Isolated Traumatic Subarachnoid Hemorrhage: An Evaluation of Critical Care Unit Admission Practices and Outcomes From a North American Perspective

Machine learning models for predicting early hemorrhage progression in traumatic brain injury

This study explores the progression of intracerebral hemorrhage (ICH) in patients with mild to moderate traumatic brain injury (TBI). It aims to predict the risk of ICH progression using initial CT scans and identify clinical factors associated with this progression. A retrospective analysis of TBI patients between January 2010 and December 2021 was performed, focusing on initial CT evaluations and demographic, comorbid, and medical history data. ICH was categorized into intraparenchymal hemorrhage (IPH), petechial hemorrhage (PH), and subarachnoid hemorrhage (SAH). Within our study cohort, we identified a 22.2% progression rate of ICH among 650 TBI patients. The Random Forest algorithm identified variables such as petechial hemorrhage (PH) and countercoup injury as significant predictors of ICH progression. The XGBoost algorithm, incorporating key variables identified through SHAP values, demonstrated robust performance, achieving an AUC of 0.9. Additionally, an individual risk assessment diagram, utilizing significant SHAP values, visually represented the impact of each variable on the risk of ICH progression, providing personalized risk profiles. This approach, highlighted by an AUC of 0.913, underscores the model's precision in predicting ICH progression, marking a significant step towards enhancing TBI patient management through early identification of ICH progression risks.

Association Between Intensive Care Unit Admission Practices and Outcomes in Patients with Isolated Traumatic Subarachnoid Hemorrhage: A Nationwide Inpatient Database Analysis in Japan

BACKGROUND

Patients with traumatic brain injury associated with intracranial hemorrhage are commonly admitted to the intensive care unit (ICU); however, the need for ICU care for patients with isolated traumatic subarachnoid hemorrhage (tSAH) remains unclear. We aimed to investigate the association between the ICU admission practices and outcomes in patients with isolated tSAH.

METHODS

This observational study used a nationwide administrative database in Japan. We identified patients with isolated tSAH from the Japanese Diagnostic Procedure Combination inpatient database from July 1, 2010, to March 31, 2020. The primary outcome was in-hospital mortality, whereas the secondary outcomes were neurosurgical interventions, activities of daily living at discharge, and total hospitalization cost. We performed a risk-adjusted mixed-effect regression analysis to evaluate the association between hospital-level ICU admission rates and study outcomes. The ICU admission rates were categorized into quartiles: lowest, middle-low, middle-high, and highest. Moreover, we assessed the robustness of the results with a patient-level instrumental variable analysis.

RESULTS

Of the 61,883 patients with isolated tSAH treated at 962 hospitals, 16,898 (27.3%) patients were admitted to the ICU on the day of admission. Overall, 2465 (4.0%) patients died in the hospital, and 783 (1.3%) patients underwent neurosurgical interventions. There was no significant difference between the lowest and highest ICU admission quartile in terms of in-hospital mortality (3.7% vs. 4.3%; adjusted odds ratio 0.93; 95% confidence interval [CI] 0.78-1.10), neurosurgical interventions, and activities of daily living at discharge. However, the total hospitalization cost in the lowest ICU admission quartile was significantly lower than that in the highest quartile (US $3032 vs. $4095; adjusted difference US $560; 95% CI 33-1087). The patient-level instrumental variable analysis did not reveal a significant difference in in-hospital mortality between the patients who were admitted to the ICU and those who were not (risk difference 0.2%; 95% CI - 0.1 to 0.5).

CONCLUSIONS

There was no significant association between the ICU admission practices and outcomes in patients with isolated tSAH, whereas higher ICU admission rates were associated with significantly higher hospitalization costs. Our results provide an opportunity for improved health care allocation in the management of patients with isolated tSAH.

