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J Neurol Surg A Cent Eur Neurosurg 2016; 77(03): 207-221
DOI: 10.1055/s-0035-1570007
Original Article
Georg Thieme Verlag KG Stuttgart · New York

Outcome after In-Hospital Rebleeding of Rupture of Intracranial Aneurysms

Jenny Kienzler
1   Department of Neurosurgery, Kantonsspital Aarau, Aarau, Switzerland
,
Serge Marbacher
1   Department of Neurosurgery, Kantonsspital Aarau, Aarau, Switzerland
,
Luca Remonda
2   Division of Neuroradiology, Department of Radiology, Kantonsspital Aarau, Aarau, Switzerland
,
Jehuda Soleman
1   Department of Neurosurgery, Kantonsspital Aarau, Aarau, Switzerland
,
Janine Ai Schlaeppi
1   Department of Neurosurgery, Kantonsspital Aarau, Aarau, Switzerland
,
Ulrich Leupold
1   Department of Neurosurgery, Kantonsspital Aarau, Aarau, Switzerland
,
Javier Fandino
1   Department of Neurosurgery, Kantonsspital Aarau, Aarau, Switzerland
› Author Affiliations
Further Information

Publication History

18 October 2014

30 September 2015

Publication Date:
25 January 2016 (online)

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Abstract

Background After initial subarachnoidal hemorrhage (SAH), due to an intracranial aneurysm, rebleeding is known as a factor influencing the devastating outcome. This complication has been reported to occur in ∼ 4% of the patients admitted with aneurysmal SAH. Moreover, ultra-early rebleeding within the first 24 hours might occur in 9 to 17% of the cases (40–87% appearing in the first 6 hours). Risk factors influencing this situation include increasing aneurysm size, deterioration of neurologic deficits, angiography within 3 hours of bleeding, sentinel symptoms, and the loss of consciousness at initial bleeding. The aim of this retrospective study was to assess factors and potential risk factors related to rebleeding, specifically the interval from initial SAH to rebleeding.

Material and Methods From a consecutive series of 243 patients who experienced aneurysmal SAH, we identified 28 patients (11.5%; 12 men, 16 women; mean age: 58 ± 10 years) who developed in-hospital rebleeding during this 49-month study (2009–2013). Demographic, radiologic, and clinical characteristics including hemodynamic parameters were analyzed.

Results Rebleeding was fatal in 20 of the 28 patients (71%) and caused severe neurologic deficits (Glasgow Outcome Scale: 3; modified Rankin Scale: 5) in 3 (29%) of the remaining 8 survivors. Rebleeding occurred within the first 4 hours in 15 patients (54%) within 7, 24, and 48 hours in 17 (61%), 6 (21%), and 1 (4%) patient, respectively. In this series, the medium arterial blood pressure was 98 ± 11 mm Hg at arrival at the emergency department, 88 ± 10 mm Hg before rebleeding, and it dramatically increased to 124 ± 22 mm Hg at rebleeding. For the patients with rebleeding after aneurysmal SAH, initial sentinel headache (79%) and loss of consciousness (68%) were the common presenting symptoms. The World Federation of Neurological Societies grade was documented on admission as follows: 1–3 (n = 14 [50%]); 4–5 (n = 14 [50%]). A Fisher grade 4 was documented in 82% of the cases on the initial computed tomography (CT) scan. Overall, 42% of the cases underwent endovascular (n = 6) or microsurgical occlusion of the aneurysm (n = 6). The rest of the patients (n = 16, 58%) did not underwent occlusion of the aneurysm because of poor clinical status. Digital substraction angiography was performed in 61% of the cases.

Conclusion Possible factors increasing the risk of in-hospital rebleeding after aneurysmal SAH are high systolic blood pressure, sentinel headache, initial loss of consciousness, poor Hunt and Hess grade, high Fisher grade on initial CT, large aneurysm size, and the performance of angiography. Most of the rebleedings in patients in our center are likely to occur within 7 hours after admission. Based on our findings, we suggest that mobilization of the patient and maneuvers including invasive procedures should be restricted to a minimum during intensive care unit treatment prior to the occlusion of the ruptured aneurysm. Stabilization of blood pressure with adequate sedation and analgesia prior to occlusion can be considered preventive strategies against rebleeding.

