Patients with traumatic subarachnoid hemorrhage are at low risk for deterioration or neurosurgical intervention

J Trauma Acute Care Surg. 2013 Jun;74(6):1504-9. doi: 10.1097/TA.0b013e31829215cf.


Background: Current standard of care for patients with traumatic intracranial hemorrhage (TIH) includes neurosurgical consultation and/or transfer to a trauma center with neurosurgical backup. We hypothesize that a set of low-risk criteria can be applied to such patients to identify those who may not require neurosurgical evaluation.

Methods: This is a cross-sectional study of consecutive emergency department patients in 2009 and 2010 with TIH on computerized tomographic scan owing to blunt head trauma. Patients presented to an urban academic Level I trauma center (volume, 92,000) were older than 15 years and had a Glasgow Coma Scale (GCS) score of 13 or greater. Charts were abstracted using a standardized data form by two emergency physicians. Our principal outcome was deterioration represented by a composite of neurosurgical intervention, clinical deterioration, or worsening computerized tomographic scan result.

Results: During the study period, 404 patients were seen with TIH and met our inclusion criteria, and 48 of those patients (11.8%) deteriorated. Patients with isolated subarachnoid hemorrhage, were less likely to deteriorate (odds ratio [OR], 0.08; 95% confidence interval [CI], 0.011-0.58). Characteristics associated with deterioration were subdural hematomas (OR, 2.63; 95% CI, 1.198-5.81) or presenting GCS of less than 15 (OR, 2.12; 95% CI, 1.01-4.43).The use of anticoagulant medications or antiplatelet agents were not associated with deterioration for warfarin, aspirin, or clopidogrel; however bleeding diatheses were corrected with vitamin K, fresh frozen plasma, and platelets as necessary.

Conclusion: Patients with isolated traumatic subarachnoid hemorrhage are at low risk for deterioration. These individuals may not need neurosurgical consultation or transfer to a trauma center where neurosurgical backup is available. Those patients with subdural hematoma or a GCS of less than 15 have a higher risk of deterioration and require neurosurgical evaluation.

Level of evidence: Therapeutic/care management, level IV.

MeSH terms

  • Adolescent
  • Adult
  • Aged
  • Aged, 80 and over
  • Cross-Sectional Studies
  • Female
  • Glasgow Coma Scale
  • Head Injuries, Closed / diagnosis
  • Head Injuries, Closed / diagnostic imaging
  • Head Injuries, Closed / surgery
  • Humans
  • Logistic Models
  • Male
  • Middle Aged
  • Risk Factors
  • Subarachnoid Hemorrhage, Traumatic / diagnosis*
  • Subarachnoid Hemorrhage, Traumatic / diagnostic imaging
  • Subarachnoid Hemorrhage, Traumatic / surgery
  • Tomography, X-Ray Computed
  • Trauma Centers / statistics & numerical data
  • Young Adult