Management of traumatic brain injury (TBI) is a common issue faced by trauma professionals. And isolated subarachnoid hemorrhage (SAH) is one of the more common presentations. In many centers, this diagnosis frequently results in admission to the hospital, neurosurgical consultation, and repeat imaging.
Is this too much care? We adopted a practice guideline nearly two years ago based on our own clinical experience that eliminated the last two. Patients were still admitted for neurologic monitoring for 16 hours. But is even this too much?
What we really need is a better understanding of the natural history of uncomplicated traumatic SAH. Well, a study from Sunnybrook and the University of Toronto does just that. They performed a 17 year meta-analysis of the literature on isolated SAH with mild TBI (GCS 13-15). They pared their initial literature search of nearly 2900 studies down to the usual few, 13 in this case. All but one were retrospective, of course, and they had the usual design flaws.
Here are the factoids:
- How many patients eventually needed neurosurgical intervention? 0 (Well, almost zero. It was 0.0017%, to be exact.)
- How many had progression of the SAH? About 6%
- How many had neurologic deterioration? 0.75%, which included two patients with increased headache and one with some confusion. Two developed intraparenchymal hemorrhage (one was on anticoagulants)
- How many died? Only 1 died from neurologic causes, and that patient was anticoagulated at the time of injury.
Bottom line: It looks like we may be overdoing it for patients with isolated SAH and mild TBI. The natural history seems to be fairly benign, unless the patient is taking anticoagulants. The type of drug was not specified, so warfarin, aspirin, clopidogrel, and the newer anticoagulants should all be included.
Perhaps it’s time to update the our practice guidelines further. It looks like most of these simple, isolated SAH can be evaluated and released. However, if the GCS is 13 or 14, they should still be admitted for monitoring for a short period. And if on anticoagulants, admission with a repeat CT is in order.
- Regions Hospital SAH practice guideline
- Do we really need to consult neurosurgery for mild TBI?
- SAH, neurosurgery consults, and repeat CT
Reference: The clinical significance of isolated traumatic subarachnoid hemorrhage in mild traumatic brain injury: A meta-analysis. J Trauma , published ahead of print, July 8 2017.