title: Patients with traumatic subarachnoid hemorrhage are at low risk for deterioration or neurosurgical intervention.
abstract: BACKGROUND
  Current standard of care for patients with traumatic intracranial hemorrhage (TIH) includes neurosurgical consultation and/or transfer to a trauma center with neurosurgical backup. We hypothesize that a set of low-risk criteria can be applied to such patients to identify those who may not require neurosurgical evaluation.
  
  
  METHODS
  This is a cross-sectional study of consecutive emergency department patients in 2009 and 2010 with TIH on computerized tomographic scan owing to blunt head trauma. Patients presented to an urban academic Level I trauma center (volume, 92,000) were older than 15 years and had a Glasgow Coma Scale (GCS) score of 13 or greater. Charts were abstracted using a standardized data form by two emergency physicians. Our principal outcome was deterioration represented by a composite of neurosurgical intervention, clinical deterioration, or worsening computerized tomographic scan result.
  
  
  RESULTS
  During the study period, 404 patients were seen with TIH and met our inclusion criteria, and 48 of those patients (11.8%) deteriorated. Patients with isolated subarachnoid hemorrhage, were less likely to deteriorate (odds ratio [OR], 0.08; 95% confidence interval [CI], 0.011-0.58). Characteristics associated with deterioration were subdural hematomas (OR, 2.63; 95% CI, 1.198-5.81) or presenting GCS of less than 15 (OR, 2.12; 95% CI, 1.01-4.43).The use of anticoagulant medications or antiplatelet agents were not associated with deterioration for warfarin, aspirin, or clopidogrel; however bleeding diatheses were corrected with vitamin K, fresh frozen plasma, and platelets as necessary.
  
  
  CONCLUSIONS
  Patients with isolated traumatic subarachnoid hemorrhage are at low risk for deterioration. These individuals may not need neurosurgical consultation or transfer to a trauma center where neurosurgical backup is available. Those patients with subdural hematoma or a GCS of less than 15 have a higher risk of deterioration and require neurosurgical evaluation.
  
  
  METHODS
  Therapeutic/care management, level IV.
authors.affiliation: Department of Emergency Medicine, Massachusetts General Hospital, Boston, Massachusetts 02114, USA. pborczuk@partners.org
authors.forename: Pierre
authors.initials: P
authors.lastname: Borczuk
authors.forename: Joshua
authors.initials: J
authors.lastname: Penn
authors.forename: David
authors.initials: D
authors.lastname: Peak
authors.forename: Yuchiao
authors.initials: Y
authors.lastname: Chang
mesh_terms: D000293:Adolescent; D000328:Adult; D000368:Aged; D000369:Aged, 80 and over; D003430:Cross-Sectional Studies; D005260:Female; D015600:Glasgow Coma Scale; D016489:Head Injuries, Closed / Q000175:diagnosis / Q000000981:diagnostic imaging / Q000601:surgery; D006801:Humans; D016015:Logistic Models; D008297:Male; D008875:Middle Aged; D012307:Risk Factors; D020206:Subarachnoid Hemorrhage, Traumatic / Q000175:diagnosis* / Q000000981:diagnostic imaging / Q000601:surgery; D014057:Tomography, X-Ray Computed; D014193:Trauma Centers / Q000706:statistics & numerical data; D055815:Young Adult