A 69-year-old man comes to the emergency department due to severe occipital headache, nausea, and vomiting for the last 3 hours. He has never had a headache like this before and has otherwise been in good physical condition. The patient was told several years ago that he has high blood pressure, but he has not been taking any medications or seen any health care providers. He has smoked half a pack of cigarettes daily for 40 years and drinks 1 or 2 cans of beer every evening. Both of his parents died of natural causes. Blood pressure is 160/90 mm Hg and pulse is 86/min and regular. His noncontrast head CT scan is shown in the image below. Which of the following physical examination findings is most likely to be seen in this patient?

Question

A 69-year-old man comes to the emergency department due to severe occipital headache, nausea, and vomiting for the last 3 hours.  He has never had a headache like this before and has otherwise been in good physical condition.  The patient was told several years ago that he has high blood pressure, but he has not been taking any medications or seen any health care providers.  He has smoked half a pack of cigarettes daily for 40 years and drinks 1 or 2 cans of beer every evening.  Both of his parents died of natural causes.  Blood pressure is 160/90 mm Hg and pulse is 86/min and regular.  His noncontrast head CT scan is shown in the image below.  Which of the following physical examination findings is most likely to be seen in this patient?

Quizplus · Accepted Answer

11ec25c8_d534_3cb5_bc81_6b9d86344122_MD0003_00 This patient has developed a spontaneous intraparenchymal hemorrhage in the right cerebellar hemisphere (red arrow) likely related to poorly controlled hypertension. The most common sites for hypertensive hemorrhage in descending order include the basal ganglia (putamen), cerebellar nuclei, thalamus, pons, and cerebral cortex. Patients with intraparenchymal hemorrhage usually present with gradual onset of symptoms (minutes to a few hours) in contrast to brain embolism or subarachnoid hemorrhage, in which symptoms are abrupt. intraparenchymal hemorrhage Typical features of cerebellar hemorrhage include occipital headache (may radiate to neck/shoulders), neck stiffness (due to extension of blood into the 4th ventricle), nausea/vomiting, and nystagmus. Patients may also have ipsilateral hemiataxia of the trunk (cerebellar vermis) and/or limbs (cerebellar hemispheres) as the corticopontocerebellar fibers decussate twice. Hemiparesis and sensory loss are usually absent, but extension of the bleed to the brainstem can cause cranial neuropathies (eg, ipsilateral facial nerve palsy). Further hematoma expansion may lead to brainstem compression resulting in stupor, coma, and ultimately death. Early diagnosis with noncontrast head CT scan is crucial as emergency decompression may be life-saving, especially if the hemorrhage is >3 cm. (Choice A) Any unilateral visual pathway lesion beyond the optic chiasm (eg, optic tract, lateral geniculate body, optic radiations, primary visual cortex) can cause contralateral homonymous hemianopia. This is frequently seen with intracerebral hemorrhage affecting the basal ganglia or occipital lobe. (Choice B) Left hemineglect can occur with a lobar hemorrhage in the nondominant (usually right) parietal lobe. (Choices C and H) Contralateral hemiplegia can occur with cortical, subcortical, or upper brainstem lesions that injure the descending corticospinal tract. This is frequently seen with intracerebral hemorrhage affecting the basal ganglia, thalamus, or frontal lobe. (Choices D and I) Contralateral hemisensory loss may occur with cortical, subcortical (eg, thalamic), or upper brainstem lesions that injure the ascending somatosensory pathways (eg, dorsal column-medial lemniscal and anterolateral pathways). This often occurs with intracranial hemorrhage affecting the basal ganglia, thalamus, or parietal lobe. (Choice E) Pinpoint pupils are typically observed in patients with a large pontine hemorrhage due to damage to the descending sympathetic fibers. (Choice F) Right eye monocular vision loss can occur with damage to the ipsilateral retina (eg, retinal detachment, retinal artery occlusion) and/or optic nerve (eg, optic neuritis). Educational objective: Spontaneous cerebellar hemorrhage is typically caused by poorly controlled hypertension and presents with occipital headache, neck stiffness, nausea/vomiting, nystagmus, and ipsilateral hemiataxia. There is usually no hemiparesis or sensory loss. Early diagnosis with noncontrast head CT scan is important as emergency surgical decompression may be life-saving. References: Guidelines for the management of spontaneous intracerebral hemorrhage: a guideline for healthcare professionals from the American Heart Association/American Stroke Association. (http://www.ncbi.nlm.nih.gov/pubmed/20651276) Unusual clinical presentation of hypertensive cerebellar hemorrhage. (http://www.ncbi.nlm.nih.gov/pubmed/22347340)

A 69-Year-Old Man Comes to the Emergency Department Due to Severe