Accepted Manuscript

Traumatic Subarachnoid Hemorrhage Due To Motor Vehicle Crash Versus Fall FromHeight: A 4-Year Epidemiological Study

Ashok Parchani, MD Ayman El-Menyar, MD Hassan Al-Thani, MD Ahmed El-Faramawy, MD Ahmad Zarour, MD Mohammad Asim, Rifat Latifi, MD

PII: S1878-8750(14)00568-3

DOI: 10.1016/j.wneu.2014.06.022

Reference: WNEU 2415

To appear in: World Neurosurgery

Received Date: 1 September 2013

Revised Date: 10 February 2014

Accepted Date: 11 June 2014

Please cite this article as: Parchani A, El-Menyar A, Al-Thani H, El-Faramawy A, Zarour A, Asim M, LatifiR, Traumatic Subarachnoid Hemorrhage Due To Motor Vehicle Crash Versus Fall From Height: A 4-Year Epidemiological Study, World Neurosurgery (2014), doi: 10.1016/j.wneu.2014.06.022.

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Traumatic Subarachnoid Hemorrhage Due To Motor Vehicle Crash Versus Fall From Height: A 4-Year Epidemiological Study

Ashok Parchani1,2 MD, Ayman El-Menyar 2,3 MD, Hassan Al-Thani1 MD, Ahmed El-Faramawy1

MD, Ahmad Zarour1 MD, Mohammad Asim3, Rifat Latifi1,2,4 MD

1From Department of Surgery, Trauma surgery Section, Hamad General Hospital, Doha, Qatar

2Weill Cornell Medical College, Doha, Qatar

3Clinical research, Trauma Surgery, Hamad General Hospital, Doha, Qatar

4Department of Surgery, Arizona University, Tucson, AZ, USA

Running title: Traumatic subarachnoid hemorrhage in Qatar

Correspondence

Ayman El-Menyar, MD

Clinical Research, Trauma Surgery Section, Hamad General Hospital, PO Box 3050, Doha, Qatar

Email: aymanco65@yahoo.com

Tel: +97444396152; Fax: +97444394031

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Abstract

Background: Traumatic brain injury (TBI) is a common cause of morbidity and mortality

worldwide. It is difficult to estimate the real incidence of traumatic subarachnoid hemorrhage

(TSAH). Despite the fact that TSAH following trauma is associated with poor prognoses, the

impact of mechanism of injury and the pathophysiology remains unknown.. We hypothesized that

outcome of TSAH caused by motor vehicle crash (MVC) or fall from height (FFH) varies based

on the mechanism of injury.

Methods: Data were collected retrospectively from a prospectively created database registry in

the section of Trauma Surgery at Hamad General Hospital between January 2008 and July 2012.

All patients presented with head trauma and TSAH were included . Patient data included age,

gender, nationality, MOI, injury severity score (ISS), types of head injuries and associated

injuries. Ventilator days, ICU length of stay, pneumonia and mortality were also studied.

Results: A total of 1665 TBI patients were identified, of them 403 had TSAH with a mean age of

35±15 years. Of them 93% were males and 86% were expatriates. MVC (53%) and FFH (35%)

were the major MOI. The overall mean ISS and head AIS were 19±10.6 and 3.4±0.96,

respectively. Patients in MVC group sustained severe TSAH had significantly greater head AIS

(3.5±0.9 vs. 3.2±0.9; p=0.009) and ISS (21.6±10.6 vs. 15.9±9.5; p=0.001) and lower scene GCS

(10.8±4.8 vs. 13.2±3.4; p=0.001) compared to FFH group. Moreover, MVC group sustained more

intraventricular hemorrhage (4.7 vs. 0.7; p=0.001) and diffuse axonal injury (4.2 vs. 2.9;

p=0.001). In contrast, extradural hemorrhage (14.3% vs. 11.6%; p=0.008) was higher in FFH

group. Lower extremities (14% vs. 4.3%; p=0.004) injury was mainly associated with MVC

group. The overall mortality was 19 % among TSAH patients. The mortality rate was higher in

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MVC group when compared to FFH group (24% vs. 10%; p=0.001). In both groups, ISS and

GCS at the scene were independent predictors of mortality.

Conclusion: Patients with TSAH have high mortality rate. In this group of population, MVCs are

associated with a 3-fold increased risk of mortality. Therefore, prevention of MVC and fall can

reduce the incidence and severity of TBI in Qatar.

