The identification of a subgroup of children with traumatic subarachnoid hemorrhage at low risk of neuroworsening

Abstract

<jats:sec><jats:title>OBJECTIVE</jats:title><jats:p>Pediatric traumatic subarachnoid hemorrhage (tSAH) often results in intensive care unit (ICU) admission, the performance of additional diagnostic studies, and ICU-level therapeutic interventions to identify and prevent episodes of neuroworsening.</jats:p></jats:sec><jats:sec><jats:title>METHODS</jats:title><jats:p>Data prospectively collected in an institutionally specific trauma registry between 2006 and 2015 were supplemented with a retrospective chart review of children admitted with isolated traumatic subarachnoid hemorrhage (tSAH) and an admission Glasgow Coma Scale (GCS) score of 13–15. Risk of blunt cerebrovascular injury (BCVI) was calculated using the BCVI clinical prediction score.</jats:p></jats:sec><jats:sec><jats:title>RESULTS</jats:title><jats:p>Three hundred seventeen of 10,395 pediatric trauma patients were admitted with tSAH. Of the 317 patients with tSAH, 51 children (16%, 23 female, 28 male) were identified with isolated tSAH without midline shift on neuroimaging and a GCS score of 13–15 at presentation. The median patient age was 4 years (range 18 days to 15 years). Seven had modified Fisher grade 3 tSAH; the remainder had grade 1 tSAH. Twenty-six patients (51%) had associated skull fractures; 4 involved the petrous temporal bone and 1 the carotid canal. Thirty-nine (76.5%) were admitted to the ICU and 12 (23.5%) to the surgical ward. Four had an elevated BCVI score. Eight underwent CT angiography; no vascular injuries were identified. Nine patients received an imaging-associated general anesthetic. Five received hypertonic saline in the ICU. Patients with a modified Fisher grade 1 tSAH had a significantly shorter ICU stay as compared to modified Fisher grade 3 tSAH (1.1 vs 2.5 days, p = 0.029). Neuroworsening was not observed in any child.</jats:p></jats:sec><jats:sec><jats:title>CONCLUSIONS</jats:title><jats:p>Children with isolated tSAH without midline shift and a GCS score of 13–15 at presentation appear to have minimal risk of neuroworsening despite the findings in some children of skull fractures, elevated modified Fisher grade, and elevated BCVI score. In this subgroup of children with tSAH, routine ICU-level care and additional diagnostic imaging may not be necessary for all patients. Children with modified Fisher grade 1 tSAH may be particularly unlikely to require ICU-level admission. Benefits to identifying a subgroup of children at low risk of neuroworsening include improvement in healthcare efficiency as well as decreased utilization of unnecessary and potentially morbid interventions, including exposure to ionizing radiation and general anesthesia.</jats:p></jats:sec>

Development of a nomogram to predict the outcome of moderate or severe pediatric traumatic brain injury

“…Nonetheless, it still remains unclear the pathophysiology of SAH that is associated with mortality, as subsequential diffuse cerebral swelling following SAH has been discussed as a cause of a poor outcome. [ 24 ]…”

Propoxyphene Mediates Oxyhemoglobin-Induced Injury in Rat Cortical Neurons Through Up-Regulation of Active-β-Catenin

“…Traumatic subarachnoid hemorrhage (tSAH), a major complication of acute craniocerebral trauma, may induce early brain injury (EBI) and elevation of intracranial pressure Abbreviations: SAH, subarachnoid hemorrhage; tSAH, traumatic subarachnoid hemorrhage; Pro, propoxyphene; OxyHb, oxyhemoglobin; EBI, early brain injury; DMEM, Dulbecco's Modified Eagle's Medium; FBS, fetal bovine serum; SDS-PAGE, sodium dodecyl sulfate-polyacrylamide gel electrophoresis; NC, immobilon nitrocellulose; TUNEL, terminal deoxynucleotidyl transferase dUTP nick-end labeling. (Dalle et al, 2018). The general assumption is that EBI induced by a decrease in cerebral blood flow is the primary cause of poor prognosis and plays an important role in the overall outcome (Feng et al, 2016).…”