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