Key words: subarachnoid hemorrhage, traumatic brain injury, motor vehicle crash, fall from

height

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Introduction

Traumatic brain injury is a common cause of morbidity and mortality worldwide (23). The annual

incidence of traumatic brain injury in industrialized and non-industrialized countries varies from

150-250 cases per 100,000 populations (17). Prevention of primary traumatic brain injury can be

achievable through prevention programs and mitigation of secondary traumatic brain injury can

be feasible (1). Traumatic subarachnoid hemorrhage (TSAH) is a common finding in the setting

of traumatic brain injury (27). Though, it is difficult to estimate the exact incidence of TSAH in

traumatic brain injury, its incidence varies from 25% to 30% in moderate and severe head injury

cases (10). TSAH is not only associated with death and unfavorable neurological outcome, it is

also linked with early cerebral contusion progression in 59%– 71% of patients, with a subsequent

poor outcome (3,13,14).

The importance of TSAH was highlighted in a report from the United States Traumatic Coma

Data Bank (8), in which 39% of patients exhibited evidence of TSAH on their first CT scans and

this finding had an independent effect in worsening outcomes. Although, similar findings were

reported in studies by Servadei et al. (22), Kakarieka (15), and Green et al. (11), the mechanism

and the pathophysiology underlying the association between TSAH and worse prognosis has not

been elucidated. However, while, there is paucity of reports on the demographic and clinical

features of patients with TSAH after head injuries, these reports were limited to cohorts of

patients selected for recruitment into pharmacological studies (10), who traditionally represent a

minority of patients admitted to participating centers. Other studies were retrospective series (15)

or included death as the only outcome measure (11). With recent advances in multidetector-row

coronal and sagittal CT reconstruction, subtle findings, such as TSAH, can now be easily detected

(28). Nonetheless, few studies have focused on describing the patterns and the prognostic

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significance of TSAH (12,18). The aim of our study is to investigate the pattern and outcome of

TSAH in two subsets of patients in regards to mechanism of injury either motor vehicle crash

(MVC) or fall from height (FFH) as both are the common mechanisms of injury (MOI) in our

region.

Methods

Data were collected retrospectively from the database registry in the section of Trauma surgery at

Hamad General Hospital (HGH) between January 2008 and July 2012. HGH has the only tertiary

trauma center in the state of Qatar. All patients presented with head trauma and TSAH requiring

admission were included in the study. Patients who died at the scene or declared dead in the

trauma resuscitation room were excluded because of incomplete data. The diagnosis of head

injury was made by clinical history, physical examination and computerized tomographic scan

(CT ) of the head at the trauma resuscitation room. The diagnosis of SAH was based on the

findings of non-contrast head CT. Also, head CT imaging was performed to find the location and

grade of Diffuse Axonal Injury (DAI). The final diagnosis and grade of DAI , however, was

made by MRI. We do not have diagnosis of DAI based on autopsy report as there is no routine

protocol for mandatory autopsy for trauma related deaths in our hospital. All patients with TSAH

were routinely and closely monitored for coagulation profile and were managed in the intensive

care unit (ICU). Both blunt and penetrating injuries affecting the skull and intracranial structures

were studied. Associated injuries were managed according to the type of injury. Patient data

included age, gender, nationality, mechanism of injury, radiological imaging, Injury severity

score (ISS), head abbreviated injury score (AIS), head injuries (skull fracture, concussion,

intracranial hematoma, epidural hematoma, subdural hematoma, diffuse axonal injury and

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contusion) and associated injuries. Acute interventions during hospital course were also recorded

in addition to ventilator days, ICU length of stay, development of complications (pneumonia, and

ARDS) and mortality.

Statistical analysis: Data were presented as proportions or mean ± standard deviation (SD) as

appropriate. Baseline demographic characteristics, presentation, management and outcomes were

compared between the two groups using the student-t test for continuous variables and Pearson

chi-square (χ2) test for categorical variables. Multivariate logistic regression analysis was

performed to calculate the odds ratio for prediction of mortality. A significant difference was

considered when the 2-tailed p-value was less than 0.05. Data analysis was carried out using the

Statistical Package for Social Sciences version 18 (SPSS Inc., Chicago, USA).

This study was approved by the medical research center (# 12275/12) at Hamad general hospital,

HMC, Doha, Qatar.

Results

Of the total 1665 identified TBI patients, 403 had TSAH (355 were related to MVCs and FFH)

with a mean age of 35±15 years. Of them 93% were males and 86% were expatriates. Motor

vehicle crashes (MVC) and fall from height (FFH) were the major causes of blunt head trauma

with TSAH (53% and 35%, respectively). Endotracheal intubation was required in 44% of cases

[50% in trauma resuscitation room and 42% at the scene]. Craniotomy was performed in 14%,

open reduction and internal fixation of associated injuries (ORIF) in 10% and tracheostomy in

7.4% of patients (Table 1).

