There study ,, reported old age and
There have been various attempts to isolate thepredictors of anresymal rebleed and natural history . Early intervention andguided management based on recognition of these risk factors should improve patient outcome.
Demographic: Althoughthere is disagreement is present in literature regarding the effect of age andsex on the risk of rebleed in aneurysmal SAH. Steiger’s 4 and the cooperatve study 1,2,3 reported old age and femaleprepodrance . Similarly in this study there was a femalepreponderance noted while the mean age of bleed was 52 years.Majority of thepatients were in the above 50 age group. Time ofrebleed: Rebleeds tend to be within the 1to 2 weeks of haemorrhage as mentionedin various studies .Our study showed similar findings with the median period torebleed being 7 days(1-80 days ). On the contrary several in other studies,rebleed happened within the first 24 hours while there are with reports ofultra early rebleeds within 6 hours.This pattern on inhospital rebleeds at 2weeks was also observed by Solanki et al In hospital rebleed in our previously published studywas 2.
14 percent while currently it is 1.1 percent. This is not reflected inany parameters regarding decrease in bleed to admission time or admission tointervention time even though the metrics have improved.Other indian studiesalso report similar findings with rates of 4.
4 % again attributable to delay inreferral to tertiary centre. The referral pattern continued to be same in boththe 1999- 2007 group and the current study group with non significant diference in bleedto admission times.This was also reflected in the control group where nodifference was noted.Activity before rebleed: The mean admission to rebleedtime was 1 day.Seven patients had rebleed within 6 hours of admission.This wasechoed in findings by park et al where admission to rebleed times were 1.3 to2.
3 hours on average.The transport of such patients from distant centres ortransport to ICU may play an important role in such situations. This patter was observed by Hijdra and coworkers, 8 whoshowed a 2% rebleed rate on the first day and attributable to additional stresswith transportation to a specialized center, movement of the patient forimaging studies along with ventriculostomies.
Two patients in this group hadictus during shifting for imaging while 2 had rupture while undergoing DSA . Risk factors for rebleed:As compared to our previousstudy relation between hypertension and a high MAP did not corelate withrebleed.Others authors have shown relation of the same and lowering of MAP maylead to reduced incidence of stroke.
Loss of consciousness was associated with rebleeds in almost allcases although was statistically significant univariate predictor.Other authorshave also isolated LOC as a risk factor associated with rebleed with averagetimes of 28 minutes of LOC. Hypertension:Juvelea et al reported the association ofhigh SBP while Solanki et al reported high Diastolic blood pressure asindependent risk factors .This was not observed in this study and no differencewas found between the two groups. Aneurysm morphology: Size is directly related with the risk ofrebleeding.
Pleizier et al. 10 reportedthat larger aneurysms have a risk of rebleeding, mostly within the first 3 daysof primary haemorrhage.Our study showed largeraneurysm as a positive risk factor in the rebleed subgroup.In a study by Guo etal aneurysms larger than 10mm were associated with higher risk,similar to ourstudy where mean size was 10mm.The study did not show any relation withmultiplicity. In contrast to other studieswhere irregularity of vessel wall and multiplicity was associated with risk ofrebleed.Location as a risk is to be studied as many contrasting reports mentioneither anterior or posterior locations as risk forrebleed6This series shows a preference for anteriorcirculation aneurysms, particularly anterior communicating artery aneurysms butwas not statistically significant.
. Ventriculostomy was also not associated with any higher risk in ourstudy as with other studies.While Pare et al reported loss of pressure gradientleading to rupture.Contrary to studies by Steiger et al where clinicalgrade at presentation was associated with rebleed Our study did not show any relation between the controland rebleed group in terms of Fisher grade and WFNS scores this was similar toa study by Park et al where 84 perecent of patients were good WFNS grade.Thisis contrast to other studies where rebleed is associated with bad wfnsgrade.While Park et al had early admissions on an average while our study had adelayed admission . Solanki et al reported Fisher grade to be an independentrisk factor for rebleed.There was significant change in both the clinical WFNSscale status and fisher grade after rupture signifying a grave outcome in mostcases The ideal protocol remains yet tobe ascertained once rebleed had occurred.
Both the conservative and surgicallymanaged groups had bad outcomes which was similar to the 1999 to 2007 study. Mangementcan be done on a case by case basis keeping in mind the poor outcome. CONCLUSION Aneurysmal Rebleed is a potentially fatal complication of aneurysmal SAH.Persistantdelayed referral patterns resulted in continuedlow incidence in this study .Loss of consciousness and larger aneurysm were theonly two variables consistent with rebleed. The rationale for aggressive management practices following a rebleed isdoubtful.
Prevention can be sought out for by streamlining transport practices ,early interventions and recognitionof high risk factors along with early referral to high volume centres.