Rebleeding

The risk of rebleeding is highest immediately following hemorrhage (4-6% over the first 24 hrs) and declines over the next few days. At two weeks, the cumulative risk approaches 20%. Rebleeding rates are highest in women and in those with poor medical condition and with elevated systolic blood pressure. Almost a half of the patients who rebleed do not survive.

In the past, antifibrinolytic agents, such as epsilon-aminocaproic or tranexamic acid, were routinely administered to prevent rebleeding. It is clear that these agents do reduce the incidence of rebleeding; however, this benefit was offset by an increase in hydrocephalus and more ischemic infarctions from vasospasm (37). A meta-analysis of several trials revealed no overall effect on outcome (38). With the advent of early surgical and endovascular management, the use of these agents has declined dramatically. Still, short-term use of antifibrinolytics has been suggested for patients awaiting surgery or endovascular treatment. The data are mixed as to whether short courses are also associated with more vasospasm.

Anecdotally, rerupture has been associated with systemic hypertension and sudden drops or elevations of ICP, the latter caused by coughing, sneezing, straining, and Valsalva maneuvers. Hence, initial management focuses on avoiding these factors. Measures should be taken to minimize coughing and straining. In intubated patients, verifying the position of the endo-tracheal tube and administering antitussives and local anesthetics may be necessary if patients cough excessively. Stool softeners are given routinely to prevent straining. Slow CSF drainage during lumbar puncture or ventriculostomy is recommended.

Excessive stimulation of patients has traditionally been avoided to prevent fluctuations in blood pressure. Although adverse effects of such stimulation have never been established, it seems prudent to medicate agitated or combative patients. Ideally, they should be sedated to the point of drowsiness but should remain responsive to stimulation. Care must be taken to prevent oversedation, so that clinical deterioration can be easily recognized. Opiates provide not only sedation but also analgesia for treating headache; long-acting sedative agents, such as barbiturates, should be avoided.

Definitive prevention of rebleeding is accomplished by aneurysm repair. The old notion that surgery is more difficult and results in a worse outcome when performed early (within three days of hemorrhage) has not been supported by careful analysis. Outcome of patients with Hunt and Hess grades II and III is improved with early surgery. Additionally, repair of aneurysms has the further advantage of permitting safe elevation of blood pressure to treat vasospasm.

A multicenter, randomized trial recently compared one-year outcomes in acute SAH patients who were randomized to have their aneurysm repaired either by surgical or endovas-cular means. Of the almost 10,000 patients screened, only approximately 2000 met the inclusion criteria, which required that the treating physicians agree that the aneurysm could be successfully repaired by either means. At one-year, outcome was somewhat better in patients treated by endovascular coiling, and long-term follow-up is underway to assess rebleeding rates (39).

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