title: Impaired coagulation is a risk factor for clinical and radiologic deterioration in patients with traumatic brain injury and isolated traumatic subarachnoid hemorrhage.
abstract: BACKGROUND
  Isolated traumatic subarachnoid hemorrhage (itSAH) is found in approximately 25% of all patients with mild traumatic brain injury (TBI). The aim of this study was to analyze the clinical course and identify risk factors for potential clinical and radiologic deterioration in consideration of impaired coagulation in patients with itSAH.
  
  
  METHODS
  A retrospective analysis of 735 patients with TBI resulting in a pathologic computer-assisted tomography (CAT) was performed. Only those patients with itSAH and Glasgow Coma Scale (GCS) of greater than 8 points and follow-up CAT scan were included. Patients with hemorrhage in any other brain compartment (subdural, epidural, and intracerebral) were excluded. Impaired coagulation was operationally defined.
  
  
  RESULTS
  Of the 735 patients, 89 met the inclusion criteria. The majority of these patients experienced mild TBI. The rate of radiologic expansion or conversion of the SAH was 28.1%. The rate of clinical deterioration was 6.7%. Neither the initial pattern of itSAH on different intracranial localizations nor the number of sulci involved in the itSAH was associated with clinical worsening. The rate of patients with impaired coagulation was 38%; 17.9% of all patients showed elevated international normalized ratio (INR). Radiologic and clinical deterioration was significantly associated with elevated INR. INR was shown to be independent of age in a logistic regression analysis.
  
  
  CONCLUSIONS
  TBI patients with itSAH and impaired coagulation especially those who showed elevated INR are at risk of clinical and radiologic deterioration. Despite coagulation status, routine repetition of cranial CAT scan is advised in patients with itSAH to detect potential radiologic worsening, which if occurring should result in close clinical monitoring.
  
  
  METHODS
  Therapeutic study, level IV; prognostic study, level III.
authors.affiliation: From the Department of Neurosurgery (C.V.D.B., I.S., L.V.D.B., U.M., J.L.), Unfallkrankenhaus Berlin, Berlin; and Departments of Neurosurgery (CVDB), and Medical Informatics and Statistics (J.H.), University of Kiel Medical Centre, Kiel, Germany.
authors.forename: Christian
authors.initials: C
authors.lastname: von der Brelie
authors.forename: Insa
authors.initials: I
authors.lastname: Schneegans
authors.forename: Leander
authors.initials: L
authors.lastname: van den Boom
authors.forename: Ullrich
authors.initials: U
authors.lastname: Meier
authors.forename: Juergen
authors.initials: J
authors.lastname: Hedderich
authors.forename: Johannes
authors.initials: J
authors.lastname: Lemcke
mesh_terms: D000328:Adult; D000368:Aged; D000369:Aged, 80 and over; D001777:Blood Coagulation / Q000502:physiology; D001921:Brain / Q000000981:diagnostic imaging; D001930:Brain Injuries / Q000175:diagnosis / Q000503:physiopathology*; D018450:Disease Progression; D005260:Female; D015600:Glasgow Coma Scale; D006801:Humans; D019934:International Normalized Ratio; D008297:Male; D008875:Middle Aged; D012189:Retrospective Studies; D012307:Risk Factors; D020206:Subarachnoid Hemorrhage, Traumatic / Q000000981:diagnostic imaging / Q000503:physiopathology*; D014057:Tomography, X-Ray Computed; D055815:Young Adult