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Andrew M. Naidech, MD, MSPH; Nazli Janjua, MD; Kurt T. Kreiter, PhD; Noeleen D. Ostapkovich, MS; Brian-Fred Fitzsimmons, MD; Augusto Parra, MD, MPH; Christopher Commichau, MD; E. Sander Connolly, MD; Stephan A. Mayer, MD

Arch Neurol. 2005;62:410-416.

Background  Aneurysm rebleeding has historically been an important cause of mortality after subarachnoid hemorrhage (SAH).

Objective  To describe the frequency and impact of rebleeding in the modern era of aneurysm care, which emphasizes early surgical or endovascular treatment.

Design  Inception cohort.

Setting  Tertiary care medical center.

Patients  A total of 574 patients enrolled in the Columbia University SAH Outcomes Project between August 1996 and June 2002. Early aneurysm repair was performed whenever feasible.

Main Outcome Measures  Rebleeding was defined by prespecified clinical and radiographic criteria, excluding prehospital, intraprocedural, and postrepair events. Functional outcome was assessed at 3 months with the modified Rankin Scale. Multiple logistic regression was used to identify predictors of rebleeding, poor functional outcome, and mortality.

Results  Rebleeding occurred in 40 (6.9%) of the 574 patients; most cases (73%) occurred within 3 days of ictus. Hunt-Hess grade on admission (odds ratio [OR], 1.92 per grade; 95% confidence interval [CI], 1.33-2.75; P<.001) and maximal aneurysm diameter (OR, 1.07/mm; 95% CI, 1.01-1.13; P = .005) were independent predictors of rebleeding. After controlling for Hunt-Hess grade and aneurysm size, rebleeding was associated with a markedly reduced chance of survival with functional independence (modified Rankin Scale score, 4; OR, 0.08; 95% CI, 0.02-0.34) at 3 months.

Conclusions  Despite an aggressive management strategy, rebleeding still occurred in 6.9% of patients and was associated with a dismal outcome. Poor Hunt-Hess grade and larger aneurysm size are related to rebleeding. Pharmacologic therapy to reduce the risk of rebleeding before aneurysm repair, particularly in patients with poor grade neurologic status and large aneurysms, deserves renewed attention.

Author Affiliations: Departments of Neurology (Drs Naidech, Janjua, Kreiter, Fitzsimmons, Parra, Commichau, and Mayer and Ms Ostapkovich) and Neurosurgery (Drs Connolly and Mayer), College of Physicians and Surgeons of Columbia University, New York, NY.

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