Outcome after In-Hospital Rebleeding of Ruptured Intracranial Aneurysms

Background: Rebleeding after initial subarachnoidal hemorrhage (SAH) is known as a factor influencing the outcome. This complication has been reported to occur in 4% of the patients admitted with SAH. Moreover, ultraearly rebleeding within the first 24 hours might occur in 9 to17% of the cases (40 to 87% appearing in the first 6 hours). Risk factors influencing this condition include increasing aneurysm size, deterioration of neurological deficits, angiography within 3 hours of bleeding, sentinel symptoms, and loss of consciousness at initial bleed. The aim of this study was to assess the incidence, timing, risk factors, and outcome in a consecutive series of patients presenting with SAH who suffer rebleeding after admission in our institution.

Material and Methods: In 2011, we admitted 117 patients with SAH. The overall mortality rate during this year was 9.4%. This study included 17 patients who presented with in-hospital rebleeding within a 26-month period (November 2009 to January 2012). This series included eight males and nine females (mean 57±9.6 years). Demographic, clinical, and radiological characteristics including hemodynamic parameters were analyzed.

Results: In this series a total of 14 patients (84%) died after in-hospital rebleeding. The rest of the patients (n = 3, 16%) survived with severe neurological deficits (Glasgow Outcome Scale 2 to 3, mRS 3–4). Rebleeding was documented during the first 7 hours after initial bleeding in 13 patients (76%). In addition, rebleeding within the first 48 and 72 was observed in two (12%) and one (6%) case, respectively. A Fisher grade 4 was documented in 82% of the cases on the initial computed tomography scan. WFNS grade was documented on admission as follows: 1 to 3 (n = 8, 47%); 4 to 5 (n = 9, 53%). Location of the aneurysm included ACA (53%), MCA (29%), ICA (12%), and BA (6%). The aneurysm size was > 6 mm (41%) and < 10 mm. there were 17% of patients who had more than 1 aneurysm and in 41% of the cases more than one rebleeding occurred. Initial sentinel headache and loss of consciousness was observed in 70% of patients. DSA was performed in 35% of cases. Only 23% of cases underwent endovascular (n = 2) or microsurgical occlusion of the aneurysm. Online hemodynamic parameters during rebleeding of patients admitted in the intensive care unit will be presented.

Conclusion: In-hospital rebleeding after SAH is a devastating condition with high mortality and poor outcome in survivors. Most of rebleedings are likely to occur within 7 hours after admission. Influencing factors such as hemodynamic parameters might still influence the risk of this complication.