From the Guidelines
The best physical exam tests to differentiate an acute intracranial process in a non-confused person include a thorough neurological examination focusing on cranial nerve function, pupillary response, visual fields, motor strength, deep tendon reflexes, coordination, and gait assessment. Begin with pupillary examination, checking for size, symmetry, and reactivity to light, as anisocoria or sluggish responses may indicate increased intracranial pressure 1. Fundoscopic examination can reveal papilledema, suggesting increased intracranial pressure. Test for subtle motor deficits through pronator drift, rapid alternating movements, and finger-to-nose testing. Assess for subtle sensory deficits, coordination problems (heel-to-shin test), and gait abnormalities. Check for meningeal signs like nuchal rigidity, Kernig's sign, and Brudzinski's sign if infection is suspected. Vital signs, particularly hypertension with bradycardia (Cushing's reflex), may indicate increased intracranial pressure.
Some key points to consider when performing a physical exam on a non-confused person with suspected acute intracranial process include:
- The yield of neuroimaging studies in patients with altered mental status is low, with only 11% of patients having relevant abnormal findings on head CT examination 1
- A study of 285 febrile elderly patients with altered mental status showed abnormal brain imaging in 16.5%, with lower Glasgow Coma Scale, presence of lateralizing sign, higher systolic blood pressure, and lower body temperature being significantly associated with abnormal brain imaging 1
- The prevalence of delirium in the ED ranges from 7% to 35%, with four factors having strong associations with ED delirium: nursing home residence, cognitive impairment, hearing impairment, and a history of stroke 1
- A comprehensive clinical variable data collection sheet was used in a study of 1,101 mild TBI patients, and the following independent variables were found to predict intracranial lesions: GCS score of 14, loss of consciousness, vomiting, headache, signs of basilar skull fracture, neurologic deficit, coagulopathy, hydrocephalus treated with shunt, associated extracranial lesions, and patient age 65 years or greater 1
These tests are valuable because they can detect subtle neurological deficits that may precede confusion or altered mental status, allowing for earlier intervention in conditions like stroke, hemorrhage, tumor, or infection. Remember that while these physical exam findings are helpful, they should be correlated with the patient's history and symptoms, and definitive diagnosis often requires neuroimaging.
From the Research
Physical Exam Tests for Acute Intracranial Process
To differentiate an acute intracranial process in a person who is not confused, several physical exam tests can be utilized. These tests are crucial for early diagnosis and prevention of severe and progressive pathological processes.
- Ocular signs, such as papillary edema and central eye movement disorders, can be predictors of increasing intracranial pressure 2.
- Measurement of the visual field, fluorescein angiography of the retinal vessels, optic coherent tomography, and ultrasound examinations of the carotid or vertebral arteries can provide help in determining the progression or remission of increasing intracranial pressure and the efficacy of treatment 2.
- Optic nerve sheath diameter (ONSD) can be used as a noninvasive measure for elevated intracranial pressure (ICP) 3.
- The interplay between intraocular and intracranial pressure can affect the optic nerve head, and changes in these pressures can deform the scleral canal and the lamina of the optic nerve head 4.
Key Findings
- Increased intracranial pressure can cause damage to the structural support of the optic nerve, leading to changes in the trabecular fibers connecting the optic nerve to the optic nerve sheath 3.
- The effects of increased intracranial pressure on the optic nerve head can be significant, and changes in intraocular pressure can also affect the susceptibility to glaucoma 4.
- Early diagnosis and treatment of increased intracranial pressure are crucial to prevent severe and progressive pathological processes, and physical exam tests can play a vital role in this process 5, 6.