The nonsurgical nature of patients with subarachnoid or intraparenchymal hemorrhage associated with mild traumatic brain injury

Ditty, Benjamin J.; Omar, Nidal B.; Foreman, Paul M.; Patel, Daxa; Pritchard, Patrick R.; Okor, Mamerhi O.

doi:10.3171/2014.10.jns132713

Cited by 37 publications

(39 citation statements)

References 15 publications

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“…Joseph et al concluded, based on their data that ACS services can independently care for patients with mild TBI without obtaining a formal neurosurgical consultation given the rarity of neurosurgical consultation in this group 12. A recent study from Alabama concluded patients with mild TBI with isolated tSAH or intraparenchymal hemorrhage should not require a neurosurgical consultation or even transfer to a major center 7. In a retrospective study specifically looking at isolated tSAH, Phelan et al concluded that these injuries are less severe brain injuries than other TBI and those with GCS scores of 13–15 demonstrate low rates of clinical progression.…”

Section: Discussionmentioning

confidence: 99%

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

Cooper

Bethea

Skrobut

et al. 2019

Trauma Surg Acute Care Open

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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.

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Section: Discussionmentioning

confidence: 99%

“…A more selective approach has been proposed, with repeat studies in patients with deterioration in their Glasgow Coma Score (GCS) 4 5. The need for a mandatory neurosurgery consultation has also been questioned 6 7…”

Section: Introductionmentioning

confidence: 99%

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

Cooper

Bethea

Skrobut

et al. 2019

Trauma Surg Acute Care Open

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“…In contrast to those patients with tSAH in the presence of other intracranial hemorrhage, the prognosis of patients with isolated tSAH is good [ 9 , 10 ]. In patients with mild TBI (Glasgow Coma Scale (GCS) score ≥13) and isolated tSAH, no neurologic decline or need for neurosurgical procedures was observed [ 11 , 12 , 13 , 14 , 15 ]. In a retrospective study evaluating isolated tSAH in patients with mild TBI (GCS 13–15), of 67 patients, only 1 patient (1.5%) experienced neurological deterioration, and not a single patient required neurosurgical intervention [ 16 ].…”

Section: Introductionmentioning

confidence: 99%

Prediction of Mortality in Patients with Isolated Traumatic Subarachnoid Hemorrhage Using a Decision Tree Classifier: A Retrospective Analysis Based on a Trauma Registry System

Rau

Chien

et al. 2017

IJERPH

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Background: In contrast to patients with traumatic subarachnoid hemorrhage (tSAH) in the presence of other types of intracranial hemorrhage, the prognosis of patients with isolated tSAH is good. The incidence of mortality in these patients ranges from 0–2.5%. However, few data or predictive models are available for the identification of patients with a high mortality risk. In this study, we aimed to construct a model for mortality prediction using a decision tree (DT) algorithm, along with data obtained from a population-based trauma registry, in a Level 1 trauma center. Methods: Five hundred and forty-five patients with isolated tSAH, including 533 patients who survived and 12 who died, between January 2009 and December 2016, were allocated to training (n = 377) or test (n = 168) sets. Using the data on demographics and injury characteristics, as well as laboratory data of the patients, classification and regression tree (CART) analysis was performed based on the Gini impurity index, using the rpart function in the rpart package in R. Results: In this established DT model, three nodes (head Abbreviated Injury Scale (AIS) score ≤4, creatinine (Cr) <1.4 mg/dL, and age <76 years) were identified as important determinative variables in the prediction of mortality. Of the patients with isolated tSAH, 60% of those with a head AIS >4 died, as did the 57% of those with an AIS score ≤4, but Cr ≥1.4 and age ≥76 years. All patients who did not meet the above-mentioned criteria survived. With all the variables in the model, the DT achieved an accuracy of 97.9% (sensitivity of 90.9% and specificity of 98.1%) and 97.7% (sensitivity of 100% and specificity of 97.7%), for the training set and test set, respectively. Conclusions: The study established a DT model with three nodes (head AIS score ≤4, Cr <1.4, and age <76 years) to predict fatal outcomes in patients with isolated tSAH. The proposed decision-making algorithm may help identify patients with a high risk of mortality.

