Discussion
A few recent studies have questioned the utility of repeat brain imaging and neurosurgical consultation in patients with TBI. Joseph et al in a prospective study of all patients with TBI concluded that without deterioration of the clinical neurological exam, a repeat CT scan is not warranted.4 Abdel-Fattah et al examined patients with mild TBI and GCS scores 13–15 and found that selective, as opposed to routine, repeat head CT scans led to decreased hospital LOS without impacting GCS.9 Borczuk et al examined all patients with traumatic intracranial hemorrhage at their center and concluded that patients with isolated tSAH are at low risk for deterioration. These individuals may not need neurosurgical consultation or transfer to a trauma center where neurosurgical backup is available. This contrasted with patients with other injuries such as subdural hematomas that had a higher risk of deterioration.10
Other studies have examined the cost-effectiveness of routine CT scans following mild TBI. Stein et al described that routine CT scans for patients aged in their 20s were more cost-effective than repeat CTs following clinical change. However, with increasing age, the relative cost-effectiveness for routine CT scans declines.11
Besides the issue of routine CT utilization, the need for mandatory neurosurgical consultation in patients with TBIs, specifically tSAH, has been challenged. A recent study of 500 patients with mild TBI demonstrated only 10% of the cohort required any neurosurgical intervention. The authors advocated for a more selective approach in obtaining neurosurgical consultation.11 Other groups have taken steps of only selectively using neurosurgical consultations based on their findings. Joseph et al concluded, based on their data that ACS services can independently care for patients with mild TBI without obtaining a formal neurosurgical consultation given the rarity of neurosurgical consultation in this group.12 A recent study from Alabama concluded patients with mild TBI with isolated tSAH or intraparenchymal hemorrhage should not require a neurosurgical consultation or even transfer to a major center.7 In a retrospective study specifically looking at isolated tSAH, Phelan et al concluded that these injuries are less severe brain injuries than other TBI and those with GCS scores of 13–15 demonstrate low rates of clinical progression. When progression occurred, there was resolution without intervention and there was no benefit to ICU admission.13
In our study, we focused specifically on patients with mild TBI with tSAH and not the general population of TBI, which includes a wide myriad of brain injuries with varying modes of clinical progression. The fact that patients with tSAH generally have good outcomes with minimal complications as seen in this study, and typically have no need for any interventions supports the recommendation that acute care surgeons can manage those patients without the need for neurosurgical consultation. This point is particularly of importance given the national shortage of neurosurgeons in the USA. This is further accentuated at trauma centers that have no neurosurgical residency programme—further complicating the manpower issues and work burden for neurosurgeons.14–16
Our study adds to the growing body of literature attempting to define the optimal use of resources in the mild TBI population. This may translate into cost savings, improved LOS and eliminate redundancy in patient care. Adoption of the findings from these studies, most of which are retrospective, should be done with caution. Prospective studies to validate guidelines for managing mild TBI are being discussed.17
In our series, patients with isolated tSAH and a GCS of 13–15 had worsening of CT findings <10% of the time. There was no significant deterioration in clinical status or need for neurosurgical intervention. Given the low acuity of this population and the tendency towards resolution without intervention, we recommend that acute care surgeons can manage this specific group of patients with TBI with only selective neurosurgical consultation. This may be of relevance in level 3 trauma centers where protocols could potentially be developed to avoid transfers in patients with normal or near-normal GCS and isolated tSAH without clinical deterioration.
There are some recognized limitations of this study. Data regarding specific mechanism of injury were not collected. Such information may sometimes indicate the severity of the overall injury burden to a patient. Additionally, the role of anticoagulant/antiplatelet agents in patients who received them was not explored for their potential contribution (or lack thereof) in the patients that had worsening CT scans. Given the ubiquitous presence of these agents in contemporary clinical practice, this would have been relevant information.
Based on our data, we recommend the continuing practice of repeat CT scanning for tSAH as this may identify new lesions, worsening or the need for further management in up to 10% of this population.