Dalle Ore Cecilia L, Rennert Robert C, Schupper Alexander J, Gabel Brandon C, Gonda David, Peterson Bradley, Marshall Lawrence F, Levy Michael, Meltzer Hal S
1Department of Neurosurgery, University of California San Diego School of Medicine; and.
Divisions of2Neurosurgery and.
J Neurosurg Pediatr. 2018 Nov 1;22(5):559-566. doi: 10.3171/2018.5.PEDS18140. Epub 2018 Aug 10.
OBJECTIVEPediatric traumatic subarachnoid hemorrhage (tSAH) often results in intensive care unit (ICU) admission, the performance of additional diagnostic studies, and ICU-level therapeutic interventions to identify and prevent episodes of neuroworsening.METHODSData prospectively collected in an institutionally specific trauma registry between 2006 and 2015 were supplemented with a retrospective chart review of children admitted with isolated traumatic subarachnoid hemorrhage (tSAH) and an admission Glasgow Coma Scale (GCS) score of 13-15. Risk of blunt cerebrovascular injury (BCVI) was calculated using the BCVI clinical prediction score.RESULTSThree hundred seventeen of 10,395 pediatric trauma patients were admitted with tSAH. Of the 317 patients with tSAH, 51 children (16%, 23 female, 28 male) were identified with isolated tSAH without midline shift on neuroimaging and a GCS score of 13-15 at presentation. The median patient age was 4 years (range 18 days to 15 years). Seven had modified Fisher grade 3 tSAH; the remainder had grade 1 tSAH. Twenty-six patients (51%) had associated skull fractures; 4 involved the petrous temporal bone and 1 the carotid canal. Thirty-nine (76.5%) were admitted to the ICU and 12 (23.5%) to the surgical ward. Four had an elevated BCVI score. Eight underwent CT angiography; no vascular injuries were identified. Nine patients received an imaging-associated general anesthetic. Five received hypertonic saline in the ICU. Patients with a modified Fisher grade 1 tSAH had a significantly shorter ICU stay as compared to modified Fisher grade 3 tSAH (1.1 vs 2.5 days, p = 0.029). Neuroworsening was not observed in any child.CONCLUSIONSChildren with isolated tSAH without midline shift and a GCS score of 13-15 at presentation appear to have minimal risk of neuroworsening despite the findings in some children of skull fractures, elevated modified Fisher grade, and elevated BCVI score. In this subgroup of children with tSAH, routine ICU-level care and additional diagnostic imaging may not be necessary for all patients. Children with modified Fisher grade 1 tSAH may be particularly unlikely to require ICU-level admission. Benefits to identifying a subgroup of children at low risk of neuroworsening include improvement in healthcare efficiency as well as decreased utilization of unnecessary and potentially morbid interventions, including exposure to ionizing radiation and general anesthesia.
目的
小儿创伤性蛛网膜下腔出血（tSAH）常导致入住重症监护病房（ICU）、进行额外的诊断性检查以及采取ICU级别的治疗干预措施，以识别和预防神经功能恶化事件。
方法
对2006年至2015年在机构特定创伤登记处前瞻性收集的数据，补充对因单纯创伤性蛛网膜下腔出血（tSAH）入院且入院时格拉斯哥昏迷量表（GCS）评分为13 - 15分的儿童进行的回顾性病历审查。使用钝性脑血管损伤（BCVI）临床预测评分计算BCVI风险。
结果
10395例小儿创伤患者中有317例因tSAH入院。在317例tSAH患者中，51名儿童（16%，23名女性，28名男性）被确定为单纯tSAH，神经影像学检查无中线移位，入院时GCS评分为13 - 15分。患者中位年龄为4岁（范围18天至15岁）。7例为改良Fisher 3级tSAH；其余为1级tSAH。26例患者（51%）伴有颅骨骨折；4例累及颞骨岩部，1例累及颈动脉管。39例（76.5%）入住ICU，12例（23.5%）入住外科病房。4例BCVI评分升高。8例接受CT血管造影；未发现血管损伤。9例患者接受了与影像检查相关的全身麻醉。5例在ICU接受了高渗盐水治疗。改良Fisher 1级tSAH患者的ICU住院时间明显短于改良Fisher 3级tSAH患者（1.1天对2.5天，p = 0.029）。未观察到任何儿童神经功能恶化。
结论
入院时单纯tSAH且无中线移位、GCS评分为13 - 15分的儿童，尽管部分儿童存在颅骨骨折、改良Fisher分级升高和BCVI评分升高的情况，但神经功能恶化风险似乎极小。在这个tSAH儿童亚组中，并非所有患者都需要常规的ICU级护理和额外的诊断性影像学检查。改良Fisher 1级tSAH儿童可能尤其不太可能需要入住ICU。识别神经功能恶化低风险儿童亚组的益处包括提高医疗效率以及减少不必要的和潜在有害的干预措施的使用，包括暴露于电离辐射和全身麻醉。
