Traumatic Intracranial Subarachnoid Hemorrhage

Aka: Traumatic Intracranial Subarachnoid Hemorrhage, Traumatic Subarachnoid Hemorrhage, Traumatic SAH

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II. Background

  1. See Subarachnoid Hemorrhage
  2. Trauma is the most common cause of Subarachnoid Hemorrhage
    1. See Aneurysmal Subarachnoid Hemorrhage
    2. This page refers only to Traumatic Subarachnoid Hemorrhage (non-aneurysmal)
  3. Results from disrupted subarachnoid vessels with Hemorrhage into the subarachnoid space
    1. Hemorrhage into the cerebrospinal fluid (CSF)

III. Mechanism

  1. See Head Injury
  2. Fall with Head Injury in the elderly
  3. Motor Vehicle Accident in younger patients

IV. Findings

  1. See Subarachnoid Hemorrhage
  2. Diffuse Headache
  3. Confusion
  4. Nausea
  5. Photophobia

V. Imaging

  1. See Subarachnoid Hemorrhage

VI. Management: General

  1. See Subarachnoid Hemorrhage

VII. Management: Small Traumatic Subarachnoid Hemorrhage

  1. Background
    1. Small Traumatic Subarachnoid Hemorrhage (SAH) is a common finding on CT Head after Closed Head Injury
    2. Unlike Aneurysmal SAH, small Traumatic SAH is much less likely to have neurologic decompensation
      1. Cerebral Vasoconstriction is much less likely in Traumatic SAH (contrast with Aneurysmal SAH)
  2. Monitoring
    1. Serial Neurologic Exams
    2. Repeat CT Head in 6 hours after first imaging CT Head
      1. Indicated for early discharge or as needed for Neurologic Exam changes on exam
  3. Indications to consider early discharge after repeat Head CT (at 6 hours)
    1. Glasgow Coma Scale (GCS) 15
    2. No Anticoagulation or antiplatelet agents
    3. Safe home social situation (e.g. not homeless, available for close interval follow-up)
    4. Small peripheral Subarachnoid Hemorrhage consistent with Traumatic SAH
      1. Central SAH is much more suggestive of Aneurysmal SAH
  4. References
    1. Marcolini and Swaminathan in Swadron (2023) EM:Rap 23(5): 13-4

VIII. Prognosis

  1. Isolated Traumatic Subarachnoid Hemorrhage has a better prognosis
    1. Prognosis is worse when other CNS structures are also injured

IX. Complications

  1. See See Subarachnoid Hemorrhage
  2. Hydrocephalus
    1. Most common complication of Traumatic Subarachnoid Hemorrhage
    2. Occurs when blood redistributes through the subarachnoid space
  3. Post-Traumatic Cerebral vasospasm
    1. Less common and typically less severe than in Aneurysmal Subarachnoid Hemorrhage
    2. Most serious direct complication of Subarachnoid Hemorrhage
      1. Associated with cerebral ischemia and, in 50%, Cerebral Infarction
      2. Risk of increased morbidity and mortality
    3. Increased risk with more Severe Head Trauma
    4. Typical onset is 48 hours (up to 2 weeks) after injury
    5. Calcium Channel Blockers (e.g. Nimodipine) are often used in Aneurysmal SAH related Cerebral vasospasm
      1. However, Calcium Channel Blocker efficacy is lower in Traumatic Subarachnoid Hemorrhage
    6. Aminmansour (2009) J Res Med Sci 14(6):343-8 +PMID: 21772907 [PubMed]

X. References

  1. Abuguyan (2024) Crit Dec Emerg Med 38(7): 4-11
  2. Swaminathan and Marcolini in Herbert (2017) EM:Rap 17(6):17-18
  3. Burgess and Stowens (2014) Crit Dec Emerg Med 28(5): 2-13
  4. Levy (2015) Crit Dec Emerg Med 29(4): 10-4
  5. Bederson (2009) Stroke 40(3): 994-1025 [PubMed]
  6. Cohen-Gadol (2013) Am Fam Physician 88(7): 451-6 [PubMed]
  7. van Gijn (2007) Lancet 369(9558): 306-18 [PubMed]

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