Keywords

subarachnoid hemorrhage - rebleeding - risk factor - intracranial aneurysm - outcome
 

  • References

  • 1 Starke RM, Connolly Jr ES ; Participants in the International Multi-Disciplinary Consensus Conference on the Critical Care Management of Subarachnoid Hemorrhage. Rebleeding after aneurysmal subarachnoid hemorrhage. Neurocrit Care 2011; 15 (2) 241-246
    CrossrefPubMedGoogle Scholar
  • 2 Ameen AA, Illingworth R. Anti-fibrinolytic treatment in the pre-operative management of subarachnoid haemorrhage caused by ruptured intracranial aneurysm. J Neurol Neurosurg Psychiatry 1981; 44 (3) 220-226
    CrossrefPubMedGoogle Scholar
  • 3 Jane JA, Winn HR, Richardson AE. The natural history of intracranial aneurysms: rebleeding rates during the acute and long term period and implication for surgical management. Clin Neurosurg 1977; 24: 176-184
    PubMedGoogle Scholar
  • 4 Fujii Y, Takeuchi S, Sasaki O, Minakawa T, Koike T, Tanaka R. Ultra-early rebleeding in spontaneous subarachnoid hemorrhage. J Neurosurg 1996; 84 (1) 35-42
    CrossrefPubMedGoogle Scholar
  • 5 Hillman J, Fridriksson S, Nilsson O, Yu Z, Saveland H, Jakobsson KE. Immediate administration of tranexamic acid and reduced incidence of early rebleeding after aneurysmal subarachnoid hemorrhage: a prospective randomized study. J Neurosurg 2002; 97 (4) 771-778
    CrossrefPubMedGoogle Scholar
  • 6 Laidlaw JD, Siu KH. Ultra-early surgery for aneurysmal subarachnoid hemorrhage: outcomes for a consecutive series of 391 patients not selected by grade or age. J Neurosurg 2002; 97 (2) 250-258 ; discussion 247–249
    CrossrefPubMedGoogle Scholar
  • 7 Larsen CC, Eskesen V, Hauerberg J, Olesen C, Romner B, Astrup J. Considerable delay in diagnosis and acute management of subarachnoid haemorrhage. Dan Med Bull 2010; 57 (4) A4139
    PubMedGoogle Scholar
  • 8 Starke RM, Kim GH, Fernandez A , et al. Impact of a protocol for acute antifibrinolytic therapy on aneurysm rebleeding after subarachnoid hemorrhage. Stroke 2008; 39 (9) 2617-2621
    CrossrefPubMedGoogle Scholar
  • 9 Guo LM, Zhou HY, Xu JW, Wang Y, Qiu YM, Jiang JY. Risk factors related to aneurysmal rebleeding. World Neurosurg 2011; 76 (3–4) 292-298 ; discussion 253–254
    CrossrefPubMedGoogle Scholar
  • 10 Cong W, Zhongxin Z, Tiangui L, Zhang Y, Min H, Chao Y. Risk factors for rebleeding of aneurysmal subarachnoid hemorrhage based on the analysis of on-admission information. Turk Neurosurg 2012; 22 (6) 675-681
    PubMedGoogle Scholar
  • 11 Naidech AM, Janjua N, Kreiter KT , et al. Predictors and impact of aneurysm rebleeding after subarachnoid hemorrhage. Arch Neurol 2005; 62 (3) 410-416
    CrossrefPubMedGoogle Scholar
  • 12 Kusumi M, Yamada M, Kitahara T , et al. Rerupture of cerebral aneurysms during angiography—a retrospective study of 13 patients with subarachnoid hemorrhage. Acta Neurochir (Wien) 2005; 147 (8) 831-837
    CrossrefPubMedGoogle Scholar
  • 13 Ohkuma H, Tsurutani H, Suzuki S. Incidence and significance of early aneurysmal rebleeding before neurosurgical or neurological management. Stroke 2001; 32 (5) 1176-1180
    CrossrefPubMedGoogle Scholar