Risk factor guided early discharge and potential resource allocation benefits in patients with traumatic subarachnoid hemorrhage

OBJECTIVES

We sought to develop screening criteria predicting the lack of poor neurological outcomes in patients presenting with traumatic subarachnoid hemorrhage (tSAH), while evaluating their potential to improve resource-allocation in these cases.

METHODS

We retrospectively reviewed patients presenting with tSAH to the emergency department (ED) of a tertiary care institution from 2016-2018. We defined good neurological outcomes as patients with stable/improving neurological status, did not require neurosurgical intervention, no expanding bleed, and no hospital readmission. Univariate and multivariate models were generated to predict risk factors inversely associated with good neurological outcome.

RESULTS

167 patients presented with tSAH from 2016-2018. The presence of depressed skull fracture, concomitant spinal fracture, low GCS, cranial nerve palsies, disorientation, concomitant hemorrhages, midline shift (MLS), elevated INR, and emergent medical intervention were inversely correlated with likelihood of good neurological outcome upon univariate analysis. Multivariate regression demonstrated that midline shift [OR=0.22 (0.05-0.89), p=0.04], GCS <13 [OR=0.22 (0.05-0.99), p=0.05], elevated INR [OR=0.18 (0.03-0.85), p=0.04], and emergent medical intervention [OR=0.18 (0.04-0.63), p=0.01] were independently associated with lower likelihood of good neurological outcome. 46 patients without any factors had good outcomes but were held in the ED or admitted to the hospital. These patients - if instead discharged directly - translated to a potential cost savings of $179,172.

CONCLUSIONS

In our study we found multiple risk factors inversely associated with good neurological outcome, namely low GCS, midline shift, emergent medical intervention, and INR ≥ 1.4. Our findings may aid clinicians in determining which tSAH patients are candidates for safe early discharge.

Traumatic Subarachnoid Hemorrhage: A Scoping Review

Sixty-nine million people have a traumatic brain injury (TBI) each year, and TBI is the most common cause of subarachnoid hemorrhage (SAH). Traumatic SAH (TSAH) has been described as an adverse prognostic factor leading to progressive neurological deterioration and increased morbidity and mortality. A limited number of studies, however, evaluate recent trends in the diagnosis and management of SAH in the context of trauma. The objective of this scoping review was to understand the extent and type of evidence concerning the diagnostic criteria and management of TSAH. This scoping review was conducted following the Joanna Briggs Institute methodology for scoping reviews. The review included adults with SAH secondary to trauma, where isolated TSAH (iTSAH) refers to the presence of SAH in the absence of any other traumatic radiographic intracranial pathology, and TSAH refers to the presence of SAH with the possibility or presence of additional traumatic radiographic intracranial pathology. Data extracted from each study included study aim, country, methodology, population characteristics, outcome measures, a summary of findings, and future directives. Thirty studies met inclusion criteria. Studies were grouped into five categories by topic: TSAH associated with mild TBI (mTBI), n = 13), and severe TBI (n = 3); clinical management and diagnosis (n = 9); imaging (n = 3); and aneurysmal TSAH (n = 1). Of the 30 studies, two came from a low- and middle-income country (LMIC), excluding China, nearly a high-income country. Patients with TSAH associated with mTBI have a very low risk of clinical deterioration and surgical intervention and should be treated conservatively when considering intensive care unit admission. The Helsinki and Stockholm computed tomography scoring systems, in addition to the American Injury Scale, creatinine level, age decision tree, may be valuable tools to use when predicting outcome and death.

Association of Hospital-Level Intensive Care Unit Use and Outcomes in Older Patients With Isolated Rib Fractures

IMPORTANCE

The optimal level of care for older patients with rib fractures as an isolated injury is unknown.

OBJECTIVES

To characterize interhospital variability in intensive care unit (ICU) vs non-ICU admission of older patients with isolated rib fractures and to evaluate whether greater hospital-level use of ICU admission is associated with improved outcomes.

