Tag Archives: subarachnoid hemorrhage

Abstracts, CNS

Best Of AAST 2022 #5: Traumatic Subarachnoid Hemorrhage

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Traditionally, just about any type of intracranial hemorrhage (ICH) prompts a thorough neurological investigation and frequently involves a neurosurgery consultation. Subarachnoid hemorrhage (SAH) is one type of ICH that has historically demonstrated very few adverse consequences. Yet the custom of performing a time-consuming and expensive evaluation has persisted.

Over the past few years, the literature about the lack of utility of this practice has been growing. Many trauma centers (including my own at Regions Hospital) have simplified the evaluation of traumatic SAH. We have actually come to a point that we don’t even admit most of these patients. And if we are not going to admit them, why should we even accept them in transfer from other hospitals?

The trauma group at Lehigh Valley in Pennsylvania performed a five-year review of their own hospital experience (Level I trauma center) from 2015-2019. They wanted to answer the question about the necessity of transferring SAH patients to a higher-level trauma center for evaluation. They limited the study to patients with an isolated SAH. These patients were evaluated for factors that would indicate the potential for a worsening repeat CT scan.

Here are the factoids:

  • The study patients were older (mean 73 years) with a slight preponderance of females
  • ISS was low (mean 5) as would be expected for an isolated injury
  • Slightly more than half (57%) were transferred from other hospitals
  • A total of 350 patients were reviewed, and 97% had a neurosurgery consult
  • Only one patient required neurosurgical intervention, and four died in hospital
  • A total of 311 patients had a repeat CT scan and 16 showed a worse result
  • Higher AIS head was associated with a worse result

The authors concluded that it is safe to manage traumatic SAH without transfer to a higher level trauma center.  They also suggest that neurosurgical consultation is not needed and that repeat imaging may not be very useful.

Bottom line: This abstract conforms to my own opinion, so I have to take great care not to succumb to my confirmation bias. The authors found that nearly no one needed neurosurgical intervention and concluded that a neurosurgical consult is probably not needed. This is all based on a low incidence of progression and few adverse events. I agree totally.

But I also think that referring hospitals will find these few adverse events and progressions troubling. Remember, 16 patients had a worse scan,  four died during their hospital stay, and one needed an operation. Thus, it will be very important for the authors to explain the details of these patients to assuage any fears that they might deteriorate in the outside hospital ED. 

My own experience indicates that “worsening CT” is typically just a slightly larger SAH and not the sudden development of subdural or epidural blood. This is more likely to happen in patients on thinners and they should be excluded from this pool anyway. They have very specific evaluation needs.

Based on recent published literature and our own clinical experience, the Regions trauma program discharges any patient with traumatic SAH who is not on thinners and has a GCS 15. They are given instructions to follow up with their primary care provider, and to schedule a TBI clinic appointment if they feel they have any persistent post-concussive symptoms. And because of this practice, the ED will not accept transfer of patients with this isolated injury.

You can download a copy of the protocol here.

Here are my questions for the authors and presenter:

  1. Please provide details on the patients with CT progression, operation, and death. We need to know if these were serious CT changes, or just incidental findings and complications from other causes.
  2. How successful have you been at resisting transfers in? Most referring centers are initially “not comfortable” with these patients, even though they can easily follow our simple evaluation guideline. It takes time and education to bring them into the fold.

I enjoyed this abstract and await the details to come in the presentation!

Head

What Happens To Your Average Subarachnoid Hemorrhage?

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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.

Related posts:

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.

Head, Imaging

EAST 2017 #5: Subarachnoid Hemorrhage, Neurosurgical Consults, and Repeat Head CT

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Neurosurgical involvement in the management of simple traumatic brain injury (TBI) has been slowly dwindling over the past several years. This is the result of the general consensus that very few of these patients progress to need neurosurgical procedures.

A group at Wright State University in Dayton sought to define the progression of one specific finding in TBI, the subarachnoid hemorrhage (SAH). Secondarily, the wanted to determine if a neurosurgery consultation was warranted in these patients.

They performed a five year retrospective review of their registry data, identifying patients with both mild TBI (GCS 13-15) and SAH. They excluded patients with any other brain lesion on CT.

Here are the factoids:

  • 301 patients were enrolled during the 5 year period
  • All had a neurosurgical consultation
  • Time between the initial CT and a followup scan was about 11 hours
  • 91% showed stable or resolving SAH on the followup scan
  • 9% showed a worsening SAH or additional lesions on the repeat scan

Bottom line: The authors conclude that initial neurosurgical consultation is not needed, since only 9% of patients have worrisome findings on repeat CT. They do, however, recommend that the practice of repeat scanning be continued because of this same number.

Our trauma service looked at this issue a year ago, and determined that most of these lesions either do not progress, or never require any intervention if they do, with a few notable exceptions. For that reason, we abandoned both neurosurgical consultation and repeat CT scans for patients with non-aneurysmal SAH, a single parenchymal hemorrhage, or linear skull fractures. We continue to do both for patients with epidural and/or subdural hemorrhage. You can download a copy of this protocol here.

Questions and comments for the authors/presenters:

  • Did you look at platelet count or INR in the study. Were patients excluded based on abnormal values?
  • Did every patient get a repeat scan?
  • Break down the lesions in the 9% of patients who had some sort of progression or new finding. Did you see any common themes (age, chronic alcohol use, etc.)?
  • Did you encounter any patients with “non-central SAH”, that might indicate an aneurysm? How were they dealt with?
  • How has or will your trauma service change its practice based on your findings.

Click here to go the the EAST 2017 page to see comments on other abstracts.

Related posts:

Reference:   Management of subarachnoid hemorrhage (SAH) by the trauma service: are repeat CT scanning & routine neurosurgical consultation necessary? Poster #16, EAST 2017.

