From the Guidelines
The management of traumatic subarachnoid hemorrhage (tSAH) should focus on preventing secondary brain injury and treating complications, with an initial approach that includes airway protection, maintaining adequate oxygenation, and hemodynamic stability with systolic blood pressure targets of 100-160 mmHg. This approach is crucial in ensuring adequate cerebral perfusion while preventing rebleeding, as supported by general principles of neurocritical care 1. Patients with tSAH require ICU admission for close neurological monitoring with frequent assessments using the Glasgow Coma Scale. Neurosurgical consultation is essential, and a non-contrast head CT should be performed to evaluate the extent of bleeding and associated injuries.
Key aspects of management include:
- Seizure prophylaxis with levetiracetam 500-1000 mg twice daily for 7 days, often recommended in moderate to severe cases.
- Pain and agitation control with acetaminophen, mild opioids, and potentially propofol or dexmedetomidine for sedation if intubated.
- Serial imaging to monitor for complications such as hydrocephalus, vasospasm, or cerebral edema.
- Deep vein thrombosis prophylaxis with sequential compression devices initiated early, with consideration of pharmacological prophylaxis after 48-72 hours if bleeding has stabilized.
- Nutritional support beginning within 24-48 hours, preferably via enteral route.
It's also important to note that nimodipine, commonly used in aneurysmal SAH, is not routinely recommended for traumatic cases, as the pathophysiology and management strategies differ between aneurysmal and traumatic subarachnoid hemorrhage, as indicated by the lack of specific recommendations for tSAH in guidelines primarily focused on aneurysmal SAH 1. The prognosis and recovery depend on the severity of the initial injury, associated brain injuries, and the development of complications.
Given the most recent and highest quality evidence available, the approach outlined above prioritizes the prevention of secondary brain injury and the management of complications, aligning with the principles of minimizing morbidity, mortality, and improving quality of life for patients with tSAH.
From the Research
Management of Traumatic Subarachnoid Hemorrhage
The management of traumatic subarachnoid hemorrhage involves several key considerations, including:
- Admission to the intensive care unit (ICU) for close monitoring and management of potential complications 2
- The use of nimodipine, a calcium channel blocker, to prevent cerebral vasospasm and delayed cerebral ischemia (DCI) 3, 4, 5
- Repeat CT scanning to identify any progression or resolution of the hemorrhage 6
- Neurosurgical consultation, although the need for this may be reevaluated in patients with mild traumatic brain injury and isolated subarachnoid hemorrhage 2, 6
ICU Admission and Management
ICU admission is common in patients with traumatic subarachnoid hemorrhage, despite the low probability of requiring neurosurgical intervention 2. The management of these patients in the ICU may involve:
- Close monitoring of neurological status and vital signs
- Management of blood pressure and intracranial pressure
- Use of medications such as nimodipine to prevent cerebral vasospasm and DCI
Role of Nimodipine
Nimodipine has been shown to be effective in preventing cerebral vasospasm and DCI in patients with aneurysmal subarachnoid hemorrhage 3, 4, 5. Its use in traumatic subarachnoid hemorrhage is less well established, but it may still be beneficial in preventing cerebral vasospasm and improving outcomes.
Repeat CT Scanning
Repeat CT scanning is commonly used to monitor the progression or resolution of traumatic subarachnoid hemorrhage 6. However, the utility of this practice has been questioned, and it may not be necessary in all patients.
Neurosurgical Consultation
Neurosurgical consultation is often obtained in patients with traumatic subarachnoid hemorrhage, although the need for this may be reevaluated in patients with mild traumatic brain injury and isolated subarachnoid hemorrhage 2, 6. The decision to obtain neurosurgical consultation should be based on the individual patient's clinical status and the presence of any complications or concerns.