Review on traumatic subarachnoid hemorrhage.

Recent studies demonstrated clinical significance of the presence of traumatic subarachnoid hemorrhage (tSAH) on the initial CT-scan after head injury. Investigations show similarities between traumatic and aneurysmal SAH suggesting that a similar therapeutic approach as used in spontaneous SAH patients might be beneficial in tSAH patients. Evidence of the clinical significance of the finding of tSAH on CT after head injury and the beneficial use of the calcium antagonist nimodipine in tSAH patients are reported.

Traumatic subarachnoid hemorrhage and its treatment with nimodipine. German tSAH Study Group.

A prospective, randomized, double-blind, placebo-controlled study of nimodipine used to treat traumatic subarachnoid hemorrhage (tSAH) was conducted in 21 German neurosurgical centers between January 1994 and April 1995. One hundred twenty-three patients with tSAH appearing on initial computerized tomography (CT) scanning were entered into the study. Requirements for inclusion included age between 16 and 70 and admission into the study within 12 hours after head injury, regardless of the patient's level of consciousness. Eligible patients received either a sequential course of intravenous and oral nimodipine or placebo treatment for 3 weeks. Patients were closely monitored using clinical neurology, computerized tomography, laboratory, and transcranial Doppler ultrasound parameters. Patients treated with nimodipine had a significantly less unfavorable outcome (death, vegetative survival, or severe disability) at 6 months than placebo-treated patients (25% vs. 46%, p = 0.02). The relative reduction in unfavorable outcome in the nimodipine-treated group was even higher (55%, p = 0.002) when only patients who complied with the protocol were considered.

[Classification of head injuries based on computerized tomography: prognostic value]. / Clasificación del traumatismo craneoencefálico en función de la tomografía computarizada: su valor pronóstico.

A new classification system for head injury based on the findings of computerized tomography was used in a population of 809 head injured patients. The system emphasizes the status of mesencephalic cisterns, the degree of midline shift and the presence or absence of mass lesions, allowing high risk patients to be identified and outcome to be predicted.

Traumatic intracerebral lesions without extracerebral haematoma in 218 patients.

218 of the 852 patients in the HIT-2 study of head injury had intracerebral lesions only. They were analysed to get more information on the optimal treatment of these severely injured patients. The initial CT scans were reviewed to exclude patients with extracerebral lesions, and to make a radiological diagnosis of contusion, contusion under a depressed fracture, diffuse axonal injury, or intracerebral haematoma. Deterioration after admission to hospital was seen in 71% of patients. Patients with contusions, and contusions from depressed fractures in particular showed a worse outcome than expected, while patients with diffuse injury had a tendency to improve rather than to deteriorate. Patients with intracerebral haematoma seemed to improve if the mass was evacuated. Nimodipine had an impact only in patients with contusions. Our findings mandate surgical evacuation of contusions and intracerebral haematomas in patients with lesions larger than 20 ml who also have radiological signs of a mass effect. Regardless of an apparently good clinical state in the early phase, intracerebral lesions larger than 50 ml seemed to benefit from surgery as compared to nonsurgical treatment. The findings indicated that a further refinement of diagnostic criteria may enable individually tailored head injury treatment to interfere with most important pathogenic mechanisms. More accurate diagnoses will improve head injury treatment and outcome, and are a prerequisite for making successful pharmaceutical trials of head injury in the future.

Clinical significance of the finding of subarachnoid blood on CT scan after head injury.

The population analysed consisted of 268 out of 819 patients of a European nimodipine multicentre trial on severe head injury, whose first CT scan after injury showed signs of subarachnoid bleeding. The study demonstrated the importance of traumatic subarachnoid haemorrhage (tSAH) per se as a prognostic factor. The outcome of patients with tSAH is significantly worse than that of patients whose first CT does not show subarachnoid blood (noSAH). The outcome was unfavourable (dead, persistent vegetative state, severe disability) in 60% of tSAH patients compared to 30% of noSAH patients (p < 0.001). The difference in mortality was 42% vs. 14% (p < 0.001). The six month follow-up of tSAH patients complying with the study protocol and treated with intravenous nimodipine, 2 mg per hour for 7 days, showed a statistically significant reduction of unfavourable outcome from 66% to 51% (p < 0.05), compared to placebo treated patients.

Clinical experiences with nimodipine in cerebral ischemia.

Increased intracellular calcium is involved in the death of neurons associated with cerebral ischemia. After extensive experimental work, the calcium antagonist nimodipine has been investigated in several clinical trials in patients with disorders of the cerebral circulation. A short overview on trials in subarachnoid hemorrhage, head injury, ischemic stroke and cerebral resuscitation is given in this paper.