title: Incidence and significance of early aneurysmal rebleeding before neurosurgical or neurological management.
abstract: OBJECTIVE
  Rebleeding is a major cause of death and disability in aneurysmal subarachnoid hemorrhage (SAH); however, there has been no report focusing on rebleeding before hospitalization in neurosurgical or neurological institutions. The aim of this study was to clarify the incidence of prehospitalization rebleeding, its impact on the clinical course and prognosis in patients with aneurysmal SAH, and the possible factors inducing it.
  
  
  METHODS
  In 273 patients who were admitted to our institution within 24 hours after the initial SAH bleeding and whose clinical course before admission could be fully evaluated, the patients' clinical conditions and CT findings on admission, operability, prognosis, and possible factors inducing rebleeding were comparatively evaluated between the patients with and without an episode of prehospitalization rebleeding.
  
  
  RESULTS
  Of the 273 patients, 37 (13.6%) patients suffered from 39 episodes of rebleeding in the ambulance or at the referring hospital before admission to our hospital. The peak time of rebleeding was within 2 hours (77%), in which the incidence was statistically significant compared with that occurring 2 to 8 hours after the initial SAH bleeding (P<0.01). The group experiencing rebleeding showed more severe Hunt and Hess grades on admission, higher rates of intracerebral hematoma, of intraventricular hematoma, and of subdural hematoma on CT scan on admission, less operability, and poorer prognoses with statistically significant differences compared with the group that did not experience rebleeding. Systolic arterial pressure >160 mm Hg was a possible risk factor of rebleeding (odds ratio 3.1, 95% CI 1.5 to 6.8).
  
  
  CONCLUSIONS
  Rebleeding during transfer and at the referring hospital is not rare. To improve overall outcome of aneurysmal SAH, the results obtained in this study should be made available to general practitioners and the doctors devoted to emergency medicine.
authors.affiliation: Department of Neurosurgery, Hirosaki University School of Medicine, Hirosaki, Japan. ohkuma@cc.hirosaki-u.ac.jp
authors.forename: H
authors.initials: H
authors.lastname: Ohkuma
authors.forename: H
authors.initials: H
authors.lastname: Tsurutani
authors.forename: S
authors.initials: S
authors.lastname: Suzuki
mesh_terms: D001794:Blood Pressure; D015897:Comorbidity; D018450:Disease Progression; D004632:Emergency Medical Services / Q000706:statistics & numerical data*; D006406:Hematoma / Q000145:classification / Q000175:diagnosis* / Q000453:epidemiology*; D006801:Humans; D015994:Incidence; D007564:Japan / Q000453:epidemiology; D019635:Neurosurgical Procedures; D011379:Prognosis; D012008:Recurrence; D013345:Subarachnoid Hemorrhage / Q000175:diagnosis* / Q000453:epidemiology* / Q000628:therapy; D014057:Tomography, X-Ray Computed