Treatment of Traumatic Subarachnoid Hemorrhage

Initial Assessment and Management

The management of traumatic subarachnoid hemorrhage (tSAH) should focus on monitoring for intracranial hypertension, preventing secondary brain injury, and treating complications, with most patients requiring only observation and supportive care rather than surgical intervention 1
Patients with tSAH should undergo rapid assessment of neurological status using validated scales to determine clinical severity, which is the most important indicator of outcome 2
Blood pressure should be controlled with titratable agents to balance the risk of rebleeding against maintenance of cerebral perfusion pressure 2
Patients with tSAH should be monitored for intracranial pressure (ICP) if they have abnormal initial CT scan with evidence of mass effect or compression of basal cisterns, emergency extracranial surgical procedures, or inability to perform neurological evaluation 1

ICP monitoring is indicated when the initial CT scan is abnormal, as more than 50% of these patients will develop intracranial hypertension 1
The presence of traumatic subarachnoid hemorrhage on CT is associated with a higher risk of intracranial hypertension 1
ICP monitoring may not be necessary if the initial CT scan is normal, as the incidence of raised ICP is particularly small (0-8%) in these cases 1
When ICP monitoring is indicated, intraparenchymal probes may be preferred over intraventricular drains due to better risk-benefit balance 1

Sedation and analgesia should be used in stabilized brain-injured patients with tSAH, though daily interruption of sedation may be deleterious in patients with signs of high ICP 1

Surgical evacuation should be considered for post-traumatic intracranial hematomas (subdural, epidural, or intraparenchymal) associated with tSAH 1

Frequent neurological assessments should be performed to detect early signs of deterioration 2

Avoid prophylactic hypervolemia as it has not been shown to improve outcomes and may be harmful 3

Do not confuse management of traumatic SAH with aneurysmal SAH, which requires different approaches including aneurysm repair and nimodipine administration 2
Avoid rapid, large reductions in systolic blood pressure, as this may worsen cerebral perfusion in the setting of impaired autoregulation 4
ICP monitoring, while useful, carries risks including infection (2.5-10%) and intracerebral hemorrhage (0-4%), so patient selection is crucial 1
Daily interruption of sedation, which is standard practice in many ICU protocols, may be harmful in tSAH patients with signs of elevated ICP 1

The American Heart Association recommends monitoring with pulse oximetry and arterial blood gas analysis to maintain appropriate oxygenation without hyperventilation, as hyperventilation may worsen cerebral ischemia 5
Aggressive control of fever to target normothermia using standard or advanced temperature modulating systems is reasonable, and careful glucose management with strict avoidance of hypoglycemia should be considered 6
Monitoring for complications such as vasospasm, hydrocephalus, electrolyte disturbances, seizures, and deep venous thrombosis is necessary, with prophylactic antiepileptic therapy with phenytoin generally accepted for seizure prevention, and treatment of deep venous thrombosis as needed 6
The American Heart Association suggests that hospitals with low volume of SAH cases should consider early transfer to high-volume centers with experienced cerebrovascular surgeons and multidisciplinary neurointensive care services, balancing the benefits of high-volume center care against the risks of transfer in unstable patients 7