the further assessment of subarachnoid hemorrhage patients. These aid rational management and prognosis. The World Federation of Neurological Surgeons (WFNS) have produced an internationally recognized system ( DiaMJ.9.8.8) in which the GCS of the patient is combined with the presence or absence of neurological deficit to provide a five-point scale ( Table,,?).

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Table 2 The WFNS grading system for assessment of subarachnoid hemorrhage patients


A flowchart summarizing the early assessment and investigation of intracranial hemorrhage patients is shown in Fig,: !■

Fig. 1 Flowchart to guide the early assessment of patients following intracranial hemorrhage: ICP, intracranial pressure; LP, lumbar puncture,

Laboratory indices

Samples for urea, electrolytes, and blood count should be taken in all patients. Arterial blood gas measurement is recommended in patients requiring any respiratory support and should be repeated at regular intervals. Clotting studies should also be performed.

Computed tomography

CT has revolutionized the assessment and treatment of intracranial disease. It provides accurate information about the location, extent, and sequelae of any intracranial hemorrhage (Fig 2). Often the underlying cause can be detected and decisions about immediate management taken. CT frequently forms part of the very early assessment of any patient with an altered conscious level but it should not precede patient stabilization.

Fig. 2 CT scan showing a large right putaminal intracranial hemorrhage, with associated intraventricular hemorrhage, causing mass effect and midline shift,

Cerebral angiography

Details of the cerebral vasculature are essential in the management of all subarachnoid hemorrhage patients in whom surgical intervention is considered. It is now commonly performed via femoral artery puncture under local anesthetic. An adequate study should reveal any underlying aneurysmal or arteriovenous malformation. In pure intracerebral hematoma, angiography is performed depending upon the clinical suspicion of an underlying vascular cause. In an unconscious or rapidly deteriorating patient with an intracerebral hematoma strongly suspicious of an underlying aneurysm, a limited angiographic study may be performed prior to emergency evacuation of the hematoma. Magnetic resonance angiography and CT angiography are being used with increasing frequency to diagnose an underlying vascular cause.

Other investigations

In any conscious patient with a normal head CT, lumbar puncture is mandatory. Even in the acute setting, CT will be negative in 10 per cent of all subarachnoid hemorrhages, and meningitis should be excluded in every patient with an altered conscious level. Single-photon-emission CT (SPECT) scanning will display the extent of ischemia surrounding the hematoma. Intracranial pressure monitoring may serve as a guide to cerebral perfusion pressure and mean arterial pressure management.

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