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“…Although a change in GCS score is used to identify neurological deterioration, which is often an indication for a neurosurgical intervention, admission GCS score has been repeatedly shown to be a poor determinant of subsequent neurosurgical intervention; our study lends support to this conclusion. 3,27,36 This reoccurring observation should not be unexpected because the GCS was designed to reflect differences in the risk for mortality, not neurosurgical intervention. When we examined the interaction of GCS score and hemorrhage thickness in a multivariable logistic regression model, the odds of neurosurgical intervention for each millimeter increase in hemorrhage thickness was similar for each admission GCS group (p-interaction 0.19).…”

Section: Discussionmentioning

confidence: 97%

“…A question repeatedly posed in the TBI literature is whether a neurosurgical consultation, or a requirement for neurosurgical coverage, is necessary for all patients with an mTBI and ICH. 2,3,8,11,14,17,36 Unfortunately, we do not have enough of an understanding of the risk for neurosurgical intervention to create management guidelines addressing particular ICH types in patients with mTBI. 9 In order to better understand the risk, we must collect detailed information about each injury and assess the influence of each variable on the risk of neurosurgical intervention through predictive modeling.…”

mentioning

confidence: 99%

Isolated subdural hematomas in mild traumatic brain injury. Part 1: the association between radiographic characteristics and neurosurgical intervention

Orlando¹,

Levy²,

Rubin

et al. 2019

Journal of Neurosurgery

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OBJECTIVE Isolated subdural hematomas (iSDHs) are one of the most common intracranial hemorrhage (ICH) types in the population with mild traumatic brain injury (mTBI; Glasgow Coma Scale score 13-15), account for 66%-75% of all neurosurgical procedures, and have one of the highest neurosurgical intervention rates. The objective of this study was to examine how quantitative hemorrhage characteristics of iSDHs in patients with mTBI at admission are associated with subsequent neurosurgical intervention. METHODS This was a 3.5-year, retrospective observational cohort study at a Level I trauma center. All adult trauma patients with mTBI and iSDHs were included in the study. Maximum length and thickness (in mm) of acute SDHs, the presence of acute-on-chronic SDH, mass effect, and other hemorrhage-related variables were double-data entered; discrepant results were adjudicated after a maximum of 4 reviews. Patients with coagulopathy, skull fractures, no acute hemorrhage, a non-SDH ICH, or who did not undergo imaging on admission were excluded. The primary outcome was neurosurgical intervention (craniotomy, burr hole, catheter drainage of SDH, placement of intracranial pressure monitor, shunt, or ventriculostomy). Multivariate stepwise logistic regression was used to identify significant covariates and to assess interactions. RESULTS A total of 176 patients were included in our study: 28 patients did and 148 patients did not receive a neurosurgical intervention. Increasing head Abbreviated Injury Scale score was significantly associated with neurosurgical interventions. There was a strong correlation between the first 3 reviews on maximum hemorrhage length (R = 0.82) and maximum hemorrhage thickness (R = 0.80). The neurosurgical intervention group had a mean maximum SDH length and thickness that were 61 mm longer and 13 mm thicker than those of the nonneurosurgical intervention group (p < 0.001 for both). After adjusting for the presence of an acute-on-chronic hemorrhage, for every 1-mm increase in the thickness of an iSDH, the odds of a neurosurgical intervention increase by 32% (95% CI 1.16-1.50). There were no interventions for any SDH with a maximum thickness ≤ 5 mm on initial presenting scan. CONCLUSIONS This is the first study to quantify the odds of a neurosurgical intervention based on hemorrhage characteristics in patients with an iSDH and mTBI. Once validated in a second population, these data can be used to better inform patients and families of the risk of future neurosurgical intervention, and to evaluate the necessity of interhospital transfers.

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The nonsurgical nature of patients with subarachnoid or intraparenchymal hemorrhage associated with mild traumatic brain injury

Abstract: Patients with the constellation of SAH and/or IPH and mTBI do not require neurosurgical consultation, and these findings should not be used as the sole criteria to justify transfer to tertiary referral centers.

Cited by 37 publications

References 15 publications

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

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

Prediction of Mortality in Patients with Isolated Traumatic Subarachnoid Hemorrhage Using a Decision Tree Classifier: A Retrospective Analysis Based on a Trauma Registry System

Isolated subdural hematomas in mild traumatic brain injury. Part 1: the association between radiographic characteristics and neurosurgical intervention

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