DESIGN, SETTING, AND PARTICIPANTS

This cohort study included trauma patients aged 65 years and older with isolated rib fractures who were admitted to US trauma centers participating in the National Trauma Data Bank between January 1, 2015, and December 31, 2016. Patients were excluded if they had other significant injuries, were intubated or had assisted respirations in the emergency department (ED), or had a Glasgow Coma Scale (GCS) score of less than 9 in the ED. Hospitals with fewer than 10 eligible patients were excluded. Data analysis was conducted from May 2019 through September 2020.

EXPOSURES

Admission to the ICU.

MAIN OUTCOMES AND MEASURES

Composite of unplanned intubation, pneumonia, or death during hospitalization.

RESULTS

Among 23 951 patients (11 066 [46.2%] women; mean [SD] age, 77.0 [7.2] years) at 573 hospitals, the median (interquartile range) proportion of ICU use was 16.7% (7.4%-32.0%), but this varied from a low of 0% to a high of 91.9%. The composite outcome occurred in 787 patients (3.3%), with unplanned intubation in 317 (1.3%), pneumonia in 180 (0.8%), and death in 451 (1.9%). Accounting for the hierarchical nature of the data and adjusting for propensity scores reflecting factors associated with ICU admission, receiving care at a hospital with the greatest ICU use (quartile 4), compared with a hospital with the lowest ICU use, was associated with decreased likelihood of the composite outcome (adjusted odds ratio, 0.71; 95% CI, 0.55-0.92).

CONCLUSIONS AND RELEVANCE

In this study, admission location of older patients with isolated rib fractures was variable across hospitals, but hospitalization at a center with greater ICU use was associated with improved outcomes. It may be warranted for hospitals with low ICU use to admit more such patients to an ICU.

Putting a halt to unnecessary transfers: Do patients with isolated subarachnoid hemorrhage and Glasgow Coma Scale of 13 to 15 need a trauma center?

OBJECTIVES

Trauma patients with isolated subarachnoid hemorrhage (iSAH) presenting to nontrauma centers are typically transferred to an institution with neurosurgical availability. However, recent studies suggest that iSAH is a benign clinical entity with an excellent prognosis. This investigation aims to evaluate the neurosurgical outcomes of traumatic iSAH with Glasgow Coma Scale (GCS) of 13 to 15 who were transferred to a higher level of care.

METHODS

The American College of Surgeon Trauma Quality Improvement Program was retrospectively analyzed from 2010 to 2015 for transferred patients 16 years and older with blunt trauma, iSAH, and GCS of 13 or greater. Those with any other body region Abbreviated Injury Scale of 3 or greater, positive or unknown alcohol/drug status, and requiring mechanical ventilation were excluded. The primary outcome was need for neurosurgical intervention (i.e., intracranial monitor or craniotomy/craniectomy).

RESULTS

A total of 11,380 patients with blunt trauma, iSAH, and GCS of 13 to 15 were transferred to an American College of Surgeon level I/II from 2010 to 2015. These patients were 65 years and older (median, 72 [interquartile range (IQR), 59-81]) and white (83%) and had one or more comorbidities (72%). Eighteen percent reported a bleeding diathesis/chronic anticoagulation on admission. Most patients had fallen (80%), had a GCS of 15 (84%), and were mildly injured (median Injury Severity Score, 9 [IQR, 5-14]). Only 1.7% required neurosurgical intervention with 55% of patients being admitted to the intensive care unit for a median of 2 days (IQR, 1-3 days). Furthermore, 2.2% of the patients died. The median hospital length of stay was only 3 days (IQR, 2-5 days), and the most common discharge location was home with self-care (62%). Patient factors favoring neurosurgical intervention included high Injury Severity Score, low GCS, and chronic anticoagulation.

CONCLUSION

Trauma patients transferred for iSAH with GCS of 13 to 15 are at very low risk for requiring neurosurgical intervention.

