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traumatic_subarachnoid_hemorrhage

Traumatic subarachnoid hemorrhage (tSAH)

Is the most common cause of subarachnoid hemorrhage SAH.

Diagnosis

CT scan

High density spread thinly over convexity and filling sulci or basal cisterns.

When the history of trauma is not clear, an arteriogram may be indicated to R/O a ruptured aneurysm (possibly precipitating the trauma).

Treatment

Calcium channel blockers

In a Cochrane review of randomised controlled trials of calcium channel blockers in acute traumatic head injury patients shows that considerable uncertainty remains over their effects. The effect of nimodipine in a subgroup of brain injury patients with subarachnoid haemorrhage shows a beneficial effect, though the increase in adverse reactions suffered by the intervention group may mean that the drug is harmful for some patients 1).

Vergouwen et al, do not lend support to the finding of a beneficial effect of nimodipine on outcome in patients with traumatic subarachnoid haemorrhage as reported in an earlier Cochrane review 2).

Conti et al,describes of a patient with symptomatic and angiographically documented vasospasm following traumatic SAH which was refractory to maximal medical therapy and successfully treated with intra-arterial infusion of Nimodipine 3).

Complications

Hydrocephalus:

But also increase with severity of traumatic brain injury.

Outcome

In 661 patients with isolated tSAH. Only four patients (0.61%) underwent any sort of aggressive neurosurgical, medical, or endovascular intervention, regardless of GCS score. Most tSAH patients without additional systemic injury were discharged home (68%), including 53% of patients with a GCS score of 3-8. However, older patients were more likely to be discharged to a rehabilitation facility (p<0.01). There were six (1.7%) in-hospital deaths, and five patients of these patients were older than 80 years old.

Isolated tSAH, regardless of admission GCS score, is a less severe intracranial injury that is highly unlikely to require aggressive operative, medical, or endovascular intervention, and is unlikely to be associated with major neurologic morbidity or mortality, except perhaps in elderly patients. Based upon our findings, we argue that impaired consciousness in the setting of isolated tSAH should strongly compel a consideration of non-traumatic factors in the etiology of the altered neurological status 4).

Case series

A prospective, randomized, double-blind, placebo-controlled study of nimodipine used to treat traumatic subarachnoid hemorrhage (tSAH) was conducted in 21 German neurosurgical centers between January 1994 and April 1995. One hundred twenty-three patients with tSAH appearing on initial computerized tomography (CT) scanning were entered into the study. Requirements for inclusion included age between 16 and 70 and admission into the study within 12 hours after head injury, regardless of the patient's level of consciousness. Eligible patients received either a sequential course of intravenous and oral nimodipine or placebo treatment for 3 weeks. Patients were closely monitored using clinical neurology, computerized tomography, laboratory, and transcranial Doppler ultrasound parameters. Patients treated with nimodipine had a significantly less unfavorable outcome (death, vegetative survival, or severe disability) at 6 months than placebo-treated patients (25% vs. 46%, p = 0.02). The relative reduction in unfavorable outcome in the nimodipine-treated group was even higher (55%, p = 0.002) when only patients who complied with the protocol were considered 5).

1)
Langham J, Goldfrad C, Teasdale G, Shaw D, Rowan K. Calcium channel blockers for acute traumatic brain injury. Cochrane Database Syst Rev. 2003;(4):CD000565. Review. PubMed PMID: 14583925.
2)
Vergouwen MD, Vermeulen M, Roos YB. Effect of nimodipine on outcome in patients with traumatic subarachnoid haemorrhage: a systematic review. Lancet Neurol. 2006 Dec;5(12):1029-32. Review. PubMed PMID: 17110283.
3)
Conti A, Angileri FF, Longo M, Pitrone A, Granata F, La Rosa G. Intra-arterial nimodipine to treat symptomatic cerebral vasospasm following traumatic subarachnoid haemorrhage. Technical case report. Acta Neurochir (Wien). 2008 Nov;150(11):1197-202; discussion 1202. doi: 10.1007/s00701-008-0141-0. Epub 2008 Oct 29. PubMed PMID: 18958388.
4)
Lee JJ, Segar DJ, Asaad WF. Comprehensive Assessment of Isolated Traumatic Subarachnoid Hemorrhage. J Neurotrauma. 2014 Feb 6. [Epub ahead of print] PubMed PMID: 24224706.
5)
Harders A, Kakarieka A, Braakman R. Traumatic subarachnoid hemorrhage and its treatment with nimodipine. German tSAH Study Group. J Neurosurg. 1996 Jul;85(1):82-9. PubMed PMID: 8683286.
traumatic_subarachnoid_hemorrhage.txt · Last modified: 2016/06/26 00:36 (external edit)