Page 158 - Critical Care Notes

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NEURO

Clinical Presentation
■ Sudden, severe “thunderclap” headache developing over seconds to minutes.
Patient complains of it being “the worst headache in their life” (WHOL).
■ Lethargy, irritability, ↓ LOC; confusion and agitation. May progress to coma.
■ Pain in neck or back.
■ Nuchal rigidity (stiff neck).
■ Nausea and vomiting.
■ Photophobia, diplopia, orbital pain, visual loss, blurred vision, and oculo-
motor nerve abnormalities (affected eye looking downward and outward,
pupil widened and less responsive to light) involving optic, oculomotor, or
trigeminal cranial nerves.
■ Paralysis; positive Brudzinski’s sign and Kernig’s sign.
■ Tinnitus, dizziness, vertigo, neurological deficits including hemiparesis.
■ Fatigue, fever, and HTN.
■ Cardiac arrhythmias (can progress to cardiac arrest).
■ Seizures may occur early on or later.
Diagnostic Tests
■ Calculate the severity of SAH using the Hunt and Hess Classification of SAH:
http://www.mdcalc.com/hunt-and-hess-classification-of-subarachnoid-
hemorrhage-sah/
■ Hunt and Hess scale is used to classify the severity of nontraumatic SAH.
Hunt and Hess Classification of SAH

Grade
I Asymptomatic, mild headache, slight nuchal rigidity
II Moderate to severe headache, nuchal rigidity, no neurological
deficit other than cranial nerve palsy
III Drowsiness/confusion, mild focal neurological deficit
IV Stupor, moderate to severe hemiparesis
V Coma, decerebrate posturing
From Hunt, W.E., Hess, R.M.: Surgical risk as related to time of intervention in the repair of
intracranial aneurysms. J Neurosurg 28(1):14–20, 1968.

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