LEVEL OF EVIDENCE

Therapeutic/care management, Level IV.

Traumatic Subarachnoid Hemorrhage Resulting from Posterior Communicating Artery Rupture

Traumatic subarachnoid hemorrhage (SAH), a common finding following head trauma, is usually a benign condition with a favorable outcome, seldom requiring surgical intervention. Unlike nontraumatic aneurysmal SAH, most cases of traumatic SAH occur in the sulci of the cerebral convexities, and only rarely arise at the base of the brain. Basal traumatic SAH can be life-threatening and is primarily associated with rupture of vertebrobasilar arteries. We herein present a rare case of basal traumatic SAH resulting from rupture of the posterior communicating artery (PCoA). A 77-year-old male was taken to the emergency department in a semicomatose state. Upon arrival at emergency room, the patient had a Glasgow coma scale (GCS) score of 6 (E1M3V2), and the neurologic examination demonstrated no focal neurologic deficit. Although the trauma history was evident from abrasions and bruising on the face and chest, brain computed tomography (CT) demonstrated basal SAH, which is typical for nontraumatic aneurysmal SAH. Subsequent digital subtraction angiography (DSA) disclosed a traumatic rupture at the mid-portion of right PCoA and ongoing extravasation of contrast media. Despite emergent trapping of the right PCoA by endovascular surgery, the patient’s clinical condition only minimally improved. The patient remained bed-ridden with stuporous mentality and persistent hydrocephalus. To the best of our knowledge, this is the first reported case of basal traumatic SAH originating from rupture of the PCoA. This case demonstrates that a meticulous vascular workup is mandatory for every patient with basal SAH, even though a trauma history is clear.

Concurrent Types of Intracranial Hemorrhage are Associated with a Higher Mortality Rate in Adult Patients with Traumatic Subarachnoid Hemorrhage: A Cross-Sectional Retrospective Study

Traumatic subarachnoid hemorrhage (SAH) is the second most frequent intracranial hemorrhage and a common radiologic finding in computed tomography. This study aimed to estimate the risk of mortality in adult trauma patients with traumatic SAH concurrent with other types of intracranial hemorrhage, such as subdural hematoma (SDH), epidural hematoma (EDH), and intracerebral hemorrhage (ICH), compared to the risk in patients with isolated traumatic SAH. We searched our hospital’s trauma database from 1 January, 2009 to 31 December, 2018 to identify hospitalized adult patients ≥20 years old who presented with a trauma abbreviated injury scale (AIS) of ≥3 in the head region. Polytrauma patients with an AIS of ≥3 in any other region of the body were excluded. A total of 1856 patients who had SAH were allocated into four exclusive groups: (Group I) isolated traumatic SAH, n = 788; (Group II) SAH and one diagnosis, n = 509; (Group III) SAH and two diagnoses, n = 493; and (Group IV) SAH and three diagnoses, n = 66. One, two, and three diagnoses indicated occurrences of one, two, or three other types of intracranial hemorrhage (SDH, EDH, or ICH). The adjusted odds ratio with a 95% confidence interval (CI) of the level of mortality was calculated with logistic regression, controlling for sex, age, and pre-existing comorbidities. Patients with isolated traumatic SAH had a lower rate of mortality (1.8%) compared to the other three groups (Group II: 7.9%, Group III: 12.4%, and Group IV: 27.3%, all p < 0.001). When controlling for sex, age, and pre-existing comorbidities, we found that Group II, Group III, and Group IV patients had a 4.0 (95% CI 2.4–6.5), 8.9 (95% CI 4.8–16.5), and 21.1 (95% CI 9.4–47.7) times higher adjusted odds ratio for mortality, respectively, than the patients with isolated traumatic SAH. In this study, we demonstrated that compared to patients with isolated traumatic SAH, traumatic SAH patients with concurrent types of intracranial hemorrhage have a higher adjusted odds ratio for mortality.