The overall mean ISS and head AIS were 19±10.6 and 3.4±0.96, respectively. Traumatic brain

injury patients with TSAH, had higher mean ISS (19±11 vs. 17±10; p=0.001), head AIS (3.4±.96

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vs. 3.2±.85; p=0.001), and mortality rate (18.4% vs. 9.6%; p=0.001) in comparison to patients

without TSAH.

The range of hospital length of stay (LOS) varies from 1 to 410 days with a median of 8 days;

ICU Stay from 1-150 days with a median of 3 days, and the mean mechanical ventilation was

5.7±4.9 days (Table 1). The overall incidence of positive blood alcohol was 8.3% with mean

blood alcohol concentration (BAC) of 45.3±19.9 mmol/L. The incidence of complications such as

pneumonia was (4.9%), ARDS (0.5%) and sepsis (0.5%).

Brain contusion (46.6%), subdural hemorrhage (36.5%), and epidural hemorrhage (13.2%) were

the other most frequently associated brain injuries. Rib fracture (14.7%) and injuries to the upper

(10%) and lower (9.6%) extremities were the commonly observed associated injuries (Figure 1).

Traumatic brain injury patients with TSAH were further analyzed according to major mechanisms

i.e. MVCs and FFH (Table 2). The two groups were comparable for gender, age and nationality.

Significantly more number of patients in MVC group required endotracheal intubation (53.5% vs.

30.7%; p=0.001). Craniotomy was done more frequently in the FFH group (14.3% vs. 12%;

p=0.007). Patients in MVC group sustained severe TSAH had significantly greater head AIS

(3.5±0.9 vs. 3.2±0.9; p=0.009) and ISS (21.6±10.6 vs. 15.9±9.5; p=0.001) and lower scene GCS

(10.8±4.8 vs. 13.2±3.4; p=0.001) compared to FFH group. Significantly higher proportion of

patients had positive blood alcohol (BAC) in the MVC group (9.8% vs. 4.3%; p=0.02).

Moreover, MVC group had more frequent intraventricular hemorrhage (4.7 vs. 0.7; p=0.001) and

diffuse axonal injury (4.2 vs. 2.9; p=0.001). In contrast, epidural hemorrhage (14.3% vs. 11.6%;

p=0.008) was significantly higher in FFH group, as well as the incidence of skull vault fractures

(35.7% vs. 27.9%; p=0.072) and base fractures (41.4% vs. 38% p= 0.79). The incidence of rib

fracture was significantly higher in MVC group (20.5% vs. 7.1%; p=0.003) (Figure 2).

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The overall mortality rate was 18.6% in TSAH patients. Furthermore, the incidence of mortality

was significantly higher in patients in the MVC group than in the FFH group (24% vs. 10%;

p=0.001). Table 3 shows univariate and multivariate analysis for the predictors of mortality in

patients with TSAH. MVCs was associated with 3-fold increase in the mortality (OR 2.8; 95% CI

1.48-5.28, p=0.001). However, after adjusting of the relevant and important variables, ISS (OR

1.11; 95% CI 1.04-1.17) and GCS at the scene (OR 0.89; 95% CI 0.79-0.99) were the

independent predictors of mortality in both groups.

Discussion

We present the first study from Qatar that evaluates the outcome of TSAH in two subsets of

patients based on the most frequent mechanism of injury (MVC vs. FFH) among traumatic brain

injury patients. Traumatic brain injury represents one of the most significant factors of disability

and death in multiple trauma patients. The devastating impact of traumatic brain injury on

patients, their families, and society in terms of limitations and resources are enormous. TSAH is a

common consequence of traumatic brain injury, occurring in 41%–55% of patients after moderate

or severe traumatic brain injury (6,7). In the present study one-fourth of the traumatic brain injury

patients had associated TSAH. It has been suggested that occurrence of TSAH indicates greater

mechanical force rather than an indicator of poor prognosis, which is evidenced by the present

study as well. Though, we did not specifically study patients with isolated TSAH, an earlier study

concluded that patients with isolated TSAH are at lower risk of deterioration than those associated

with other intracranial injuries (3).

Wong et al (26) reported that age, severity of injury, thickness of SAH, subdural hematoma, and

mass effect were the independent predictors of mortality and severe neurological outcomes. The

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diagnosis of TSAH in our study was based on the findings of non-contrast head CT. In our series,

ISS and GCS at the scene were independent predictors of mortality in TSAH patients, irrespective

of injury mechanism.

