Risk Factors Associated With Neurosurgical Intervention in Patients With Mild Traumatic Intracranial Hemorrhage

Published:November 17, 2022DOI:



      Community centers commonly transfer patients with traumatic intracranial hemorrhage (ICH) to level 1 and 2 trauma centers for neurosurgical evaluation regardless of the degree of injury. Determining risk factors leading to neurosurgical intervention (NSI) may reduce morbidity and mortality of traumatic ICH and the transfer of patients with lower risk of NSI.


      A retrospective chart review was performed on patients admitted or transferred to a level 1 trauma center from October 2015 to September 2019 with Glassgow Coma Scale score 13-15 and traumatic ICH on initial head computerized tomography (CTH) scan. Bivariate analyses and multivariable regression were used to identify factors associated with progression to NSI.


      Of 1542 included patients, 8.2% required NSI. A greater proportion were male (69.1% versus 52.3%, P = 0.0003), on warfarin (37.7% versus 21.6%, P = 0.0023), presented with subdural hemorrhage (98.4% versus 63.3%, P < 0.0001, larger subdural hemorrhage size (median 19 mm [interquartile range {IQR}: 14-25] versus 5 mm [IQR: 3-8], P < 0.0001), and had a worsening repeat CTH (24.4% versus 13%, P < 0.0001). On physical examination, more patients had confusion (40.5% versus 31.4%, P = 0.0495) and hemiparesis (16.2% versus 2.6%, P < 0.0001). CTH findings of midline shift (80.2% versus 10.8%, P < 0.0001) and shift size (median 8.0 mm [IQR: 5.0-12.0] versus 4 mm [IQR: 3-5], P < 0.0001) were significantly associated with NSI.


      Clinical factors and patient characteristics can be used to infer a greater risk of requiring NSI. These factors could reduce unnecessary transfers and hasten the transfer of patients more likely to progress to NSI.


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        • Thompson H.J.
        • McCormick W.C.
        • Kagan S.H.
        Traumatic brain injury in older adults: epidemiology, outcomes, and future implications.
        J Am Geriatr Soc. 2006; 54: 1590-1595
        • Centers for Disease Control and Prevention
        TBI-related emergency department visits, hospitalizations, and deaths (EDHDs).
        (Available at:)
        • Choudhry O.J.
        • Prestigiacomo C.J.
        • Gala N.
        • Slasky S.
        • Sifri Z.C.
        Delayed neurological deterioration after mild head injury: cause, temporal course and outcomes.
        Neurosurgery. 2013; 73: 753-760
        • Teasdale G.
        • Jennett B.
        Assessment of coma and impaired consciousness. A practical scale.
        Lancet. 1974; 2: 81-84
        • Son S.
        • Yoo C.J.
        • Lee S.G.
        • et al.
        Natural course of initially non-operated cases of acute subdural hematoma: the risk factors of hematoma progression.
        J Korean Neurosurg Soc. 2013; 54: 211-219
        • Croce M.A.
        • Dent D.L.
        • Menke P.G.
        • et al.
        Acute subdural hematoma: nonsurgical management of selected patients.
        J Trauma. 1994; 36: 820-827
        • Feliciano C.E.
        • De Jesús O.
        Conservative management outcomes of traumatic acute subdural hematomas.
        P R Health Sci J. 2008; 27: 220-223
        • Bee T.K.
        • Magnotti L.J.
        • CroceMA
        • et al.
        Necessity of repeat head CT and ICU monitoring in patients with minimal brain injury.
        J Trauma. 2009; 66: 1015-1018
        • Yun B.J.
        • White B.A.
        • Harvey H.B.
        • et al.
        Opportunity to reduce transfer of patients with mild traumatic brain injury and intracranial hemorrhage to a Level 1 trauma center.
        Am J Emerg Med. 2017; 35: 1281-1284
        • Joseph B.
        • Friese R.S.
        • Sadoun M.
        • et al.
        The BIG (brain injury guidelines) project: defining the management of traumatic brain injury by acute care surgeons.
        J Trauma Acute Care Surg. 2014; 76: 965-969
        • Carroll L.J.
        • Cassidy J.D.
        • Holm L.
        • Kraus J.
        • Coronado V.G.
        Methodological issues and research recommendations for mild traumatic brain injury: the WHO Collaborating Centre Task Force on mild Traumatic Brain Injury.
        J Rehabil Med. 2004; 36: 113-125
        • Harris P.A.
        • Taylor R.
        • Thielke R.
        • Payne J.
        • Gonzalez N.
        • Conde J.G.
        Research electronic data capture (REDCap) – a metadata-driven methodology and workflow process for providing translational research informatics support.
        J Biomed Inform. 2009; 42: 377-381
        • Harris P.A.
        • Taylor R.
        • Minor B.L.
        • et al.
        • REDCap Consortium
        The REDCap consortium: building an international community of software partners.
        J Biomed Inform. 2019; 95: 103208
        • Finkelstein E.
        • Corso P.
        • Miller T.
        The Incidence and Economic Burden of injuries in the United States.
        Oxford University Press, New York, NY2006
        • Orlando A.
        • Levy A.S.
        • Rubin B.A.
        • et al.
        Isolated subdural hematomas in mild traumatic brain injury. Part 1: the association between radiographic characteristics and neurosurgical intervention.
        J Neurosurg. 2018; : 1-10
        • Sweeney T.E.
        • Salles A.
        • Harris O a
        • Spain D a
        • Staudenmayer K.L.
        Prediction of neurosurgical intervention after mild traumatic brain injury using the national trauma data bank.
        World J Emerg Surg. 2015; 10
        • Tourigny J.N.
        • Boucher V.
        • Paquet V.
        • et al.
        External validation of the updated Brain Injury Guidelines for complicated mild traumatic brain injuries: a retrospective cohort study.
        J Neurosurg. 2022; 137: 1-7