Clinical Syndromes, Features, Presentation, Physical Examination and Neurologic Findings
Intracerebral Hemorrhage (ICH)
The classic presentation of ICH includes sudden onset of focal neurological deficit while the patient is active, with smooth symptomatic progression over minutes to hours—a pattern uncommon in ischemic stroke and rare in subarachnoid hemorrhage. 1
Clinical Features
- Headache is more common with ICH than ischemic stroke, though less common than subarachnoid hemorrhage 1
- Vomiting is more common with ICH than either ischemic stroke or subarachnoid hemorrhage 1
- Elevated blood pressure and impaired level of consciousness are common findings 1
- Fever >37.5°C persisting for >24 hours is found in 83% of patients with poor outcomes and correlates with ventricular extension 1
Physical Examination Priorities
The examination focuses on: 1
- Level of consciousness (Glasgow Coma Scale score is one of the most powerful predictors of 30-day mortality)
- Degree of neurological deficit
- Airway, breathing, circulation, and vital signs
- Elevated systolic blood pressure >160 mm Hg on admission (associated with hematoma growth in retrospective studies) 1
Prognostic Indicators
- ICH volume and Glasgow Coma Scale grade on admission are the most powerful predictors of death by 30 days 1
- Hydrocephalus is an independent indicator of 30-day death 1
- Cortical location, mild neurological dysfunction, and low fibrinogen levels are associated with good outcomes 1
Seizures and Status Epilepticus
Clinical Presentation
New-onset seizures require assessment for metabolic abnormalities including hypoglycemia, hyponatremia, and hypocalcemia, as history and physical examination may not predict all metabolic causes. 1, 2
Key Historical Features
- Medication non-compliance significantly increases seizure recurrence risk in epilepsy patients 2
- Prescribed medications (e.g., tramadol) can lower seizure threshold 2
- Alcohol withdrawal is a common cause of seizures 1
- Fever in 9 patients with new-onset seizures: 5 of 9 had CNS infection 1
Physical Examination Findings
- Focal neurological examination: 97% of patients with focal examination had symptomatic seizures; 81% with focal neurologic examination had focal lesion on CT 1
- Normal neurologic examination: 17% still had focal CT abnormalities 1
- Meningeal signs: Important for identifying CNS infections 1
Laboratory Considerations
- Metabolic abnormalities (hypoglycemia, hyponatremia, hypocalcemia) can be identified, though 3 cases in one study were not predicted by history and physical examination 1
- Hypomagnesemia: 8 of 18 alcohol-related seizure patients had magnesium <1.5 mEq/L 1
Gliomas and Brain Tumors
Temporal Evolution of Symptoms
The evolution of neurological symptoms enables estimation of tumor growth dynamics: symptoms present for only weeks suggest fast-growing tumors, while symptoms for years suggest slow-growing tumors. 1
Characteristic Presentations
- New-onset epilepsy 1
- Focal deficits (pareses or sensory disturbances) 1
- Neurocognitive impairment 1
- Symptoms and signs of increased intracranial pressure 1
Physical Examination Components
- Systemic cancer detection to differentiate primary brain tumors from metastases 1
- Neurological Assessment in Neuro-Oncology (NANO) scale can document neurological examination results 1
- Karnofsky performance score (KPS) and neurological function assessment 1
- Neurocognitive assessment using standardized test battery, MMSE, or MoCA 1
Sudden Sensorineural Hearing Loss (SSNHL)
Modifying Factors Requiring Assessment
Clinicians must assess for bilateral hearing loss, recurrent episodes, and focal neurologic findings, as idiopathic SSNHL is rarely bilateral or recurrent and lacks other focal neurologic symptoms. 1
Red Flag Features
- Bilateral sudden hearing loss 1
- Antecedent fluctuating hearing loss on one or both sides 1
- Concurrent severe bilateral vestibular loss with oscillopsia 1
- Gaze-evoked or downbeat nystagmus 1
- Focal neurologic symptoms: headache, confusion, diplopia, dysarthria, focal weakness, focal numbness, ataxia, facial weakness 1
- Recent head trauma, acoustic trauma, or barotrauma 1
Associated Conditions
- Multiple sclerosis: Isolated eighth nerve palsy is extremely rare (<1%); usually other focal neurologic symptoms present 1
- Meningitis (infectious, inflammatory/autoimmune, or neoplastic): Usually associated with headache, other cranial nerve palsies, and focal neurologic signs 1
- Ménière's disease: Most common cause of fluctuating hearing loss presenting as SSNHL 1
Elevated Intracranial Pressure (ICP)
Clinical Manifestations
Symptoms of elevated ICP may be difficult to distinguish from other disease states, requiring high clinical suspicion and early monitoring before changes in vital signs or neurological status occur. 3, 4
Physical Examination Findings
- Level of consciousness changes 1
- Focal neurological deficits 1
- Signs of herniation: Clinical evidence may be present even when CT fails to detect it 5
Imaging Findings Associated with Elevated ICP
- Sulcal obliteration (significantly associated with ICP ≥20 mm Hg) 6
- Third ventricular compression (significantly associated with ICP ≥20 mm Hg) 6
- Lateral ventricle compression 6
- Midline shift 6
- Herniation 6
Critical Pitfall
Cranial CT may fail to rule out severely raised ICP or cerebral herniation in patients with bacterial meningitis or other conditions—clinical suspicion should guide ICP monitoring regardless of CT appearance. 5
COVID-19 Neurological Manifestations
CNS Involvement Frequency
CNS involvement occurs in 36.4% of COVID-19 cases overall, increasing to 45.5% in severe disease. 1
Mild CNS Manifestations
- Dizziness (16.8%) 1
- Headache (13.1%) 1
- Hypogeusia (5.6%) 1
- Hyposmia (5.1%) 1
- Ataxia (0.5%) 1
- Neuralgia (2.3%) 1
Severe Manifestations
- Skeletal muscle injury (10.7%) 1
- Acute cerebrovascular disease (2.8%) 1
- Epilepsy (0.5%) 1
- Confusion (65% in ICU patients) 1
- Agitation (69% in ICU patients) 1
- Corticospinal tract signs (67% in ICU patients) 1
- Dysexecutive syndrome (36% in ICU patients) 1
- Leptomeningeal enhancement on brain MRI (62% of patients imaged) 1
Subarachnoid Hemorrhage from Aneurysm
Clinical Presentation
Typical symptoms include severe headache, nausea, vomiting, photophobia, and nuchal rigidity. 1