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13 -14, without focal deficit 13 -14, with focal deficit 7-1 2 S - e

Abbreviation: GCS, Glasgow Coma Scale.

of patients with aSAH on admission (18), and an additional 3% develop hydrocephalus within

1 week after aSAH (19), resulting in shunt-dependent hydrocephalus in more than 20% of all aSAH patients (20-23). When associated with IVH, CSF outflow is blocked at the foramina of Magendie and Luschka, resulting in a noncommunicating 4-ventricle dilation hydrocephalus (7). However, approximately 50% of patients with hydrocephalus do not have radiographically evident IVH (18). When decreasing mental status is in the setting of hydrocephalus, the standard of care is insertion of an intraventricular catheter for external CSF drainage, which can be done under standard sterility at the bedside and improves the level of consciousness in 78% of patients (19). However, rebleeding rate is reported to increase to 43% with intraventricular drainage, versus 15% in patients without drainage (19). To prevent this dreadful complication, it is recommended to set the initial pop-off pressure at >20 mmHg to prevent the creation of a pressure gradient that could cause re-rupture of the aneurysm.

Rebleeding increases morbidity and mortality significantly. One study reported a mortality rate for rebleeding of 80%, compared to 41% in patients without rebleeding (24). Rebleeding is a major risk in all patients with aSAH within the first 24 hr and remains high during the first

2 weeks. The actual rate is unknown but has been reported to be as high as 15% (25) in the initial hours. Afterward, the rate of rebleeding drops to 1.5% per day and continues to decline over the next 2 weeks. The total risk of rebleeding for the first 2 weeks has been reported at 19% (25). Considering the high mortality associated with rebleeding and the incidence of early rebleeding, prompt medical and surgical management is critical in the setting of an aSAH.

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