title: Predictive Factors for Rebleeding After Aneurysmal Subarachnoid Hemorrhage: Rebleeding Aneurysmal Subarachnoid Hemorrhage Study.
abstract: OBJECTIVE
  Aneurysmal subarachnoid hemorrhage (aSAH) is a devastating type of stroke associated with high morbidity and mortality. One of the most feared complications is an early rebleeding before aneurysm repair. Predictors for such an often fatal rebleeding are largely unknown. We therefore aimed to determine predictors for an early rebleeding after aSAH in relation with time after ictus.
  
  
  METHODS
  This observational prospective cohort study included all consecutive patients admitted with aSAH between January 1998 and December 2014 (n=1337) at our University Neurovascular Center. Clinical predictors for rebleeding ≤24 hours were identified using multivariable Cox regression analyses. Kaplan-Meier analyses were applied to evaluate the time of rebleeding ≤72 hours after aSAH.
  
  
  RESULTS
  A modified Fisher grade of 3 to 4 was a predictor for an in-hospital rebleeding ≤24 hours after ictus (adjusted hazard ratio, 4.4; 95% confidence interval, 2.1-10.6; P<0.001). The numbers needed to treat to prevent 1 rebleeding ≤24 hours was calculated 15 (95% confidence interval, 10-25). Also, the initiation of external cerebrospinal fluid-drainage (adjusted hazard ratio, 1.9; 95% confidence interval, 1.4-2.5; P<0.001) was independently associated with a rebleeding ≤24 hours. Cumulative in-hospital rebleeding rates were 5.8% ≤24 hours, and 1.2% in the time frame 24-72 hours after ictus.
  
  
  CONCLUSIONS
  In our opinion, timing of treatment of aSAH patients, especially those with an modified Fisher grade of 3 or 4 in a good clinical condition, should be reconsidered. These aSAH patients might be regarded a medical emergency, requiring aneurysm repair as soon as possible. In this respect, our findings should provoke the debate on timing of aneurysm repair, especially in patients considered to be at high risk for rebleeding.
authors.affiliation: From the Department of Neurosurgery (C.E.v.D., N.A.B., J.D.M.M., R.J.M.G., J.M.C.v.D.), Department of Intensive Care Medicine (N.A.B.), Department of Clinical Epidemiology and Trial Coordination Center (N.J.G.M.V.), Department of Neurology (M.U., G.-J.L.), and Department of Radiology (M.U.), University Medical Center Groningen, University of Groningen, Groningen, The Netherlands. c.e.van.donkelaar@umcg.nl.
authors.forename: Carlina E
authors.initials: CE
authors.lastname: van Donkelaar
authors.affiliation: From the Department of Neurosurgery (C.E.v.D., N.A.B., J.D.M.M., R.J.M.G., J.M.C.v.D.), Department of Intensive Care Medicine (N.A.B.), Department of Clinical Epidemiology and Trial Coordination Center (N.J.G.M.V.), Department of Neurology (M.U., G.-J.L.), and Department of Radiology (M.U.), University Medical Center Groningen, University of Groningen, Groningen, The Netherlands.
authors.forename: Nicolaas A
authors.initials: NA
authors.lastname: Bakker
authors.affiliation: From the Department of Neurosurgery (C.E.v.D., N.A.B., J.D.M.M., R.J.M.G., J.M.C.v.D.), Department of Intensive Care Medicine (N.A.B.), Department of Clinical Epidemiology and Trial Coordination Center (N.J.G.M.V.), Department of Neurology (M.U., G.-J.L.), and Department of Radiology (M.U.), University Medical Center Groningen, University of Groningen, Groningen, The Netherlands.
authors.forename: Nic J G M
authors.initials: NJ
authors.lastname: Veeger
authors.affiliation: From the Department of Neurosurgery (C.E.v.D., N.A.B., J.D.M.M., R.J.M.G., J.M.C.v.D.), Department of Intensive Care Medicine (N.A.B.), Department of Clinical Epidemiology and Trial Coordination Center (N.J.G.M.V.), Department of Neurology (M.U., G.-J.L.), and Department of Radiology (M.U.), University Medical Center Groningen, University of Groningen, Groningen, The Netherlands.
authors.forename: Maarten
authors.initials: M
authors.lastname: Uyttenboogaart
authors.affiliation: From the Department of Neurosurgery (C.E.v.D., N.A.B., J.D.M.M., R.J.M.G., J.M.C.v.D.), Department of Intensive Care Medicine (N.A.B.), Department of Clinical Epidemiology and Trial Coordination Center (N.J.G.M.V.), Department of Neurology (M.U., G.-J.L.), and Department of Radiology (M.U.), University Medical Center Groningen, University of Groningen, Groningen, The Netherlands.
authors.forename: Jan D M
authors.initials: JD
authors.lastname: Metzemaekers
authors.affiliation: From the Department of Neurosurgery (C.E.v.D., N.A.B., J.D.M.M., R.J.M.G., J.M.C.v.D.), Department of Intensive Care Medicine (N.A.B.), Department of Clinical Epidemiology and Trial Coordination Center (N.J.G.M.V.), Department of Neurology (M.U., G.-J.L.), and Department of Radiology (M.U.), University Medical Center Groningen, University of Groningen, Groningen, The Netherlands.
authors.forename: Gert-Jan
authors.initials: GJ
authors.lastname: Luijckx
authors.affiliation: From the Department of Neurosurgery (C.E.v.D., N.A.B., J.D.M.M., R.J.M.G., J.M.C.v.D.), Department of Intensive Care Medicine (N.A.B.), Department of Clinical Epidemiology and Trial Coordination Center (N.J.G.M.V.), Department of Neurology (M.U., G.-J.L.), and Department of Radiology (M.U.), University Medical Center Groningen, University of Groningen, Groningen, The Netherlands.
authors.forename: Rob J M
authors.initials: RJ
authors.lastname: Groen
authors.affiliation: From the Department of Neurosurgery (C.E.v.D., N.A.B., J.D.M.M., R.J.M.G., J.M.C.v.D.), Department of Intensive Care Medicine (N.A.B.), Department of Clinical Epidemiology and Trial Coordination Center (N.J.G.M.V.), Department of Neurology (M.U., G.-J.L.), and Department of Radiology (M.U.), University Medical Center Groningen, University of Groningen, Groningen, The Netherlands.
authors.forename: J Marc C
authors.initials: JM
authors.lastname: van Dijk
mesh_terms: D000328:Adult; D000368:Aged; D015331:Cohort Studies; D005260:Female; D006470:Hemorrhage / Q000175:diagnosis / Q000453:epidemiology / Q000628:therapy; D006801:Humans; D002532:Intracranial Aneurysm / Q000175:diagnosis* / Q000453:epidemiology* / Q000628:therapy; D008297:Male; D008875:Middle Aged; D011237:Predictive Value of Tests; D011446:Prospective Studies; D012008:Recurrence; D012189:Retrospective Studies; D012307:Risk Factors; D013345:Subarachnoid Hemorrhage / Q000175:diagnosis* / Q000453:epidemiology* / Q000628:therapy; D016896:Treatment Outcome; D055815:Young Adult
keywords: aneurysm; rebleeding; regression analysis; stroke; subarachnoid hemorrhage