Management of traumatic subarachnoid hemorrhage by the trauma service: is repeat CT scanning and routine neurosurgical consultation necessary?

Abstract

Subarachnoid hemorrhage (SAH) results frequently from traumatic brain injury (TBI). The standard management for these patients includes brief admission by the acute care surgery (trauma) service with neurological checks, neurosurgical consultation and repeat head CT within 24 hours to identify any progression or resolution. Recent studies have questioned the need for repeat CT imaging and specialty consultation in mild TBI. We reviewed patients with mild TBI specifically with isolated SAH to determine progression of the pathology and need for neurosurgical involvement. All patients with SAH secondary to mild TBI (Glasgow Coma Score (GCS) of 13–15) who presented over a 5-year period (January 2010 to December 2014) to a level I trauma center were identified from the trauma registry. Demographic data, initial CT findings, neurosurgical consultation, follow-up CT findings, Injury Severity Score (ISS), admission GCS and length of stay (LOS) were all obtained from the patient’s charts. Patients with other traumatic brain lesions on the initial CT were excluded. There were 299 patients (male, 48.5%), mean age 60.9 and mean ISS 8. Average time between the first and second CT was 11.3 hours. In all, 267 (89.2%) patients had either no change or an improvement/resolution on follow-up CT scan. Only 26 patients (8.7%) had either worsening or new findings on CT. Eight patients did not have a second scan completed (2.6%). All patients had neurosurgical consultation. Patients with mild TBI with isolated SAH generally have low morbidity, short LOS and negligible mortality. Less than 10% of this population had worsening of their head injury on repeat CT scanning. Given the low acuity of these patients with SAH and tendency towards resolution without intervention, acute care surgeons can manage this specific group of patients with TBI without routine neurosurgical consultation. Repeat CT scanning continues to have utility as it may identify new lesions, deterioration or need for further management.

Repeat Head CT for Neurologically Stable Patients With Mild Traumatic Subarachnoid Hemorrhage During Interfacility Transfer and Follow-Up Does Not Alter Patient Care

“…16 However, Cooper et al noted that around 10% of patients with mild isolated tSAH required repeat CT scanning in their study and recommended repeat CT scan even in isolated mild tSAH. 17 Nassiri et al, in their meta-analysis, noted that out of 15 327 patients with isolated tSAH, only 0.75% showed neurological deterioration and 5.76% showed progression on imaging, similar to our experience. None of the patients required intervention at presentation and only 0.0017% subsequently needing neurosurgical intervention.…”

Multicenter assessment of the Brain Injury Guidelines and a proposal of guideline modifications

“…2 Most protocols governing patient care for TBI with intracranial hemorrhage (ICH) mandate an inpatient or intensive care unit (ICU) admission, a neurosurgery consult, and at least one repeat head CT scan. [3][4][5][6][7][8][9][10][11] The allocation of resources is at the forefront of the current discussion regarding healthcare. Decreasing unnecessary hospital and ICU admissions, reducing consults of questionable utility and minimizing CT scans of limited clinical relevance are all potential sources for dramatic cost savings.…”

<p>Traumatic Subarachnoid Hemorrhage Resulting from Posterior Communicating Artery Rupture</p>

“…1,2 It is the second most common acute brain injury finding on computed tomography (CT) in traumatic brain injury (TBI) patients. 3 Traumatic SAH in patient with mild TBI is a favorable finding not likely to require surgical intervention; [1][2][3][4][5][6][7] the mortality rate in these patients is not different from that in concussion patients. 3 Some investigators have even proposed that routine neurosurgical consultation 6 or intensive care unit admission is not mandatory in the absence of other significant trauma or clinical deterioration.…”