Traumatic Subarachnoid Hemorrhage (tSAH), caused by a blow to the head, has characteristics that set it apart from other types of traumatic bleeding. If the bleeding is minor and isolated, the prognosis is excellent, and treatment is primarily conservative. However, if it is accompanied by severe brain injury or delayed complications—such as cerebral vasospasm or hydrocephalus—the condition can rapidly deteriorate, leading to a poor prognosis.
This article explains the principles of conservative treatment for tSAH and why surgical interventions, such as V-P Shunting, are necessary in severe cases. We also focus on the risk of delayed hydrocephalus, which can manifest as cognitive impairment or gait disturbance (Hakim’s Triad) long after the initial injury.
Overview of Traumatic Subarachnoid Hemorrhage (tSAH)
| Item | Details |
| Pathology | Bleeding spreads between the arachnoid and pia mater (the subarachnoid space), pooling along the brain’s grooves (sulci). |
| Causes | Rupture of small vessels on the brain surface due to impact, or bleeding originating from a concurrent cerebral contusion. |
| CT Findings | Linear or hazy high-density areas (white streaks of blood) visible along the sulci or subarachnoid spaces. |
| Urgency | Low for isolated minor bleeding. Extremely high if accompanied by cerebral contusion or acute subdural hematoma. |
1. Treatment Principles
For isolated tSAH, treatment is generally conservative (non-surgical). Surgical intervention is only required if intracranial pressure rises due to massive bleeding or severe complications.
A. Conservative Treatment (Non-surgical)
- Absolute Bed Rest: Maintaining quiet and avoiding sudden spikes in blood pressure.
- General Management: Symptomatic relief for headaches and nausea, with strict neurological monitoring for signs of increased intracranial pressure.
- Systemic Control: Precise management of fluids, electrolytes, and blood sugar levels.
- Prevention of Vasospasm: A narrowing of the brain’s blood vessels that occurs days to two weeks post-injury. This is managed through blood pressure control and medications such as Calcium channel blockers (e.g., Nimodipine).
B. Surgical Treatment
While surgery for tSAH itself is rare, it is performed for associated or delayed conditions:
- Decompression: If an associated contusion or subdural hematoma is compressing the brain.
- V-P Shunt (Venticuloperitoneal Shunt): If blood components block the drainage of cerebrospinal fluid (CSF), leading to hydrocephalus. A bypass is created to drain excess fluid into the abdomen.
2. Medical Fees and Hospitalization (Japan Context)
Under the DPC/PDPS system, tSAH is classified as “Traumatic Intracranial Hemorrhage.”
- Mild Cases: Hospitalization usually lasts from a few days to a week. Costs center on CT/MRI scans, medication, and basic inpatient fees.
- Severe Cases: If craniotomy or shunting is required, costs increase significantly, and hospitalization can last months. If severe aftereffects persist, a transfer to a Recovery Phase Rehabilitation Ward (up to 150–180 days) is often necessary.
3. Prognosis and Aftereffects
A. Favorable Prognosis (Isolated/Mild Cases)
Minor, isolated bleeding typically has an excellent outlook. Most blood is absorbed naturally, allowing for a full return to society without lasting disability.
B. Poor Prognosis (Severe Cases)
The prognosis is dictated by the severity of concurrent injuries like cerebral contusions or Diffuse Axonal Injury (DAI). Low initial GCS scores often indicate a poor outcome.
C. Risks of Delayed Aftereffects
Even if the initial recovery is good, patients must watch for:
- Normal Pressure Hydrocephalus (Delayed): Characterized by Hakim’s Triad: 1. Cognitive impairment (Dementia), 2. Gait disturbance, and 3. Urinary incontinence.
- Cerebral Vasospasm: Severe narrowing can lead to a secondary cerebral infarction (stroke), causing paralysis.
Summary
Because tSAH carries the risk of “silent” delayed complications, long-term follow-up is essential even if the patient appears to have recovered well at the time of discharge.