Chieregato et al. (5) conducted a prospective study of 141 patients with a CT diagnosis of TSAH

and found that amount of subarachnoid blood and presence of brain contusions at admission were

the significant independent factors that correlated with CT progression. Servadei et al. (22) in a

study of 750 patients showed significant association between TSAH and poor prognosis. The

authors also found an association of TSAH with old age and lower admission GCS. In contrast,

our patients were relatively younger in age and had moderate to severe GCS score.

TSAH may be complicated with vasospasm, hydrocephalus, brain edema and ischemia. Eighteen

percent of our patients had brain edema but none had vasospasm or hydrocephalus.

TSAH patients could be managed through the maintenance of hypervolemia, mean arterial

pressure to ensure adequate cerebral perfusion pressure and hemodilution (16).

A systematic review found no beneficial effect of the calcium antagonist; nimodipine on the

outcome after TSAH (25). Owing to its ineffectiveness, we did not use nimodipine for our TSAH

patients.

Despite the fact that TSAH is associated with poor prognosis following traumatic injuries, the

impact of injury mechanism remains unexplored. We believe that the outcome of TSAH patients

varies according to the mechanism of injury either MVC or FFH and provide insight for the

development of injury prevention strategies. MVCs, falls and firearms were the frequently

observed injury mechanism that leads to traumatic brain injury (2,4,9,20) . According to National

Institutes of Health (20), FFH is the most frequent cause of TSAH among elderly patients.

However, MVC remains the major cause of TSAH among physically active young population

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(20). A recent study from Qatar reported MVC and FFH to be the commonly associated

mechanisms of traumatic brain injury (9). Consistent with earlier reports, MVCs and FFH are the

major determinants of TSAH mainly involve young population in our study. Moreover, alcohol

intoxication was incidentally higher among the MVC group than FFH group in our cases. It is

noteworthy that alcohol-impaired driving is prohibited by law of the land in Qatar. This explains

the overall low incidence of elevated blood alcohol level in our cohort. Also, in our study one-

third of patients comprised of young working population who sustained traumatic brain injury due

to FFH at construction sites, which reflects the unique demographics of population in Qatar (24).

MVC patients sustained significantly severe injuries with high ISS and low GCS than FFH

patients in our study. Also, MVC victims had significantly higher incidence of intraventricular

hemorrhage, and diffuse axonal injury when compared to FFH group. While, FFH patients

sustained significantly greater incidence of extradural hemorrhage than MVC group.

Pobereskin (21) showed the case fatality rates for TSAH patients at 24 hours, 1 week, and 30 days

were 21%, 37%, and 44% respectively. Another study by Morris and Marshall (19) reported that

patients with TSAH had 26% mortality. Consistent with these findings our study demonstrated an

overall mortality rate was 18.6% in TSAH patients. Furthermore, the incidence of mortality was

significantly higher in patients in the MVC group than in the FFH group. Therefore, our study

highlighted the important mechanisms of head injury together with alarming figures of mortality

among young patients with TSAH, which should be of particular focus to design an effective

injury prevention programs in Qatar.

Limitations: There are a number of limitations to our study. One of the limitations is the

retrospective nature of the study. We did not elaborate on the pathophysiology of injury and

evolution of injury cascades that leads to higher mortality of patients with severe TSAH. Also, we

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have not discussed the management of these patients. The information regarding the rehabilitation

of traumatic brain injury patients, thickness and grading of SAH are missing. We do not have

diagnosis of DAI based on autopsy reports as there is no routine protocol for mandatory autopsy

for trauma-related deaths in our hospital. Moreover, there are no comments on the prehospital

deaths because SAH cannot be diagnosed at this stage particularly in the absence of postmortem

data.

Conclusion: One-fourth of the head injury patients sustained TSAH with a high (19%) mortality

rate. Our study demonstrated that MVCs associated with severe head injuries have a 3-fold

increased risk of mortality. The ISS and GCS at the scene were found to the independent

predictors of mortality in both the groups. Interestingly, a higher proportion of morbidity and

mortality is associated with severe mechanisms (MVC & Falls) of injury in TSAH patients.

Therefore, prevention of MVC and fall can reduce both the incidence and severity of traumatic

brain injury in Qatar.

Acknowledgments

The authors thank the registry database team in the section of trauma surgery for their

contribution. The authors have no conflict of interests and no financial issues to disclose. All

authors read and approved the manuscript.

