Isolated Subarachnoid Hemorrhage in Mild Traumatic Brain Injury: Is a Repeat CT Scan Necessary?

Objective: 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 to 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.

Methods: We reviewed the medical charts of all patients with mild TBI and iSAH, between January 2015 and October 2017. CT scan at admission and control at 24 hours to 72 hours were examined for each patient to detect any possible change. Exclusion criteria were age under 18, any other TBI entity on CT scan, and Glasgow Coma Scale (GCS) < 13.

Neurological deterioration (GCS and/or focal deficit), antiplatelet/anticoagulant therapy, coagulopathy, SAH location, associated injuries, and length of stay in hospital were analyzed.

Results: A total of 106 patients with iSAH met the inclusion criteria. Fifty-four 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 to 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 hemostasis 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.

Conclusion: 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 to safely change our practice.