Management of Small Hemorrhagic Contusion in Left Parietal Region with GCS 15/15
For a patient with a small hemorrhagic contusion in the left parietal region with GCS 15/15 two days after a road traffic accident, close observation with serial neurological examinations is recommended rather than surgical intervention.
Initial Assessment
- The Glasgow Coma Scale (GCS) is a standardized clinical scale used to assess neurological status in head injury patients, with the motor component being particularly robust even in sedated patients 1
- A GCS score of 15 indicates the patient is fully conscious with no apparent neurological deficits, which is a positive prognostic indicator 1
- Small hemorrhagic contusions with GCS 15 have a low risk of neurological deterioration requiring neurosurgical intervention 2
Management Approach
Observation and Monitoring
- Serial neurological examinations should be performed to detect any secondary neurological deterioration 1
- Monitor for warning signs that may indicate deterioration, including:
- Any decrease in GCS score (particularly within the first 6 hours)
- New onset confusion
- Vomiting
- Restlessness
- Severe headache 2
- Approximately 13.1% of patients with intracranial injuries and initial GCS of 13-15 may show progression on repeat head CT, though neurosurgical intervention is required in a much smaller percentage 3
Imaging Considerations
- A repeat CT scan is indicated if there is any neurological deterioration or a decrease of at least two points in the GCS score 1
- The Canadian CT Head Rule has shown 100% sensitivity in identifying patients with GCS 15 who require neurosurgical intervention 2
Medical Management
- Maintain adequate blood pressure (systolic >100 mmHg or mean arterial pressure >80 mmHg) to ensure proper cerebral perfusion 1, 4
- Ensure adequate oxygenation with PaO₂ between 60-100 mmHg 4
- Avoid hyperthermia, as initial body temperature ≥37.5°C is associated with neurological deterioration 5
Risk Factors for Deterioration
- Regular antiplatelet use prior to injury increases risk of hemorrhagic progression 5
- Contusion size: Small contusions (<5 mm) are generally considered clinically unimportant lesions 1
- Location: Parietal contusions may have better prognosis compared to temporal contusions 2
- Early presentation (within 3 hours of injury) is associated with higher risk of progression 5
Discharge Planning
- For patients with stable neurological status after 24-48 hours of observation, discharge may be considered 1
- Provide clear discharge instructions regarding:
- Warning signs requiring return to hospital
- Activity restrictions
- Follow-up appointments 1
- Restrict physical and cognitive activities during the first days after TBI to minimize symptom exacerbation 6
Special Considerations
- Early hemorrhagic progression of contusions occurs in approximately 43.5% of TBI patients and is associated with worse outcomes 7
- However, for small contusions with GCS 15, conservative management is appropriate as neurosurgical intervention is rarely needed 8
- Patients with GCS 15 who deteriorate typically do so within the first 6 hours after injury, with most showing warning signs before precipitous decline 2
Common Pitfalls to Avoid
- Do not underestimate the importance of serial neurological examinations, as early detection of deterioration is crucial 1
- Avoid early pessimistic prognostication, as most patients with small contusions and GCS 15 have favorable outcomes 4
- Do not discharge patients without clear instructions on warning signs that should prompt return to medical care 1