title: Pre-protection re-haemorrhage following aneurysmal subarachnoid haemorrhage: Where are we now?
abstract: BACKGROUND
  Re-haemorrhage is a negative, prognostic predictor of outcome in aneurysmal subarachnoid haemorrhage (aSAH). The process of aSAH care has changed however, and most reports on re-haemorrhage are from a time when aneurysms were treated predominantly by open microneurosurgery. The current frequency and impact of re-haemorrhage on outcome in the 'post-ISAT' era is therefore unknown. The aim of this study was to review current outcome, risk factors and causes for inpatient re-haemorrhage in aSAH patients.
  
  
  METHODS
  The departmental aSAH database was reviewed between Jan 2008 and March 2014 (N = 1008) to identify cases of re-haemorrhage. Re-haemorrhage was defined as inhospital deterioration in neurological status with CT confirmation of rebleeding. Binary logistic regression was used to (a) determine the impact of re-haemorrhage on outcome adjusted for age and injury severity and (b) to identify any independent predictors of its occurrence.
  
  
  RESULTS
  Re-haemorrhage occurred in 55 (5.4%) of patients and most cases had occurred within 24h of ictus (32, 58.1%). Re-haemorrhage was an independent predictor of death (AOR 10.0, p < 0.0005, 95%CI 4.9, 20.2) and unfavourable outcome (AOR 5.8 p < 0.0005, 95%CI 2.4, 14.0). Only WFNS grade on admission was an independent predictor (AOR 1.7, p < 0.0005, 95%CI 1.4, 1.9) of re-haemorrhage. Of the patients who re-bled, in 20 there was no intention to treat due to severe brain injury and in the remainder, the majority occurred early (<24h) (19/35, 54%), or had complicated aneurysm morphology (10/35, 31%) which necessitated a delayed treatment strategy.
  
  
  CONCLUSIONS
  Re-haemorrhage remains a poor prognostic predictor in aSAH and the grade of SAH is an independent risk factor. Earlier treatment of complex aneurysms could offer the most immediate improvements in its incidence.
authors.affiliation: Dept of Neurosurgery, Greater Manchester Neuroscience Centre, Salford Royal Foundation Trust (SRFT), Salford, UK.
authors.forename: Benjamin M
authors.initials: BM
authors.lastname: Davies
authors.affiliation: Dept of Neurosurgery, Greater Manchester Neuroscience Centre, Salford Royal Foundation Trust (SRFT), Salford, UK.
authors.forename: K H Carlos
authors.initials: KH
authors.lastname: Chung
authors.affiliation: Dept of Neurosurgery, Greater Manchester Neuroscience Centre, Salford Royal Foundation Trust (SRFT), Salford, UK.
authors.forename: Louise
authors.initials: L
authors.lastname: Dulhanty
authors.affiliation: Dept of Neurosurgery, Greater Manchester Neuroscience Centre, Salford Royal Foundation Trust (SRFT), Salford, UK.
authors.forename: James
authors.initials: J
authors.lastname: Galea
authors.affiliation: Dept of Neurosurgery, Greater Manchester Neuroscience Centre, Salford Royal Foundation Trust (SRFT), Salford, UK. Electronic address: hiren.patel@srft.nhs.uk.
authors.forename: Hiren C
authors.initials: HC
authors.lastname: Patel
mesh_terms: D000328:Adult; D000368:Aged; D000369:Aged, 80 and over; D017542:Aneurysm, Ruptured / Q000000981:diagnostic imaging* / Q000401:mortality; D002533:Cerebral Angiography; D016208:Databases, Factual; D005260:Female; D006801:Humans; D002532:Intracranial Aneurysm / Q000000981:diagnostic imaging* / Q000401:mortality; D016015:Logistic Models; D008297:Male; D008875:Middle Aged; D011379:Prognosis; D012008:Recurrence; D012189:Retrospective Studies; D012307:Risk Factors; D012720:Severity of Illness Index; D013345:Subarachnoid Hemorrhage / Q000000981:diagnostic imaging* / Q000401:mortality
keywords: Aneurysm; Re-haemorrhage; Stroke; Subarachnoid haemorrhage