Abstract

Background: Differentiating cerebral aneurysm–related hemorrhage from purely traumatic intracranial hemorrhage in patients with head trauma is crucial yet challenging in emergency settings. This distinction directly influences clinical priorities, resource allocation, and the urgency of intervention. This study assessed the accuracy of neurosurgeons’ clinical judgment in identifying aneurysm-related hemorrhage in patients with traumatic intracranial hemorrhage and contextualized these findings through a meta-analysis of the literature.

Methods: This retrospective analysis included patients with severe head and neck trauma (Abbreviated Injury Scale score ≥ 3) and intracranial hemorrhage who presented to a single trauma center between June 2021 and May 2023. Neurosurgeons determined the need for computed tomography angiography (CTA) based on clinical suspicion. To understand the basis for these decisions, demographic data, clinical presentations, and initial noncontrast computed tomography (CT) findings were analyzed in patients who underwent CTA and those who did not. Additionally, a systematic literature search and meta-analysis were performed to evaluate the prevalence and management of aneurysms in this population.

Results: Of 932 eligible patients, 49 (5.3%) underwent CTA. These patients had lower Glasgow Coma Scale scores, higher Injury Severity Scores (ISS), and more frequent subarachnoid hemorrhage, parenchymal hemorrhage, subdural hemorrhage, intraventricular hemorrhage, skull fractures, and facial bone fractures than those who did not undergo CTA. Among the CTA group, four patients (8.2%) had a cerebral aneurysm; none required emergent neurosurgical intervention. Clinical and imaging characteristics did not significantly differ between patients with and without aneurysms. The meta-analysis, which included our cohort and three additional studies (totaling 3,431 patients), showed a pooled aneurysm detection rate of 8.3% among the 664 patients who underwent CTA. However, only 11 patients (1.7%) had aneurysm-related hemorrhage requiring neurosurgical intervention.

Conclusions: CTA is essential for detecting aneurysms. However, clinical presentation and initial CT findings alone are insufficient to reliably identify trauma patients whose hemorrhage is aneurysm-related. Routine CTA for all patients with traumatic intracranial hemorrhage may not alter acute management and could delay time-sensitive interventions for other injuries. Integrating our findings with meta-analysis evidence supports a more selective CTA approach, guided by refined clinical and imaging criteria, to prioritize urgent trauma care while accurately identifying the small subset of patients who truly require vascular evaluation.