Traumatic midline subarachnoid hemorrhage on initial computed tomography as a marker of severe diffuse axonal injury

Abstract

OBJECTIVE The objective of this study was to test the hypothesis that midline (interhemispheric or perimesencephalic) traumatic subarachnoid hemorrhage (tSAH) on initial CT may implicate the same shearing mechanism that underlies severe diffuse axonal injury (DAI). METHODS The authors enrolled 270 consecutive patients (mean age [± SD] 43 ± 23.3 years) with a history of head trauma who had undergone initial CT within 24 hours and brain MRI within 30 days. Six initial CT findings, including intraventricular hemorrhage (IVH) and tSAH, were used as candidate predictors of DAI. The presence of tSAH was determined at the cerebral convexities, sylvian fissures, sylvian vallecula, cerebellar folia, interhemispheric fissure, and perimesencephalic cisterns. Following MRI, patients were divided into negative and positive DAI groups, and were assigned to a DAI stage: 1) stage 0, negative DAI; 2) stage 1, DAI in lobar white matter or cerebellum; 3) stage 2, DAI involving the corpus callosum; and 4) stage 3, DAI involving the brainstem. Glasgow Outcome Scale-Extended (GOSE) scores were obtained in 232 patients. RESULTS Of 270 patients, 77 (28.5%) had DAI; tSAH and IVH were independently associated with DAI (p < 0.05). Of tSAH locations, midline tSAH was independently associated with both overall DAI and DAI stage 2 or 3 (severe DAI; p < 0.05). The midline tSAH on initial CT had sensitivity of 60.8%, specificity of 81.7%, and positive and negative predictive values of 43.7% and 89.9%, respectively, for severe DAI. When adjusted for admission Glasgow Coma Score, the midline tSAH independently predicted poor GOSE score at both hospital discharge and after 6 months. CONCLUSIONS Midline tSAH could implicate the same shearing mechanism that underlies severe DAI, for which midline tSAH on initial CT is a probable surrogate.

Traumatic subarachnoid hemorrhage: a scoping review

“…Conversely, the absence of midline tSAH on initial CT was a reliable marker to exclude severe DAI. 32 Furthermore, the maximum thickness of traumatic SAH was independently associated with neurological outcome and death but not with the extent or location of hemorrhage. 31 The amount of subarachnoid blood and associated parenchymal damage are independent factors associated with CT progression, thus linking poor outcomes and CT changes.…”

“…31 A prospective cohort study of 270 tSAH patients who underwent brain MRI within 30 days found that 28.5% (n=77) had diffuse axonal injury (DAI) and that tSAH was independently associated with DAI. 32 Midline tSAH was independently associated with both overall DAI and DAI stage two or three. The midline tSAH on initial CT had a sensitivity of 60.8%, a specificity of 81.7%, and positive and negative predictive values of 43.7% and 89.9%, respectively, for severe DAI.…”

Novel Subgroups in Subarachnoid Hemorrhage and Their Association With Outcomes—A Systematic Review and Meta-Regression

“…Trauma (aSAH-T) is the most common cause of an aneurysm, such as a middle meningeal artery aneurysm (Maekawa et al, 2009 ). In addition to a direct correlation between na-t-SAH and the incidence of hypoxia, hypotension, skull fractures, brain contusions, and intracranial hypertension, trauma is also one of the most important independent negative prognostic factors of the abovementioned cases (Mata-Mbemba et al, 2015 , 2018 ). na-t-SAH and aSAH-T may exhibit different bleeding patterns on CT, but there may be significant tentorial SAH in the former (Connolly et al, 2012 ; Perry et al, 2015 ).…”

Evaluation of the platelet volume index as a prognostic factor after aneurysmal subarachnoid hemorrhage

“…Higher grades in this scale indicate the need for more aggressive and serious observation of the patient. Its importance for higher risk of developing cerebral damage, especially vasospasm, is evident [15,16].…”