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Figure 1: Percentage of traumatic head and associated injuries

Figure 2: Percentage of traumatic brain and associated injuries based on the injury mechanism

(* Statistically significant)

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Table 1: Demographics, mechanism of injury and interventions

TSAH Patients n=403 (%)

TSAH related to MVC and FFH 355 (88)

Male 381 (93.4)

Age (mean ± SD) 34±15

Nationality

Qatari 57 (14.2)

Non-Qatari 344 (85.8)

Mechanism of injury

MVCs 215 (53)

FFH 140 (35)

Others 48 (12)

ETT Intubation 181 (44.4)

- Emergency Department 78 (49.8)

- On-scene 75 (42.1)

- Referring hospital 18 (10.1)

Tracheostomy 30 (7.4)

ORIF 39 (9.6)

Craniotomy 57 (14)

ISS 19±10.6

Head AIS (mean ± SD) 3.4±0.96

Chest AIS (mean ± SD) 2.8±0.6

Abdominal AIS (mean ± SD) 2.3±0.6

GCS Scene (mean ± SD) 11.5±4.6

GCS Emergency Department (mean ± SD) 10.7±5.3

Hospital LOS (median; range) 8 (1-410)

ICU LOS(median; range) 3 (1-150)

Ventilatory days (mean ± SD) 5.7±4.9

Positive Blood Alcohol 34 (8.3%)

Blood alcohol concentration (BAC) (mean ± SD) 45.3±19.9

Complications

Pneumonia 20 (4.9)

ARDS 2 (0.5)

Sepsis 2 (0.5)

Overall Mortality 75 (18.6)

MVC: Motor Vehicle crashes; FFH: Fall from height; ORIF: Open reduction and

internal fixation; LOS: length of stay; ISS: Injury severity score; GCS: Glasgow coma

score; ARDS: Acute Respiratory distress syndrome

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Table 2: Traumatic SAH according to mechanism of injury

MVCs

(n=215)

FFH

(n=140)

P value

Male (%) 92 95.7 0.68

Age (mean ± SD) 34±14.2 34±15.9 0.99

ETT Intubation (%) 53.5 31 0.001

Tracheostomy (%) 12 1.4 0.053

ORIF (%) 13 5.7 0.29

Craniotomy (%) 12 14.3 0.007

ISS (mean ± SD) 21.6±10.6 15.9±9.5 0.001

Head AIS (mean ± SD) 3.5±0.9 3.2±0.9 0.009

Chest AIS (mean ± SD) 2.8±0.5 2.7±0.7 0.44

Abdominal AIS (mean ± SD) 2.3±0.6 2.2±0.6 0.48

Hospital LOS (median; range) 9 (1-410) 8 (1-91) 0.08

ICU LOS (median; range) 4 (1-150) 3 (1-42) 0.43

Ventilatory days (mean ± SD) 5.9±5 5.9±4.9 0.95

GCS Scene (mean ± SD) 10.8±4.8 13.2±3.4 0.001

Alcohol intake (%) 9.8 4.3 0.02

BAC (mean ± SD) 44.9±22.3 50.2±23.4 0.61

Pneumonia (%) 6 5 0.93

ARDS (%) 0.9 0 0.98

Sepsis (%) 0 1.4 0.87

Mortality (%) 24 10 0.001

MVC: Motor Vehicle crashes, FFH: Fall from height; AIS: Abbreviated injury

score; ISS: injury severity score; BAC: Blood alcohol concentration; ARDS:

Acute Respiratory distress syndrome

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Table 3 : univariate and multivariate analysis for the predictors of mortality in patients

with Traumatic SAH

Univariate analysis Multivariate analysis

Variable Odd ratio 95% CI P value Odd ratio 95% CI P value

Mechanism of

injury (MVC)

2.79 1.48-5.28 0.001 1.26 0.31-5.16 0.74

GCS at scene

0.72 0.66-0.77 0.001 0.89 0.79-0.99 0.046

ISS

1.19 1.15-1.25 0.001 1.11 1.04-1.17 0.001

SBP (scene)

1.008 0.995-

1.021

0.25 1.02 1.00-1.04 0.051

Oxygen

saturation

(scene)

0.88 0.83-0.94 0.001 0.95 0.89-1.01 0.12

95% CI: 95% confidence interval; MVC: Motor Vehicle crashes; ISS: Injury severity

score; SBP: systolic blood pressure

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Abbreviations

TSAH: traumatic subarachnoid hemorrhage

Motor vehicle crash: MVC

Fall from height: FFH

Injury severity score: ISS

Abbreviated injury score: AIS

Glasgow coma scale: GCS

Mechanism of injury: MOI

Traumatic brain injury: TBI