Dr. Ramona Guatta
University Hospital Geneva
Isolated subarachnoid hemorrhage in mild traumatic brain injury: is a repeat CT scan necessary?
Traumatic brain injury (TBI) with isolated subarachnoid hemorrhage (iSAH) is a common pathology in the emergency department. In many centers, including our institution, a repeat CT scan is routinely performed at 24-72 hours to rule out further hemorrhage progression. In mild TBI patients (GCS 13-15) with iSAH findings, some authors suggest that a repeat head CT scan is of poor value. The aim of this study is to assess the clinical utility of the repeat CT scan in our hospital.
We reviewed the medical charts of all patients with mild TBI and isolated SAH, between January 2015 and October 2017. CT scan at admission and control at 24h to 72h were examined for each patient in order to detect any possible change. Exclusion criteria: age under 18, any other TBI entity on CT scan and GCS less than 13.
Neurological deterioration (GCS and or focal deficit), antiplatelet/anticoagulant therapy, coagulopathy, SAH location, associated injuries and length of stay in hospital were analyzed.
A total of 106 patients with iSAH met the inclusion criteria. 54 patients were female and 52 were male with a mean age of 68.2 years.
Radiological iSAH progression was found in 2 of 106 (1.89%) patients, one of them was under antiplatelet therapy. No neurological deterioration was observed. The mean length of stay in hospital was 12.5 days due other comorbidities. Ten of 106 (9.4%) patients were under anticoagulation therapy and 28 of 106 (26.4%) were under antiplatelet therapy. Of note, two patients out of 106 (1.89%) presented with haemostasis disease (advanced cirrhosis and deficit of factor VII) and no radiological or neurological progression was observed. One patient with extensive iSAH in the sylvian fissure (but no aneurysm) beneficiated a transcranial doppler with normal results.
iSAH in TBI seems to show radiological stability over 72 hours with no neurological deterioration, regardless of antiplatelet or anticoagulation therapy and coagulopathy. Clinical utility of a repeat head CT in such patients is questionable, considering its radiation exposure and cost-effectiveness. Hospital length of stay is due to patients' comorbidities other than TBI. Regardless of anticoagulation/antiplatelet therapy, a 24 hours neurologic observation and a symptomatic treatment solely could be a reasonable alternative. Medico legal controversies and lack of data warrant larger and more consistent studies in order to safely change our practice.