General

Delayed Intracranial Hemorrhage In Patients On Anticoagulants

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A sizable portion of our population is taking one type of anticoagulant or another. Heck, even golf star Arnold Palmer and comedian Kevin Nealon are on Xarelto! Any trauma professional, and anyone who reads the package insert, knows that there is an increased risk of bleeding if they are injured while taking these drugs, whether it be warfarin or the new, novel anticoagulants.

But does the risk stop soon after injury? That is the presumption at many hospitals that initially treat these patients. They are seen in the ED, examined, scanned, and sent home if nothing is found. Is this a safe practice?

I have personally seen a patient who had an initially clean CT present within 12 hours after ED discharge with a catastrophic bleed and die. Yes, this is anecdotal, but I have talked to other trauma professionals with similar experiences. If this were just a minor complication, no big deal. But they died. Big problem for everyone involved.

So what does the literature say? Unfortunately, it consists of a collection of relatively small studies. Here are the collected factoids that I can glean from them:

  • Most are retrospective, observational studies 
  • Most are from a single hospital, which may miss readmissions to other facilities in the area
  • The delayed bleeding rate is about 0.5% to 1%
  • Some papers recommended discharging patients with a normal head CT and giving them instructions to return if new symptoms develop (this is what happened with my patient; what if they live alone or in a care center where these may not be recognized?!)
  • A few papers did identify patients needing neurosurgical intervention or who died
  • Immediate bleeds were more common with antiplatelet agents, delayed bleeds were more common with warfarin
  • I could find nothing that looked at this problem in patients taking novel anticoagulants like Pradaxa or Xarelto

Bottom line: The literature provides little guidance at this point. A good multi-institutional trial is needed to generate the numbers to tell us what to do. While we get around to this, I recommend that a selective brief observation (12 hrs) protocol be adopted. This protocol recognizes that subclinical bleeding may be present on initial presentation, and that a little more time is needed for it to declare itself.

Here is a link to our protocol. If the initial head CT is negative and the INR is less than 2.5, we will only discharge the patient if all of these criteria are true:

  • Age < 65
  • No skull fx
  • No new focal neurologic deficits
  • No soft tissue injury visible on CT (hematoma, laceration)
  • GCS = 15
  • No persistent vomiting
  • Brief TBI screen passed (Short Blessed Test, link here)

Most do not pass all of these, usually failing the age criterion. They are admitted for observation and neurologic monitoring for 12 hours, at which time the head CT is repeated. If it is still normal, then they can go home.

And although this protocol was designed with warfarin in mind, we apply it to patients taking novel anticoagulants like Pradaxa and Xarelto as well. We’ve had no epic fails yet, but I keep my fingers crossed!

Related posts:

References:

  • Management of minor head injury in patients receiving oral anticoagulant therapy: a prospective study of a 24-hour observation protocol. Ann Emerg Med 59(6):451-455, 2012.
  • Immediate and delayed traumatic intracranial hemorrhage in patients with head trauma and preinjury warfarin or clopidogrel use. Ann Emerg Med 59(6):460-468, 2012.
  • Delayed intracranial hemorrhage after blunt trauma: are patients on preinjury anticoagulants and prescription antiplatelet agents at risk? J Trauma 71(6):1600-1604, 2011.
  • Low risk of late intracranial complications in mild traumatic brain injury patients using oral anticoagulation after an initial normal brain computed tomography scan: education instead of hospitalization. Eur J Neurol 21(7):1021-1025, 2014.
  • Can anticoagulated patients be discharged home safely from the emergency department after minor head injury? J Emerg Med 46(3):410-417, 2014.
  • Patients with blunt head trauma on anticoagulation and antiplatelet medications: can they be safely discharged after a normal initial cranial computed tomography scan? Am Surg 80(6):610-613, 2014.
General

When To Worry About Subarachnoid Hemorrhage

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Neurosurgeons tend to worry about aneurysms a lot. They can cause devastating and lasting neurologic dysfunction. The most common diagnostic finding, besides the classic “worst headache of my life” complaint, is subarachnoid hemorrhage (SAH). And one of the more common CT findings after head trauma is also SAH. 

For that reason, CT angiography tends to get added on to the trauma workup from time to time. Trauma professionals are faced with the “chicken or the egg” question, trying to figure out if a leaking aneurysm caused the subarachnoid blood and then the fall/crash, or the fall/crash caused the blood.

A group at St. Luke’s Hospital in Bethlehem PA looked at this question using 5 years worth of retrospective data from their Level I trauma center. They noted a significant increase in the number of CT angiographic (CTA) studies being ordered in their head trauma patients and wanted to determine which patients would benefit most from this study.

Here are the factoids:

  • 617 patients were identified with traumatic SAH during the study period, and 186 of them (30%) underwent CTA
  • 13 patients (7%) who had CTA actually had an aneurysm
  • Of these 13 patients, 8 were believed to have presented with trauma caused by the aneurysm because they were found to be ruptured

  • All patients who had a ruptured aneurysm had a pattern of central subarachnoid hemorrhage on CTA

  • Of the patients who were “found down”, none had an aneurysm

Bottom line: Pre-existing aneurysms are not any more common in TBI patients than they are in the general population. However, they may be the cause of trauma on occasion. Contrary to what many think, they seem to be uncommon in cases of patients who are found down; it looks like the trauma usually comes first. However, a pattern of central subarachnoid hemorrhage is reasonably predictive of this uncommon yet dangerous problem, so addition of CT angiography of the head when it is seen on non-contrast CT appears to be warranted.

Related posts:

Reference: Selected computed tomographic angiography in traumatic subarachnoid hemorrhage: a pilot study. J Surg Research, in press, 2015.