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Predictors of aneurysmal rebleed before definitive surgical or endovascular management

  • Clinical Article - Vascular
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Abstract

Background

Aneurysmal rebleed is the most dreaded complication following subarachnoid hemorrhage. Being a cause of devastating outcome, the stratification of risk factors can be used to prioritize patients, especially at high volume centers.

Method

A total of 99 patients with aneurysmal rebleed were analyzed in this study both prospectively and retrospectively from August 2010 to July 2014. In the control group, 100 patients were selected randomly from the patient registry. A total of 25 variables from the demographic, historical, clinical and radiological data were compared and analyzed by univariate and multivariate logistic regression analysis.

Results

Significant independent predictors of aneurysm rebleed were the presence of known hypertension (p = 0.023), diastolic blood pressure of >90 mmHg on admission (p = 0.008); presence of loss of consciousness (p = 0.013) or seizures (p = 0.002) at first ictus; history of warning headaches (p = 0.005); higher Fisher grade (p < 0.001); presence of multiple aneurysms (p = 0.021); irregular aneurysm surface (0.002).

Conclusions

Identification of high risk factors can help in stratifying patients in the high risk group. The risk stratification strategy with early intervention can prevent rebleeds. This in turn may translate into better outcomes of patients with intracranial aneurysms.

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Author information

Authors and Affiliations

  1. Department of Neurosurgery, NIMHANS (National Institute of Mental Health and Neuroscinences), Bengaluru, Karnataka, 560029, India

    Chirag Solanki

  2. Consultant Neurosurgeon, Manipal Hospital, Bengaluru, Karnataka, India

    Paritosh Pandey

  3. Department of Neurosurgery, NIMHANS, Bengaluru, Karnataka, 560029, India

    K. V. L. N. Rao

  4. Department of Neurosurgery, Faculty Block, Neurosurgery office, NIMHANS campus, Bengaluru, Karnataka, 560029, India

    K. V. L. N. Rao

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  1. Chirag Solanki
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  2. Paritosh Pandey
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  3. K. V. L. N. Rao
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Correspondence to K. V. L. N. Rao.

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Funding

No funding was received for this research.

Conflict of interest

All authors certify that they have no affiliations with or involvement in any organization or entity with any financial interest (such as honoraria; educational grants; participation in speakers’ bureaus; membership, employment, consultancies, stock ownership, or other equity interest; and expert testimony or patient-licensing arrangements), or non-financial interest (such as personal or professional relationships, affiliations, knowledge or beliefs) in the subject matter or materials discussed in this manuscript.

Ethical approval

All procedures performed in studies involving human participants were in accordance with the ethical standards of NIMHANS (National Institute of Mental health and Neuro Sciences, Bengaluru, Karnataka, India) and with the 1964 Helsinki Declaration and its later amendments or comparable ethical standards. For this type of study formal consent is not required.

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Comment

Spontaneous subarachnoid hemorrhage (SAH), which is most frequently due to aneurysmal rupture, is a significant source of morbidity and mortality. However, the continued evolution of both open and endovascular treatment modalities are actively improving the expected outcome of this disease process. As the authors point out, though, aneurysmal rebleed prior to treatment is both largely unpredictable and clinically devastating to the patient. On both retrospective and prospective review of their own patient series, the authors attempt to identify the risk factors that portend a higher likelihood of rebleed before a patient can receive treatment. By examining a variety of demographic, comorbid and radiographic characteristics, the authors are able to identify clinical variables that reliably identify those patients at a higher risk of early rebleed. They further posit that following these clinical variables in practice may allow for more urgent treatment of high-risk cases and therefore further improve patient outcomes.

The authors make a valiant attempt to more thoroughly delineate the risk factors that predispose patients to this devastating complication of aneurysmal SAH. While the authors attempt to clarify which patients should be targeted to early therapy, the interval at which treatment should be instituted remains ambiguous. It is well documented in the literature that the highest risk of aneurysmal rebleed is in the first 24 h after initial hemorrhage (1–3). The patients in this series vary widely in their times from initial bleeding event to presentation, transfer and eventual treatment (24 to 72 h). Therefore, it would be of more clinical relevance to explore these intervals scrupulously in the context of the risk factors discussed. If patients with risk factors that predispose them to rebleed are also at risk of earlier rebleed, this assists in designing treatment algorithms. Without this analysis, the presence of risk factors is identified and patients are placed in a ‘high risk’ class, but not treated differently from any other aneurysmal rupture. This timing of therapy is the crucial variable that has the most potential impact on patient outcome.

Previous works have attempted to delineate the risk factors for both aneurysmal rupture and rebleed (2, 4, 5). The authors admit as much and compare their sometimes contradictory results with previous work. While this is meaningful to some extent and helps to better define the ‘high-risk’ group, it takes the focus off of the proposed novel factors the authors suggest. The authors do their best, in the discussion, to spend less time focusing on previously documented risks and instead examining if their factors of interest (diastolic hypertension, seizure, LOC, warning headache, etc.) have an additive effect with known risks or impart a higher clinical risk.

The data presented highlight several interesting points regarding the discord between the existing data and the management of SAH. The authors and others cited focus on the highest risk of rebleed being in the first 24 h. The authors then point out that a minority of patients even arrive at their tertiary care center within 24 h of hemorrhage (<20 %), and few of these patients are treated in this time period (35 %). The data presented herein and the current treatment data call for change in the way SAH patients are prioritized, transferred to properly equipped facilities and treated promptly.

The authors are to be commended for their careful, diligent examination of the risk factors that increase the likelihood of aneurysmal rebleed prior to treatment. As we acquire insight into aneurysmal rebleed, its risk factors and the appropriate timing of definitive treatment, this paper holds the potential to serve as a framework to utilize for patient prioritization.

References

1. Pare L, Delfino R, Leblanc R. The relationship of ventricular drainage to aneurysmal rebleeding. Journal of Neurosurgery. 1992;76(3):422–7.

2. Kaptain GJ, Lanzino G, Kassell NF. Subarachnoid haemorrhage: epidemiology, risk factors, and treatment options. Drugs Aging. 2000;17(3):183–99.

3. Robbert M, Hoogmoed J, van Straaten HA, Coert BA, Peter Vandertop W, Verbaan D. Time intervals from aneurysmal subarachnoid hemorrhage to treatment and factors contributing to delay. J Neurol. 2014;261(3):473–9.

4. Hillman J, Fridriksson S, Nilsson O, Yu Z, Saveland H, Jakobsson KE. Immediate administration of tranexamic acid and reduced incidence of early rebleeding after aneurysmal subarachnoid hemorrhage: a prospective randomized study. Journal of Neurosurgery. 2002;97(4):771–8.

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Drew Spencer, Christopher M. Loftus

Illinois, USA

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Solanki, C., Pandey, P. & Rao, K.V.L.N. Predictors of aneurysmal rebleed before definitive surgical or endovascular management. Acta Neurochir 158, 1037–1044 (2016). https://doi.org/10.1007/s00701-016-2784-6

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