Predictors of good functional outcomes and mortality in patients with severe rebleeding after aneurysmal subarachnoid hemorrhage
Introduction
Aneurysmal subarachnoid hemorrhage (aSAH) is a devastating stroke subtype. Aneurysm rebleeding occurs in about 5.8–19.3% of patients after initial aSAH [1], [2], [3], [4], however, rebleeding is a major cause of morbidity and mortality. Numerous studies have demonstrated the risk factors for rebleeding, including poor-grade aSAH, higher modified Fisher grade, posterior circulation aneurysms, larger aneurysms, and the presence of intraventricular hemorrhage [4], [5], [6], [7], [8]. However, no study has focused on the severity of rebleeding. Limited data are available on clinical outcomes and predictors of outcomes after rebleeding [9], [10], [11]. Detailed knowledge about predictors of the outcomes after severe rebleeding is essential for treatment decision-making process.
In this report, we defined severe rebleeding after initial aSAH and performed a retrospective analysis of data from a multicenter poor-grade aneurysm study (AMPAS). We aimed to determine predictors of good functional outcomes and mortality after severe rebleeding.
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Patient cohorts
The AMPAS was a prospective, multicenter, observational registry of patients who presented with poor-grade aSAH. The study protocol was approved by the Chinese Ethics Committee of Registering Clinical Trials. From October 2010 to March 20 2012, 366 patients were enrolled from 11 tertiary referral centers. Details of characteristics of patient population have been described previously [12], [13]. Severe rebreeding was defined as rebleeding (an increase of subarachnoid, intracerebral, or
Patient characteristics
Baseline characteristics of the 58 patients are presented in Table 1. 30 (51.7%) patients were female. The mean age was 53.7 ± 12.2 years (range 23–74 years). 24 (41.3%) patients experienced rebleeding within 24 h after ictus, 19 (32.8%) experienced rebleeding between after 24 h and 7 days, and 15 (25.9%) after 7days. The timing of rebleeding after initial aSAH is demonstrated in Fig. 1. Most rebleedings occurred within 24 h and the peak incidence was within the first week. 11 (19.0%) patients had a
Discussion
Although no study have focused on the severity of rebleeding, Cha et al. [9] mentioned that most patients presented with poor clinical condition after rebleeding. Tanno et al. [17] also reported that 152 (84%) of 181 patients presented with semicoma to coma after rebleeding. Our study showed that 81.4% of patients had a WFNS grade of V. These findings suggest that the majority of patients may present with poor clinical condition after rebleeding.
Our results are in line with previous studies
Conclusions
Our results showed that WFNS grade IV after rebleeding and aggressive treatment were independently associated with good outcomes and a higher modified Fisher grade before rebledding, larger aneurysms, and a lower GCS score after rebleeding were independently associated with increased mortality. Although patients had a high mortality after severe rebleeding, those with a lower WFNS grade treated with aggressive treatment were more likely to have a good outcome.
Disclosure
The authors have no conflicts of interest to declare.
AMPAS study investigators
Hongqi Zhang, MD, Xuan Wu Hospital, Capital Medical University; Chuansheng Liang, MD, the first hospital of China Medical University; Huaizhang Shi, MD, the first affiliated hospital of Harbin Medical University; Jing Xu, MD, the second affiliated Hospital, School of Medicine, Zhejiang University; Li Pan, MD, Wuhan General Hospital of Guangzhou Command; Xin Zhang, MD, Nanjing General Hospital of Nanjing Command; Gang Zhu, MD, West South Hospital, the Third Military Medical University; Jianping
Acknowledgments
This work was supported by the Chinese Ministry of Health (grant WKJ2010-2-016), the Ministry of Science and Technology of China (grant 2011BAI08B06), and Wenzhou Bureau of Science and Technology (grant Y20090005).
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These authors contributed equally to this work.