Predictors and impact of aneurysm rebleeding after subarachnoid hemorrhage.
BACKGROUND
Aneurysm rebleeding has historically been an important cause of mortality after subarachnoid hemorrhage (SAH).


OBJECTIVE
To describe the frequency and impact of rebleeding in the modern era of aneurysm care, which emphasizes early surgical or endovascular treatment.


METHODS
Inception cohort.


METHODS
Tertiary care medical center.


METHODS
A total of 574 patients enrolled in the Columbia University SAH Outcomes Project between August 1996 and June 2002. Early aneurysm repair was performed whenever feasible.


METHODS
Rebleeding was defined by prespecified clinical and radiographic criteria, excluding prehospital, intraprocedural, and postrepair events. Functional outcome was assessed at 3 months with the modified Rankin Scale. Multiple logistic regression was used to identify predictors of rebleeding, poor functional outcome, and mortality.


RESULTS
Rebleeding occurred in 40 (6.9%) of the 574 patients; most cases (73%) occurred within 3 days of ictus. Hunt-Hess grade on admission (odds ratio [OR], 1.92 per grade; 95% confidence interval [CI], 1.33-2.75; P<.001) and maximal aneurysm diameter (OR, 1.07/mm; 95% CI, 1.01-1.13; P = .005) were independent predictors of rebleeding. After controlling for Hunt-Hess grade and aneurysm size, rebleeding was associated with a markedly reduced chance of survival with functional independence (modified Rankin Scale score, </=4; OR, 0.08; 95% CI, 0.02-0.34) at 3 months.


CONCLUSIONS
Despite an aggressive management strategy, rebleeding still occurred in 6.9% of patients and was associated with a dismal outcome. Poor Hunt-Hess grade and larger aneurysm size are related to rebleeding. Pharmacologic therapy to reduce the risk of rebleeding before aneurysm repair, particularly in patients with poor grade neurologic status and large aneurysms, deserves renewed attention.
Naidech
Andrew M
AM
Department of Neurology, College of Physicians and Surgeons of Columbia University, New York, NY, USA.
Janjua
Nazli
N
Kreiter
Kurt T
KT
Ostapkovich
Noeleen D
ND
Fitzsimmons
Brian-Fred
BF
Parra
Augusto
A
Commichau
Christopher
C
Connolly
E Sander
ES
Mayer
Stephan A
SA
D000368:Aged; D005260:Female; D006801:Humans; D002532:Intracranial Aneurysm / Q000175:diagnosis / Q000453:epidemiology* / Q000517:prevention & control*; D008297:Male; D008875:Middle Aged; D011237:Predictive Value of Tests; D011446:Prospective Studies; D055502:Secondary Prevention; D013345:Subarachnoid Hemorrhage / Q000175:diagnosis / Q000453:epidemiology* / Q000517:prevention & control*; D016019:Survival Analysis; D016896:Treatment Outcome