What is the treatment for traumatic subarachnoid hemorrhage?

Treatment of Traumatic Subarachnoid Hemorrhage

The management of traumatic subarachnoid hemorrhage (tSAH) should focus on monitoring for intracranial hypertension, preventing secondary brain injury, and treating complications, with most patients requiring only observation and supportive care rather than surgical intervention. 1

Initial Assessment and Management

• Patients with tSAH should undergo rapid assessment of neurological status using validated scales to determine clinical severity, which is the most important indicator of outcome 2
• Blood pressure should be controlled with titratable agents to balance the risk of rebleeding against maintenance of cerebral perfusion pressure 2
• Patients with tSAH should be monitored for intracranial pressure (ICP) if they have:
  • Abnormal initial CT scan with evidence of mass effect or compression of basal cisterns 1
  • Emergency extracranial surgical procedures (except life-threatening conditions) 1
  • Inability to perform neurological evaluation 1

Monitoring and Management of Intracranial Pressure

• ICP monitoring is indicated when the initial CT scan is abnormal, as more than 50% of these patients will develop intracranial hypertension 1
• The presence of traumatic subarachnoid hemorrhage on CT is associated with a higher risk of intracranial hypertension 1
• ICP monitoring may not be necessary if the initial CT scan is normal, as the incidence of raised ICP is particularly small (0-8%) in these cases 1
• When ICP monitoring is indicated, intraparenchymal probes may be preferred over intraventricular drains due to better risk-benefit balance 1

Medical Management

• Sedation and analgesia should be used in stabilized brain-injured patients with tSAH, though daily interruption of sedation may be deleterious in patients with signs of high ICP 1
• For patients with elevated ICP, first-line treatments include:
  • Head elevation
  • Hyperventilation (short-term use only)
  • Hyperosmolar agents (mannitol or hypertonic saline) 3, 4
• For refractory intracranial hypertension, consider:
  • Barbiturate coma
  • Hypothermia
  • Decompressive craniectomy 4, 5

Surgical Management

• Most patients with isolated tSAH and mild traumatic brain injury (Glasgow Coma Scale 13-15) can be managed conservatively without surgical intervention 6
• Surgical evacuation should be considered for post-traumatic intracranial hematomas (subdural, epidural, or intraparenchymal) associated with tSAH 1
• Decompressive craniectomy may be considered for refractory elevated ICP when medical management becomes insufficient 5

Monitoring and Follow-up

• Repeat CT scanning is recommended within 24 hours for patients with tSAH, as approximately 8.7% may show worsening or new findings that could alter management 6
• Frequent neurological assessments should be performed to detect early signs of deterioration 2
• Most patients with isolated tSAH have low morbidity, short length of stay, and negligible mortality 6

Special Considerations

• Unlike aneurysmal SAH, nimodipine is not routinely indicated for traumatic SAH as its benefits have only been proven in aneurysmal SAH 7
• Acute care surgeons can manage patients with mild TBI and isolated SAH without routine neurosurgical consultation, though this should be determined on a case-by-case basis 6
• Avoid prophylactic hypervolemia as it has not been shown to improve outcomes and may be harmful 8

Common Pitfalls and Caveats

• Do not confuse management of traumatic SAH with aneurysmal SAH, which requires different approaches including aneurysm repair and nimodipine administration 2, 7
• Avoid rapid, large reductions in systolic blood pressure, as this may worsen cerebral perfusion in the setting of impaired autoregulation 1
• ICP monitoring, while useful, carries risks including infection (2.5-10%) and intracerebral hemorrhage (0-4%), so patient selection is crucial 1
• Daily interruption of sedation, which is standard practice in many ICU protocols, may be harmful in tSAH patients with signs of elevated ICP 1