  • 14 Beck J, Raabe A, Szelenyi A , et al. Sentinel headache and the risk of rebleeding after aneurysmal subarachnoid hemorrhage. Stroke 2006; 37 (11) 2733-2737
    CrossrefPubMedGoogle Scholar
  • 15 Ando T, Sakai N, Yamada H , et al. Analysis of reruptured cerebral aneurysms and the prophylactic effects of barbiturate therapy on the early stage. Neurol Res 1989; 11 (4) 245-248
    PubMedGoogle Scholar
  • 16 Fisher CM, Kistler JP, Davis JM. Relation of cerebral vasospasm to subarachnoid hemorrhage visualized by computerized tomographic scanning. Neurosurgery 1980; 6 (1) 1-9
    CrossrefPubMedGoogle Scholar
  • 17 Drake C. Report of World Federation of Neurological Surgeons Committee on a Universal Subarachnoid Hemorrhage Grading Scale. J Neurosurg 1988; 68 (6) 985-986
    PubMedGoogle Scholar
  • 18 Hunt WE, Hess RM. Surgical risk as related to time of intervention in the repair of intracranial aneurysms. J Neurosurg 1968; 28 (1) 14-20
    CrossrefPubMedGoogle Scholar
  • 19 Colford Jr JM, Wade TJ, Sandhu SK , et al. A randomized, controlled trial of in-home drinking water intervention to reduce gastrointestinal illness. Am J Epidemiol 2005; 161 (5) 472-482
    CrossrefPubMedGoogle Scholar
  • 20 Yonekawa Y, Imhof HG, Ogata N , et al. Aneurysm surgery in the acute stage: results of structured treatment. Neurol Med Chir (Tokyo) 1998; 38 (Suppl): 45-49
    CrossrefPubMedGoogle Scholar
  • 21 Fandino J, Schuknecht B, Yüksel C, Wieser HG, Valavanis A, Yonekawa Y. Clinical, angiographic, and sonographic findings after structured treatment of cerebral vasospasm and their relation to final outcomes. Acta Neurochir (Wien) 1999; 141 (7) 677-690
    CrossrefPubMedGoogle Scholar
  • 22 Fandino J, Taussky P, Marbacher S , et al. The concept of a hybrid operating room: applications in cerebrovascular surgery. Acta Neurochir Suppl (Wien) 2013; 115: 113-117
    PubMedGoogle Scholar
  • 23 Stienen MN, Weisshaupt R, Fandino J , et al; Swiss SOS study group. Current practice in neuropsychological outcome reporting after aneurysmal subarachnoid haemorrhage. Acta Neurochir (Wien) 2013; 155 (11) 2045-2051
    CrossrefPubMedGoogle Scholar
  • 24 Larsen CC, Sørensen B, Nielsen JD, Astrup J. Reduced clot-stability during the first 6 hours after aneurysmal subarachnoid haemorrhage—a prospective case-control study. Thromb Res 2012; 129 (5) e229-e232
    CrossrefPubMedGoogle Scholar
  • 25 Molyneux A, Kerr R, Stratton I , et al; International Subarachnoid Aneurysm Trial (ISAT) Collaborative Group. International Subarachnoid Aneurysm Trial (ISAT) of neurosurgical clipping versus endovascular coiling in 2143 patients with ruptured intracranial aneurysms: a randomized trial. J Stroke Cerebrovasc Dis 2002; 11 (6) 304-314
    CrossrefPubMedGoogle Scholar
  • 26 Kitsuta Y, Suzuki N, Sugiyama M, Yamamoto I. Changes in level of consciousness and association with hyperglycemia as tool for predicting and preventing re-bleeding after spontaneous subarachnoid hemorrhage. Prehosp Disaster Med 2006; 21 (3) 190-195
    CrossrefPubMedGoogle Scholar
