Risk Stratification for Traumatic Sah Enlargement and Surgical Intervention: Guides to Follow-Up Imaging in Patients With Trauma Publisher Pubmed



Azzi C ; Radmard M ; Tafazolimoghadam A ; Speer S ; Yousem DM
Source: American Journal of Neuroradiology Published:2026

Abstract

BACKGROUND AND PURPOSE: SAH is a frequent intracranial finding in patients with trauma and poses significant diagnostic and prognostic challenges. Identifying which patients need closer follow-up because of potential complications of posttraumatic SAH is important because the need for serial imaging is debated. The purpose of this study was to evaluate the rate of posttraumatic subarachnoid hemorrhage enlargement, identify predictors of hemorrhage progression and need for surgical intervention, and propose a risk-stratified approach to follow-up imaging in trauma patients. MATERIALS AND METHODS: This retrospective study analyzed 32,401 trauma-related NCCT scans from 2 trauma centers during 6 years, identifying 250 cases of traumatic SAH. Patient demographics, clinical presentation, imaging characteristics, and follow-up data were reviewed. Univariate, bivariate, logistic, and linear regression analyses were performed to determine predictors of SAH enlargement and the need for surgical intervention. RESULTS: Among patients with SAH, 64% were 65 years of age or older, and falls were the most common injury mechanism (66.8%). SAH enlargement occurred in 40/222 (18%) cases that had follow-up CT and was significantly associated with intraparenchymal hemorrhage (IPH), elevated international normalized ratio and prothrombin time, and lower Glasgow Coma Scale scores. Surgical intervention was more commonly required in cases with midline shift or severe traumatic brain injury (Glasgow Coma Scale 3–8). Aneurysms were present in 11/114 patients who underwent CTA, with 9 believed to be the cause of the traumatic episode. CONCLUSIONS: Traumatic SAH is often stable in patients without coexistent hemorrhages or coagulopathy. Risk factors such as IPH and elevated international normalized ratio and prothrombin time should guide follow-up imaging and intervention decisions. A tailored imaging protocol based on risk stratification may optimize patient care while reducing unnecessary imaging. © 2026 American Society of Neuroradiology. All rights reserved.