Neurosurgical Outcomes of Isolated Hemorrhagic Mild Traumatic Brain Injury

Introduction Mild traumatic brain injury (TBI) is common but its management is variable. Objectives To describe the acute natural history of isolated hemorrhagic mild TBI. Methods This was a single-center, retrospective chart review of 661 patients. Inclusion criteria were consecutive patients with hemorrhagic mild TBI. Exclusion criteria were any other acute traumatic injury and significant comorbidities. Variables recorded included neurosurgical intervention and timing, mortality, emergency room disposition, intensive care unit (ICU) length of stay (LOS), discharge disposition, repeat computed tomography head (CTH) indications and results, neurologic exam, age, sex, Glasgow Coma Scale (GCS) score, and hemorrhage type. Results Overall intervention and unexpected delayed intervention rates were 9.4% and 1.5%, respectively. The mortality rate was 2.4%. A 10-year age increase had 26% greater odds of intervention (95% CI, 9.6-45%; P<.001) and 53% greater odds of mortality (95% CI, 11-110%; P=.009). A one-point GCS increase had 49% lower odds of intervention (95% CI, 25-66%; P<.001) and 50% lower odds of mortality (95% CI, 1-75%; P=.047). Subdural and epidural hemorrhages were more likely to require intervention (P=.02). ICU admission was associated with discharge to an acute care facility (OR, 2.9; 95% CI, 1.4-6.0; P=.003). Neurologic exam changes were associated with a worsened CTH scan (OR, 12.3; 95% CI, 7.0-21.4; P<.001) and intervention (OR, 15.1; 95% CI, 8.4-27.2; P<.001). Conclusions Isolated hemorrhagic mild TBI patients are at a low, but not clinically insignificant, risk of intervention and mortality.

Clinical significance of posttraumatic intracranial hemorrhage in clinically mild brain injury: a retrospective cohort study

BACKGROUND

Much attention has been focused on management of severe traumatic brain injury (TBI); however, comparatively little is known about management of traumatic hemorrhage in clinically mild TBI. We aimed to clarify the role of clinical observation and repeat radiography for patients with mild TBI and abnormal findings on initial computed tomography (CT) of the head.

METHODS

We queried the neurotrauma database of the Ontario Trauma Registry and the Sunnybrook institutional database to identify patients with CT findings of a traumatic hemorrhage or calvarial fracture between November 2014 and December 2016. Exclusionary criteria were age less than 16 years, Glasgow Coma Scale (GCS) score less than 13, anticoagulant use, bleeding diathesis and midline shift greater than 5 mm. The primary outcome was the need for neurosurgical intervention.

RESULTS

A total of 607 patients were included. Most (374 [61.6%]) had a GCS score of 15; 185 (30.5%) and 48 (7.9%) had a GCS score of 14 and 13, respectively. Five patients (0.8%) required surgical intervention, all within the first 72 hours, owing to clinical deterioration with subsequently demonstrated radiographic evidence of expanding hemorrhage. Most patients (506 [83.4%]) had routine repeat imaging, without documented change in their neurologic status.

INTERPRETATION

The majority of patients in our cohort had repeat imaging, which did not influence surgical management, at substantial cost to the health care system. The findings suggest the need to reevaluate repeat imaging protocols for this subset of patients with TBI.

Imaging of Brain Trauma

Conventional imaging in the acute setting of brain trauma, relevant pathophysiology of injury, and advanced imaging techniques that may provide value in understanding the immediate management and long-term sequela of traumatic brain injury are reviewed. Key imaging findings that can guide clinical management related to such injuries as concussions, hematomas, dissections, dural atrioventricular fistula, and diffuse axonal injury are discussed. The role and accuracy of computed tomography, dual-energy computed tomography, computed tomography angiography, and magnetic resonance angiography in the acute setting are evaluated. In addition, caveats related to imaging the elderly and pediatric population are addressed.