  • 27 Sakai N, Yamada H, Ando T, Nishimura Y. Prevention of rebleeding after operation for subarachnoid hemorrhage of unknown cause. Neurosurgery 1985; 17 (6) 942-946
    CrossrefPubMedGoogle Scholar
  • 28 Sakaki T, Morimoto T, Hoshida T, Kawaguchi S, Nakase H, Fukuzumi A. Rebleeding during transport of patients with a ruptured intracranial aneurysm. J Stroke Cerebrovasc Dis 1999; 8 (1) 38-41
    CrossrefPubMedGoogle Scholar
  • 29 Kassell NF, Torner JC. Aneurysmal rebleeding: a preliminary report from the Cooperative Aneurysm Study. Neurosurgery 1983; 13 (5) 479-481
    CrossrefPubMedGoogle Scholar
  • 30 Cha KC, Kim JH, Kang HI, Moon BG, Lee SJ, Kim JS. Aneurysmal rebleeding : factors associated with clinical outcome in the rebleeding patients. J Korean Neurosurg Soc 2010; 47 (2) 119-123
    CrossrefPubMedGoogle Scholar
  • 31 Tsuang FY, Su IC, Chen JY , et al. Hyperacute cerebral aneurysm rerupture during CT angiography. J Neurosurg 2012; 116 (6) 1244-1250
    CrossrefPubMedGoogle Scholar
  • 32 Wu TC, Tsui YK, Chen TY, Lin CJ, Wu TC, Tzeng WS. Rebleeding of aneurysmal subarachnoid hemorrhage in computed tomography angiography: risk factor, rebleeding pattern, and outcome analysis. J Comput Assist Tomogr 2012; 36 (1) 103-108
    CrossrefPubMedGoogle Scholar
  • 33 Molyneux A, Kerr R, Stratton I , et al; International Subarachnoid Aneurysm Trial (ISAT) Collaborative Group. International Subarachnoid Aneurysm Trial (ISAT) of neurosurgical clipping versus endovascular coiling in 2143 patients with ruptured intracranial aneurysms: a randomised trial. Lancet 2002; 360 (9342) 1267-1274
    CrossrefPubMedGoogle Scholar
  • 34 Komiyama M, Tamura K, Nagata Y, Fu Y, Yagura H, Yasui T. Aneurysmal rupture during angiography. Neurosurgery 1993; 33 (5) 798-803
    CrossrefPubMedGoogle Scholar
  • 35 Aoyagi N, Hayakawa I. Study on early re-rupture of intracranial aneurysms. Acta Neurochir (Wien) 1996; 138 (1) 12-18
    CrossrefPubMedGoogle Scholar
  • 36 Tanno Y, Homma M, Oinuma M, Kodama N, Ymamoto T. Rebleeding from ruptured intracranial aneurysms in North Eastern Province of Japan. A cooperative study. J Neurol Sci 2007; 258 (1–2) 11-16
    CrossrefPubMedGoogle Scholar
  • 37 Larsen CC, Astrup J. Rebleeding after aneurysmal subarachnoid hemorrhage: a literature review. World Neurosurg 2013; 79 (2) 307-312
    CrossrefPubMedGoogle Scholar
  • 38 Hellingman CA, van den Bergh WM, Beijer IS , et al. Risk of rebleeding after treatment of acute hydrocephalus in patients with aneurysmal subarachnoid hemorrhage. Stroke 2007; 38 (1) 96-99
    CrossrefPubMedGoogle Scholar
  • 39 Jamous MA, Nagahiro S, Kitazato KT, Tamura T, Kuwayama K, Satoh K. Role of estrogen deficiency in the formation and progression of cerebral aneurysms. Part II: experimental study of the effects of hormone replacement therapy in rats. J Neurosurg 2005; 103 (6) 1052-1057
    CrossrefPubMedGoogle Scholar
  • 40 Ruigrok YM, Slooter AJ, Rinkel GJ , et al. Genes influencing coagulation and the risk of aneurysmal subarachnoid hemorrhage, and subsequent complications of secondary cerebral ischemia and rebleeding. Acta neurochirurgica 2010; 152 (2) 257-262
    CrossrefPubMedGoogle Scholar