What signs should be looked for on physical exam to rule out intracranial (within the skull) bleeding?

Physical Examination Signs to Rule Out Intracranial Bleeding

A thorough neurological examination is essential for detecting intracranial bleeding, but neuroimaging remains the gold standard as physical examination alone cannot definitively rule out intracranial hemorrhage.

Key Neurological Assessment Components

Level of Consciousness

• Glasgow Coma Scale (GCS) assessment 1, 2
  • Eye opening response (1-4 points)
  • Verbal response (1-5 points)
  • Motor response (1-6 points)
  • GCS <15 increases suspicion for intracranial bleeding
• Mental status changes - confusion, lethargy, or decreased level of consciousness strongly suggest possible intracranial pathology 1

Vital Signs

• Blood pressure - hypertension (systolic BP >220 mmHg) suggests possible ICH 1
• Cushing's triad - hypertension, bradycardia, and irregular respirations indicate increased intracranial pressure 2
• Temperature - fever may suggest infectious etiology rather than primary hemorrhage

Cranial Nerve Examination

• Pupillary abnormalities - unequal pupils, sluggish reaction to light 2
• Extraocular movements - abnormal eye movements or gaze preference
• Facial asymmetry - may indicate compression of cranial nerves

Motor and Sensory Function

• Focal weakness - hemiparesis or monoparesis suggests localized brain injury 1
• Asymmetric reflexes - hyperreflexia or pathological reflexes (Babinski sign)
• Sensory deficits - asymmetric responses to sensory stimuli

Meningeal Signs

• Nuchal rigidity (neck stiffness) - particularly important in subarachnoid hemorrhage 1
• Kernig's sign - pain/resistance when extending knee with hip flexed
• Brudzinski's sign - spontaneous hip/knee flexion when neck is flexed

Additional Warning Signs

• Severe headache - especially sudden onset "thunderclap" headache 1
• Vomiting - particularly projectile vomiting without nausea 1
• Seizures - focal or generalized 1
• Photophobia - sensitivity to light, particularly with subarachnoid hemorrhage 1
• Progression of symptoms over minutes to hours strongly suggests expanding hemorrhage 1

High-Risk Populations Requiring Lower Threshold for Imaging

• Patients on anticoagulants - even minor head trauma carries 15.9% risk of intracranial bleeding in warfarin users 3
• Elderly patients - increased risk of intracranial hemorrhage, especially with anticoagulant use 4
• History of hypertension - major risk factor for spontaneous ICH 4
• Previous stroke - increases risk of hemorrhagic transformation 4

Important Caveats

1. Physical examination alone is insufficient - the American Heart Association guidelines emphasize that it is impossible to rule out intracranial hemorrhage based on clinical characteristics alone; neuroimaging is mandatory 1

2. Early hematoma expansion - 28-38% of ICH patients experience significant hematoma expansion within the first few hours, which may not be detectable on initial examination 1, 2

3. Silent hemorrhages - some intracranial bleeds may present with minimal or atypical symptoms, especially in elderly patients or those with altered mental status 1

4. Rapid deterioration risk - patients with intracranial hemorrhage can deteriorate rapidly, requiring frequent neurological reassessments (every 15-30 minutes initially) 2

5. Covert brain lesions - imaging-detected hemorrhages without obvious clinical symptoms can occur at more than tenfold the rate of clinically symptomatic bleeds 1

When intracranial bleeding is suspected based on physical examination findings, immediate CT imaging is the first-line diagnostic test, with MRI as an alternative when available 1.