Subarachnoid Hemorrhage: Examination

A comprehensive clinical examination is the basis for selecting further diagnostic steps:

  • Assessment of consciousness or severity of subarachnoid hemorrhage using the “World Federation of Neurosurgical” (WFNS) classification – oriented to the Glasgow Coma Scale (GCS; scale for estimating a disorder of consciousness).
  • General physical examination – including blood pressure, pulse, body weight, height; furthermore:
    • Inspection (viewing).
      • Eyes: vitreous hemorrhage (Terson syndrome)? Reaction of pupils to light?
      • Skin and mucous membranes
      • Neck vein congestion?
      • Central cyanosis? (bluish discoloration of skin and central mucous membranes, e.g., tongue).
      • Abdomen (abdomen):
        • Shape of the abdomen?
        • Skin color? Skin texture?
        • Efflorescences (skin changes)?
        • Pulsations? Bowel movements?
        • Visible vessels?
        • Scars? Hernias (fractures)?
      • Extremities (palpation (feeling) of peripheral pulses, looking for edema/water retention).
    • Auscultation (listening) of the heart and central arteries (flow sounds?).
    • Auscultation of the lungs
    • Palpation (palpation) of the abdomen (abdomen) (tenderness?, knocking pain?, coughing pain?, defensive tension?, hernial orifices?, kidney bearing knocking pain?)
  • Neurological examination – assessment of patient’s level of consciousness; functional deficits (severity)?
    • Epileptic seizures (convulsions)?
    • Hemiparesis (hemiplegia)?
    • Cranial nerve palsies?
    • Stretch synergies (abnormal stretching)?
    • Stupor (rigidity of the body)?
    • Checking the sensitivity and motor function
    • Testing reflexes (especially the biceps tendon reflex (BSR), triceps tendon reflex (TSR), radius periosteal reflex (RPR), patellar tendon reflex (PSR) and the Achilles tendon reflex (ASR, also triceps surae reflex), Babinski reflex (the pressureful brushing of the lateral edge of the foot leads to an upward extension of the big toe)).

Square brackets [ ] indicate possible pathological (pathological) physical findings. FAST test

With the help of the so-called FAST test can be checked – even for medical laymen – the typical apoplexy symptoms:

  • F = Face (face paralyzed on one side? ); Test: ask the patient to smile.
  • A = Arms (arm movement restricted? ; Test: ask patient to raise both arms simultaneously, turning palms upward.
  • S = Speech (speech slurred? ); Have the patient repeat a simpler sentence.
  • T = Time (Do not waste time! Tel. 112).

The FAST test has a sensitivity (percentage of diseased patients in whom the disease is detected by the application of the history, that is, a positive result occurs) of 64-97% and a specificity (probability that actually healthy people who do not have the disease in question are also detected as healthy by the procedure) of 13-63%.Assessment of consciousness or severity of subarachnoid hemorrhage using the World Federation of Neurosurgical (WFNS) classification.

Class Criterion GCS score
1 – – 15
2 Without focal CNS signs 13-14
3 with focal CNS signs 13-14
4 With or without focal CNS signs. 7-12
5 With or without focal CNS signs. < 7

Glasgow Coma Scale (GCS) – scale for estimating a disorder of consciousness.

Criterion Score
Eye opening spontaneous 4
on request 3
on pain stimulus 2
no reaction 1
Verbal communication conversational, oriented 5
conversational, disoriented (confused) 4
incoherent words 3
unintelligible sounds 2
no verbal reaction 1
Motor response Follows prompts 6
Targeted pain defense 5
untargeted pain defense 4
on pain stimulus flexion synergisms 3
on pain stimulus stretching synergisms 2
No response to pain stimulus 1

Assessment

  • Points are awarded for each category separately and then added together. The maximum score is 15, the minimum 3 points.
  • If the score is 8 or less, a very severe brain dysfunction is assumed and the there is a risk of life-threatening respiratory disorders.
  • With a GCS ≤ 8, securing the airway by endotracheal intubation must be considered.