title: Comparison of prognosis and complications after warning leaks in subarachnoidal hemorrhage--experience with 214 patients following aneurysm clipping.
abstract: OBJECTIVE
  The 'warning leak', a smaller bleeding event from an aneurysm, which sometimes occurs before an acute massive subarachnoidal hemorrhage (SAH), was first described in 1967. The present study was performed to compare the complications and prognosis for 214 patients with and without a warning leak; aneurysm clipping had been performed in all.
  
  
  METHODS
  The interval between the warning headache and the actual SAH was calculated. The following complications were examined: preoperative hemorrhage, intra-operative rupture of the aneurysm, postoperative re-bleeding, symptomatic vasospasm, shunt-requiring hydrocephalus, ventriculitis, postoperative wound infection, and outcome according to the Glasgow Outcome Scale (GOS).
  
  
  RESULTS
  Sixty-seven (31%) out of the 214 patients had a warning leak with a median distance of 11 days before suffering from major SAH. Preoperative angiographic vasospasms occurred more frequently in the group with a warning bleeding (22.4 versus 6.1%; p<0.05), which means that the warning leaks induce vascular reactions similar to SAH. The outcome of both groups after a mean follow-up time of 22 months did not show any difference. But 30 out of the 67 patients with a warning leak were graded H&H III-V at admission to hospital after a major SAH. The overall outcome for patients graded H&H I and II was in 92% favorable, compared with only a 54% favorable outcome for H&H III-V patients. Long-term outcome in the warning leak group was not impaired by angiographically proven vasospasm.
  
  
  CONCLUSIONS
  To give patients the chance to start their treatment in a better clinical condition it is important to recognize the early warning signs.
authors.affiliation: Department of Neurosurgery, Eberhard-Karls University Tuebingen, 72076 Tuebingen, Germany. rainer.ritz@med.uni-tuebingen.de
authors.forename: Rainer
authors.initials: R
authors.lastname: Ritz
authors.forename: Johannes
authors.initials: J
authors.lastname: Reif
mesh_terms: D000328:Adult; D018450:Disease Progression; D005260:Female; D015600:Glasgow Coma Scale / Q000706:statistics & numerical data; D006261:Headache / Q000209:etiology; D006801:Humans; D002532:Intracranial Aneurysm / Q000150:complications / Q000175:diagnosis*; D008297:Male; D009460:Neurologic Examination; D011183:Postoperative Complications; D011379:Prognosis; D012189:Retrospective Studies; D013345:Subarachnoid Hemorrhage / Q000150:complications / Q000601:surgery*; D013525:Surgical Instruments / Q000009:adverse effects*; D013997:Time Factors; D016896:Treatment Outcome; D020301:Vasospasm, Intracranial