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

Abstract Object Isolated traumatic subarachnoid hemorrhage in mild head injuries has growing evidence that triage to a tertiary care facility, ICU admission, and repeat imaging is not warranted. The authors try to identify certain factors that predict radiographic and clinical progression in hopes of preventing avoidable cost that occur with transfer and subsequent management. Methods A retrospective analysis identified 67 patients transferred between January 2010 and December 2014 who met inclusion criteria. Primary outcomes assessing neurosurgical intervention, radiographic and clinical progression were documented. Secondary outcomes included any operative intervention, length of stay, standardized hospital costs, disposition at discharge, and 30-day mortality. Results The mean age of the cohort was 67.7 +/- 16.4 with the majority (82.1%) having a glasgow coma score (GCS) of 15. Warfarin was used in 10 patients (14.9%), although 55.2% were on an antiplatelet or anticoagulation agent. No patient required neurosurgical intervention. One patient, on Plavix and Warfarin, neurologically declined with radiographic progression. Older age seem to correlate with radiographic progression (p=0.05). Dementia (p=0.05) as well as Warfarin use (p=0.06) correlated with clinical progression. Cost in patients without other injuries was associated with Warfarin (p=0.0002), injury severity scores (ISS) (p=0.01) and initial GCS (p=0.0003) on multivariate analysis. Conclusion In this series of patients with mild TBI , the rate of neurologic deterioration due to expansion of iTSAH in patients is low, regardless of the use of antiplatelets/anticoagulants. Triage to a tertiary care facility generally is not warranted and can prove costly to patients with iTSAH without other injures.