What is the management for traumatic subarachnoid hemorrhage (SAH)?

Management of Traumatic Subarachnoid Hemorrhage

The management of traumatic SAH differs fundamentally from aneurysmal SAH and focuses primarily on observation, supportive care, monitoring for intracranial hypertension, and preventing secondary brain injury—most patients do not require surgical intervention. 1

Critical Distinction: Traumatic vs. Aneurysmal SAH

Do not confuse traumatic SAH management with aneurysmal SAH management. 1 Traumatic SAH does not require:

• Aneurysm repair or angiography 1
• Nimodipine administration 1
• Vasospasm-directed triple-H therapy 1

Initial Assessment and Stabilization

Airway and Breathing Management

• Ensure adequate airway, breathing, and circulation with specific attention to preoxygenation and avoidance of blood pressure fluctuations during intubation if needed 2
• Following intubation, place nasogastric or orogastric tube to reduce aspiration risk 2
• Maintain appropriate oxygenation without hyperventilation, as hyperventilation may worsen cerebral ischemia 2
• Monitor with pulse oximetry and arterial blood gas analysis 3

Neurological Assessment

• Perform rapid neurological assessment using validated scales (Glasgow Coma Scale, Hunt and Hess Scale, Fisher Scale, or World Federation of Neurological Surgeons Scale) 2, 1
• The degree of neurological impairment is the most important indicator of outcome 1
• Perform frequent serial neurological assessments to detect early deterioration 1

Blood Pressure Management

Control blood pressure with titratable agents to balance rebleeding risk against maintenance of cerebral perfusion pressure. 2, 1

• Avoid systolic blood pressure >160 mmHg 2
• Avoid rapid, large reductions in systolic blood pressure, as this may worsen cerebral perfusion in the setting of impaired autoregulation 1

Intracranial Pressure Monitoring

Indications for ICP Monitoring

ICP monitoring is indicated when: 1

• Initial CT scan is abnormal with evidence of mass effect or compression of basal cisterns
• Patient requires emergency extracranial surgical procedures
• Inability to perform neurological evaluation exists

More than 50% of patients with abnormal initial CT scans will develop intracranial hypertension. 1

When ICP Monitoring May Not Be Necessary

• ICP monitoring may not be necessary if initial CT scan is normal, as the incidence of raised ICP is particularly small (0-8%) in these cases 1

Technical Considerations

• When ICP monitoring is indicated, intraparenchymal probes may be preferred over intraventricular drains due to better risk-benefit balance 1
• Be aware that ICP monitoring carries risks including infection (2.5-10%) and intracerebral hemorrhage (0-4%) 1

Medical Management

Sedation and Analgesia

• Use sedation and analgesia in stabilized brain-injured patients with traumatic SAH 1
• Daily interruption of sedation, which is standard practice in many ICU protocols, may be harmful in traumatic SAH patients with signs of elevated ICP 1

Fluid Management

• Avoid prophylactic hypervolemia, as it has not been shown to improve outcomes and may be harmful 1
• Maintain euvolemia 2
• Avoid excessive fluid administration that could worsen cerebral edema 2

Temperature Management

• Aggressive control of fever to target normothermia using standard or advanced temperature modulating systems is reasonable 3

Glucose Management

• Careful glucose management with strict avoidance of hypoglycemia should be considered 3

Surgical Management

Surgical evacuation should be considered for post-traumatic intracranial hematomas (subdural, epidural, or intraparenchymal) associated with traumatic SAH. 1

Transfer Considerations

• Hospitals with low volume of SAH cases (<10 per year) should consider early transfer to high-volume centers (>35 cases per year) with experienced cerebrovascular surgeons and multidisciplinary neurointensive care services 2, 4
• Balance the benefits of high-volume center care against the risks of transfer in unstable patients 3

Monitoring for Complications

Monitor for and treat: 5

• Vasospasm (though less common and less severe than in aneurysmal SAH)
• Hydrocephalus
• Electrolyte disturbances
• Seizures (prophylactic antiepileptic therapy with phenytoin is generally accepted) 6
• Deep venous thrombosis 3

Common Pitfalls

• Most critical pitfall: Confusing traumatic SAH with aneurysmal SAH and pursuing unnecessary angiography or aneurysm-directed therapies 1
• Hyperventilating intubated patients, which worsens cerebral ischemia 2
• Rapid blood pressure reduction compromising cerebral perfusion 1
• Routine daily sedation interruption in patients with elevated ICP 1
• Prophylactic hypervolemia 1