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

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 microneuro-surgery. 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. Method: 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 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 (<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. (C) 2015 Elsevier B.V. All rights reserved.