Triage Patterns of Traumatic Subarachnoid Hemorrhage: Is Referral to a Tertiary Care Center Necessary?

Gates, Marcus J.; Mallory, Grant W.; Planchard, Ryan; Nothdurft, Georgia; Graffeo, Christopher S.; Atkinson, John D.

doi:10.1016/j.wneu.2017.01.046

Cited by 19 publications

(24 citation statements)

References 17 publications

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“…Studies from European trauma centers have reported a low threshold for ICU admission (Huijben et al 2020 ; Volovici et al 2019 ). Other studies question the necessity ICU admission or transfer to trauma center of low-risk TBI patients (Gates et al 2017 ; Nishijima et al 2011 ; Pruitt et al 2017 ; Borczuk et al 2019 ). A large proportion had a short LOS.…”

Section: Discussionmentioning

confidence: 99%

Characteristics of traumatic brain injury patients with abnormal neuroimaging in Southeast Norway

et al. 2020

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Background: The vast majority of hospital admitted patients with traumatic brain injury (TBI) will have intracranial injury identified by neuroimaging, requiring qualified staff and hospital beds. Moreover, increased pressure in health care services is expected because of an aging population. Thus, a regular evaluation of characteristics of hospital admitted patients with TBI is needed. Oslo TBI Registry-Neurosurgery prospectively register all patients with TBI identified by neuroimaging admitted to a trauma center for southeast part of Norway. The purpose of this study is to describe this patient population with respect to case load, time of admission, age, comorbidity, injury mechanism, injury characteristics, length of stay, and 30-days survival. Methods: Data for 5 years was extracted from Oslo TBI Registry-Neurosurgery. Case load, time of admission, age, sex, comorbidity, injury mechanism, injury characteristics, length of stay, and 30-days survival was compiled and compared. Results: From January 1st, 2015 to December 31st, 2019, 2153 consecutive patients with TBI identified by neuroimaging were registered. The admission rate of TBI of all severities has been stable year-round since 2015. Mean age was 52 years (standard deviation 25, range 0-99), and 68% were males. Comorbidities were common; 28% with pre-injury ASA score of ≥3 and 25% used antithrombotic medication. The dominating cause of injury in all ages was falls (55%) but increased with age. Upon admission, the head injury was classified as mild TBI in 46%, moderate in 28%, and severe (Glasgow coma score ≤ 8) in 26%. Case load was stable without seasonal variation. Majority of patients (68%) were admitted during evening, night or weekend. 68% was admitted to intensive care unit. Length of hospital stay was 4 days (median, interquartile range 3-9). 30-day survival for mild, moderate and severe TBI was 98, 94 and 69%, respectively. Conclusions: The typical TBI patients admitted to hospital with abnormal neuroimaging were aged 50-79 years, often with significant comorbidity, and admitted outside ordinary working hours. This suggests the necessity for allhour presence of competent health care professionals.

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Section: Discussionmentioning

confidence: 99%

Characteristics of traumatic brain injury patients with abnormal neuroimaging in Southeast Norway

et al. 2020

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“…For those with mild-to-moderate TBI, with a GCS score of 9–15, the mortality was twice as high among elderly adults compared to their younger counterparts [ 39 ]. Age was also recognized as an independent predictor of mortality in patients with tSAH [ 9 , 40 ], and especially in patients with isolated tSAH [ 16 ]. In a previously conducted study, age 58 years was identified as the best threshold for discriminating injury mortality in the case of SAH [ 41 ].…”

Section: Discussionmentioning

confidence: 99%

“…In patients with mild TBI (Glasgow Coma Scale (GCS) score ≥13) and isolated tSAH, no neurologic decline or need for neurosurgical procedures was observed [ 11 , 12 , 13 , 14 , 15 ]. In a retrospective study evaluating isolated tSAH in patients with mild TBI (GCS 13–15), of 67 patients, only 1 patient (1.5%) experienced neurological deterioration, and not a single patient required neurosurgical intervention [ 16 ]. In a meta-analysis study, the cumulative incidences of radiographic progression and eventual neurosurgical intervention after isolated tSAH were 5.76% (95% confidence interval (CI) 1.18–12.9%) and 0.0017% (95% CI 0–0.39%), respectively [ 10 ].…”

Section: Introductionmentioning

confidence: 99%

Prediction of Mortality in Patients with Isolated Traumatic Subarachnoid Hemorrhage Using a Decision Tree Classifier: A Retrospective Analysis Based on a Trauma Registry System

