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The clinical significance of isolated traumatic subarachnoid hemorrhage in mild traumatic brain injury

A meta-analysis

Nassiri, Farshad MD; Badhiwala, Jetan H. MD; Witiw, Christopher D. MD; Mansouri, Alireza MD; Davidson, Benjamin MD; Almenawer, Saleh A. MD; Lipsman, Nir MD, PhD; Da Costa, Leodante MD; Pirouzmand, Farhad MD; Nathens, Avery B. MD, PhD

Journal of Trauma and Acute Care Surgery: October 2017 - Volume 83 - Issue 4 - p 725–731
doi: 10.1097/TA.0000000000001617
Systematic Review

BACKGROUND The rates of clinical and radiographic progression and the need for neurosurgical intervention in patients with isolated traumatic subarachnoid hemorrhage (itSAH) after mild traumatic brain injury (Glasgow Coma Scale score, 13–15) has not been well established.

The aim of this work was to review the evidence regarding patient outcomes after mild traumatic brain injury with itSAH.

METHODS Two authors independently extracted the data according to a predefined protocol. The proportions of patients who had the outcomes of interest were pooled using random-effects model. The quality of included studies was assessed using the methodological index for nonrandomized studies scale.

RESULTS Thirteen studies reporting on 15,327 patients met inclusion criteria, and outcomes were pooled where available. No patient required neurosurgical intervention on presentation to hospital, and the incidence of need for eventual neurosurgical intervention was 0.0017% (95% confidence interval [CI], 0–0.39%). Moreover, the pooled analyses for all patients with available data showed an incidence of 5.76% (95% CI, 1.18–12.94%) for radiographic progression, 0.75% (95% CI, 0–2.39%) for neurologic deterioration, and 0.60% (95% CI, 0.09–1.41%) for mortality. Only one patient had died due to neurological injury.

CONCLUSIONS These patients experience very low rates of radiographic progression and neurologic deterioration and rarely require neurosurgical intervention or die due to neurological injury.

LEVEL OF EVIDENCE Meta-analysis, level III.

From the Division of Neurosurgery, Department of Surgery (F.N., J.H.B., C.D.W., A.M., B.D.), University of Toronto, Toronto Ontario, Canada; Division of Neurosurgery (N.L., L.D.C., F.P.), Sunnybrook Health Sciences Center, Toronto Ontario, Canada; Division of Neurosurgery, Department of Clinical Epidemiology and Biostatistics (S.A.A), McMaster University, Hamilton, Ontario, Canada; and Division of General Surgery and Trauma (A.B.N.), Sunnybrook Health Sciences Center, Toronto, Ontario, Canada.

Submitted: April 14, 2017, Revised: May 30, 2017, Accepted: May 31, 2017, Published online: July 10, 2017.

Supplemental digital content is available for this article. Direct URL citations appear in the printed text, and links to the digital files are provided in the HTML text of this article on the journal’s Web site (

Address for reprints: Farshad Nassiri, MD, Division of Neurosurgery, Department of Surgery, University of Toronto, 399 Bathurst St, Toronto, Ontario, M5T 2S8 Canada; email:

© 2017 Lippincott Williams & Wilkins, Inc.