In the last few decades an abundance of publications have accumu lated on the clinical implications of subarachnoid haemorrhage (SAH) due to aneurysmal rupture. In contrast, until about 6 years ago, SAH due to traumatic head injury mainly, if not only, drew the attention of the forensic pathologist. In their analysis of the data from the American Traumatic Coma Data Bank, Eisenberg et al. concluded in 1990 that the presence of SAH on the initial computed tomographic scan (tSAH) had an un favourable effect on outcome. This conclusion has since been con firmed in other series. Dr. Kakarieka, the author of the present monograph, has been fascinated by tSAH since his participation in 1989 as International Trial Coordinator of the large European Trial on the effect of nimodipine on outcome after severe injury (HIT 2). This study re vealed a statistically significant, favourable effect in the subgroup of patients with tSAH, a result which warranted a further trial on the efficacy of nimodipine administration in patients with tSAH. This trial, the so-called German trial which was completed in 1995, not only revealed that tSAH is an important and independent factor predicting unfavourable outcome in head injury, but also showed convincingly the statistically significant, favourable effect of nimodipine adminis tration in patients with tSAH.

Survey of the Literature

Pathology
Incidence
Relation to Age
Relation to Alcohol Intoxication
Prognosis
Vasospasm and Ischaemic Neurological Deficits After tSAH
Summary
Patient Characteristics and Methodology
Patient Population
Variables Recorded
Laboratory Evaluation
Treatment of Patients
CT Evaluation
Criteria for Assessment of Amount of Blood on CT
Criteria for Classification of the Mechanism of Injury
Criteria for Defining Severity of Head Injury on Entry to the Trial
Criteria for Assessment of Outcome
Biometric Methods
Summary
Analysis of CT Findings in tSAH
Frequency
Time of CT
Amount of Blood
Clearance of tSAH
Topographic Location of Blood
Associated CT Findings
Contusions
Subdural Haematoma
Epidural Haematoma
Intracerebral Haematoma
Intraventricular Blood
Signs of Raised ICP on CT
Hypodensity Compatible with Ischaemia
Summary
Demographic and Clinical Aspects of tSAH
Age
Sex
Cause of Injury
Alcohol Intake Before Injury
Multiple Injuries
Interval Between Injury and Admission
Severity of Head Injury on Entry to the Trial
Plain Skull X-Rays
Craniotomy for Removal of Mass Lesions
Intracranial Pressure Monitoring
Haemodynamics
Neurological Status
Body Temperature
Mortality
Summary
Outcome in tSAH
Outcome in tSAH
Amount of Blood and Outcome
Fisher's Categories and Outcome
Location of Blood and Outcome
Associated CT Lesions and Outcome
Relationship of Various Demographic and Clinical Aspects to Outcome
Functional Assessment
Post-traumatic Epilepsy
Summary
tSAH as a Prognostic Factor
Risk of Unfavourable Outcome in tSAH Patients
Determination of Prognostic Factors
Summary
Clinical Laboratory Evaluation in tSAH
Haematocrit
Leucocytes.-Platelets
Serum Aminotransferases
Serum Lipase
Serum Amylase
Summary
Therapeutic Prospects of tSAH with the Calcium Antagonist Nimodipine
Pharmacological and Clinical Rational for the Use of the Calcium Antagonist Nimodipine in Head Injury
The Effect of Nimodipine in the Overall Head-Injury Study Population
The Effect of Nimodipine on tSAH
Adverse Events
Summary
Confirmation of the Hypothesis: The German tSAH Study
Patient Population
Treatment with the Test Drug
Statistical Analysis
Demographic Results
CT Findings
Transcranial Doppler Blood Flow Velocities
Blood Pressure and ICP
Follow-Up Investigation
Post-traumatic Epilepsy
Pool Analysis of 460 tSAH Patients
Summary
Discussion and Conclusions
tSAH, a Frequent Finding in Head Injury
tSAH: CT Aspects
tSAH: Clinical Aspects
tSAH and Outcome
tSAH and Vasospasm
tSAH and Post-traumatic Epilepsy
tSAH as a Prognostic Factor
tSAH and Its Treatment with Nimodipine
References.