Rau

Chien

et al. 2017

IJERPH

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Background: In contrast to patients with traumatic subarachnoid hemorrhage (tSAH) in the presence of other types of intracranial hemorrhage, the prognosis of patients with isolated tSAH is good. The incidence of mortality in these patients ranges from 0–2.5%. However, few data or predictive models are available for the identification of patients with a high mortality risk. In this study, we aimed to construct a model for mortality prediction using a decision tree (DT) algorithm, along with data obtained from a population-based trauma registry, in a Level 1 trauma center. Methods: Five hundred and forty-five patients with isolated tSAH, including 533 patients who survived and 12 who died, between January 2009 and December 2016, were allocated to training (n = 377) or test (n = 168) sets. Using the data on demographics and injury characteristics, as well as laboratory data of the patients, classification and regression tree (CART) analysis was performed based on the Gini impurity index, using the rpart function in the rpart package in R. Results: In this established DT model, three nodes (head Abbreviated Injury Scale (AIS) score ≤4, creatinine (Cr) <1.4 mg/dL, and age <76 years) were identified as important determinative variables in the prediction of mortality. Of the patients with isolated tSAH, 60% of those with a head AIS >4 died, as did the 57% of those with an AIS score ≤4, but Cr ≥1.4 and age ≥76 years. All patients who did not meet the above-mentioned criteria survived. With all the variables in the model, the DT achieved an accuracy of 97.9% (sensitivity of 90.9% and specificity of 98.1%) and 97.7% (sensitivity of 100% and specificity of 97.7%), for the training set and test set, respectively. Conclusions: The study established a DT model with three nodes (head AIS score ≤4, Cr <1.4, and age <76 years) to predict fatal outcomes in patients with isolated tSAH. The proposed decision-making algorithm may help identify patients with a high risk of mortality.

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“…Nassiri et al found through meta-analysis that although 5.7% of patients had the progression of lesions on interval imaging, only 0.75% experienced neurological deterioration and 0.0017% eventually required specialized neurosurgical services [16]. Gates et al, in fact, found that radiographic progression and clinical deterioration of isolated SAH was low despite anticoagulation and/or antiplatelet medication use [17].…”

Section: Discussionmentioning

confidence: 99%

Association of Patterns of Mild Traumatic Brain Injury with Neurologic Deterioration: Experience at a Level I Trauma Center

Kavi

Abdelhady

DeChiara

et al. 2019

Cureus

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Introduction: There are about 2.5 million emergency room visits for traumatic brain injury (TBI) every year and 75%-95% of all TBI patients have mild TBI. Previous studies have suggested that a large proportion of mild TBI patients can be treated in a non-aggressive manner, but they have not differentiated mild TBI as per radiological patterns to help in the selection of these patients. Our study aimed to identify different patterns of mild TBI to determine if certain injuries make patients more prone to neurologic worsening than others, and thus require more intensive monitoring. We also studied the factors associated with neurologic deterioration.Methods: We conducted a retrospective study using an institutional trauma database to identify TBI patients between the years of 2015 and 2016 with admission Glasgow Coma Score (GCS) of 13 to 15, through chart review by the investigators. Radiological and neurological worsening was determined through computed tomography (CT) scan results, GCS scores, and the requirement for neurosurgical intervention. We identified the prevalence of demographic characteristics, radiological patterns, and risk factors. We studied neurologic deterioration (decline in GCS to less than 13 at 48 hours or earlier after admission) and surgical intervention among patients with different radiological patterns of TBI. We further studied the cohort of isolated subdural hematoma (SDH) patients requiring surgery to evaluate the associated risk factors.Results: Out of 374 patients with mild TBI (mean age was 63 years), 59% were male, 77% were Caucasian, the median GCS was 15, majority of patients had isolated SDH (45%), and mixed pattern of hemorrhage (39%); the use of antiplatelet (33%) was the most commonly identified risk factors. Overall 7% of patients were found to have neurologic deterioration (GCS to less than 13) and 9% required surgical intervention at 48 hours or earlier after admission. The most common pattern of TBI requiring surgical intervention was isolated SDH (85%). Among the cohort of patients with isolated SDH, 17% required surgical intervention and 69% of those isolated SDH patients requiring surgery had neurologic deterioration. The most common risk factor in isolated SDH patients requiring surgery was antiplatelet use (34%), anticoagulant use (20%), alcohol abuse (17%), severe renal failure (17%), and thrombocytopenia (7%). Mean size of SDH in patients requiring surgery was 1.6 cm with 0.8 cm of midline shift.Conclusion: This study identified the pattern of mild TBI associated with neurological worsening at our Level I Trauma Center. Among patients with mild TBI, SDH patients seem to be at highest risk for deterioration and requirement for surgery. If these results can be externally validated through a multi-center study, these patients could be selectively identified for aggressive monitoring in the intensive care unit (ICU) and repeat CT scans.

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Triage Patterns of Traumatic Subarachnoid Hemorrhage: Is Referral to a Tertiary Care Center Necessary?

Cited by 19 publications

References 17 publications

Characteristics of traumatic brain injury patients with abnormal neuroimaging in Southeast Norway

Characteristics of traumatic brain injury patients with abnormal neuroimaging in Southeast Norway

Prediction of Mortality in Patients with Isolated Traumatic Subarachnoid Hemorrhage Using a Decision Tree Classifier: A Retrospective Analysis Based on a Trauma Registry System

Association of Patterns of Mild Traumatic Brain Injury with Neurologic Deterioration: Experience at a Level I Trauma Center

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