What is the appropriate management for an adult road‑traffic accident patient with a parietal‑lobe contusion and traumatic subarachnoid haemorrhage?

Management of RTA Patient with Parietal Lobe Contusion and Traumatic SAH

Patients with parietal lobe contusion and traumatic subarachnoid hemorrhage require immediate neurosurgical consultation, admission to a neurosurgical center with ICU monitoring capabilities, and serial neurological assessments with repeat CT imaging only if clinically indicated by neurological deterioration. 1, 2

Immediate Emergency Department Management

Initial Stabilization and Assessment

• Secure large-bore IV access (8-Fr central line preferred in adults) and establish hemodynamic stability while controlling any external bleeding with direct pressure 1
• Administer high-flow oxygen and actively warm the patient if hypothermic 1
• Perform rapid neurological examination assessing Glasgow Coma Scale, pupillary responses, motor/sensory function, and signs of increased intracranial pressure 3, 2
• Obtain baseline labs including complete blood count, coagulation studies (PT, aPTT, fibrinogen), and type and cross-match 1

Critical Imaging

• Non-contrast head CT has already been obtained showing parietal contusion and traumatic SAH 3, 2
• Assess CT for mass effect, midline shift, hydrocephalus, and volume of hemorrhage 2
• Obtain cervical spine imaging as 6-19% of patients with significant craniofacial/head trauma have cervical spine injuries 2
• Consider whole-body CT if patient is stable and polytrauma is suspected 1

Neurosurgical Consultation and Admission Criteria

All patients with traumatic SAH and cerebral contusions require urgent neurosurgical consultation regardless of neurological status 1, 2. These patients should be managed in centers with neurosurgical expertise 1.

Admission Location

• Admit to ICU or neurosurgical step-down unit for continuous neurological monitoring 1, 2
• Even neurologically intact patients with contusions and SAH can deteriorate hours after initial trauma 2

Medical Management

Blood Pressure Management

• Avoid hypotension (SBP <90 mmHg) as it worsens secondary brain injury 1
• Target adequate cerebral perfusion without aggressive hypertension 1
• Avoid vasopressors until bleeding is controlled and volume resuscitation is adequate 1

Antiplatelet and Anticoagulation Management

• If patient was on aspirin prior to injury, hold aspirin for at least 24 hours 1
• If on anticoagulation, reverse according to specific agent per institutional protocols 1
• Do NOT administer aspirin or other antiplatelets acutely in the setting of traumatic intracranial hemorrhage 1

Transfusion Strategy

• There is no benefit to liberal transfusion (transfusing at Hgb <10 g/dL) in moderate-to-severe traumatic brain injury 1
• Transfuse only if Hgb <7-8 g/dL unless patient has active bleeding or cardiovascular instability 1
• Decisions regarding transfusion must be individualized as there is no clear evidence that transfusion improves outcomes in brain-injured patients 1

Seizure Prophylaxis

• Consider short-term (7 days) seizure prophylaxis with levetiracetam or phenytoin, particularly for cortical contusions 3

Pain Management

• Use acetaminophen as first-line for headache management 4
• Avoid opioids when possible due to sedation masking neurological changes, though they may be necessary for severe pain 4
• Avoid NSAIDs due to antiplatelet effects and bleeding risk 4

Monitoring and Serial Assessment

Neurological Monitoring

• Perform serial neurological examinations every 1-2 hours initially, then every 4 hours if stable 2
• Monitor for signs of deterioration: worsening headache, altered consciousness, new focal deficits, vomiting, or seizures 2

Repeat Imaging Strategy

• Do NOT obtain routine repeat outpatient CT in asymptomatic patients - only 2.9% show new findings and only 1% require treatment changes 5
• Obtain urgent repeat CT only if: 2, 5
  • Neurological deterioration (decreased GCS, new focal deficits)
  • Severe or worsening headache with nausea/vomiting
  • New seizure activity
  • Unexplained change in vital signs suggesting increased ICP
• For asymptomatic patients, repeat imaging at 24-48 hours may be considered but is not mandatory 5

Surgical Indications

Surgical intervention is rarely needed for isolated contusions and traumatic SAH 6, 5. Consider neurosurgical intervention if: 2

• Significant mass effect with midline shift >5mm
• Progressive neurological deterioration despite medical management
• Obstructive hydrocephalus requiring external ventricular drain
• Posterior fossa lesions with brainstem compression

Venous Thromboembolism Prophylaxis

Initiate mechanical prophylaxis (sequential compression devices) immediately 1. Chemical prophylaxis with low-dose heparin should be started 24-48 hours after injury once repeat imaging confirms hemorrhage stability 1.

Discharge Planning and Follow-up

Discharge Criteria

• Neurologically stable for 24-48 hours 5
• No progression on repeat imaging if obtained 5
• Adequate pain control with oral medications 4
• Reliable caregiver for home monitoring 3

Outpatient Management

• Neurosurgery follow-up in 2-4 weeks with repeat CT only if patient develops significant symptoms (moderate-severe headache, focal deficits, altered consciousness) 5
• Asymptomatic patients do not require routine repeat imaging as it rarely changes management 5
• Avoid contact sports and activities with fall risk for 3-6 months 3

Critical Pitfalls to Avoid

• Do not discharge patients with traumatic SAH and contusions from the emergency department - these require admission even if neurologically intact 2, 6
• Do not obtain routine repeat CT scans in asymptomatic patients - this exposes patients to unnecessary radiation and cost without clinical benefit 5
• Do not administer aspirin or antiplatelet agents acutely in the setting of intracranial hemorrhage 1
• Do not use liberal transfusion strategies (Hgb threshold <10 g/dL) as this does not improve outcomes and increases complications 1
• Do not rely on absence of symptoms to rule out deterioration - patients can deteriorate suddenly hours after initial stability 2