Pre-protection re-haemorrhage following aneurysmal subarachnoid haemorrhage: Where are we now?

• Despite improvements, the rate and outcomes for re-haemorrhage remain unchanged.
• Only grade of SAH was an independent predictor of re-haemorrhage.
• Early re-haemorrhage and re-haemorrhage from complex aneurysms were common causes.
• Early re-haemorrhage occurs within 24 h of ictus and is a challenge for treatment.
• Earlier treatment of complex aneurysms may be more achievable.

BackgroundRe-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.MethodThe 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.ResultsRe-haemorrhage occurred in 55 (5.4%) of patients and most cases had occurred within 24 h 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 (<24 h) (19/35, 54%), or had complicated aneurysm morphology (10/35, 31%) which necessitated a delayed treatment strategy.ConclusionsRe-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.