Rebleeding, aneurysms

In subarachnoid hemorrhage due to a ruptured intracranial aneurysm or arteriovenous malformation, surgical intervention to clip or ablate the vascular abnormality substantially reduces mortality from rebleeding. The benefits of surgery are less well documented in cases of primary intracerebral hemorrhage. In patients with intracerebral hematomas, insertion of an intraventricular drain with monitoring of intracranial pressure is... 

Approximately 10% of untreated saccular aneurysms rebleed within hours and another 30% within a few weeks (Brilstra et al. 2002). Subsequently, the rebleeding rate is approximately 2-3% per aimum. Deterioration is usually sudden, with reduced conscious level or fixed dilatation of the pupils in ventilated patients. 

Late rebleeding occurs in 2-3% of patients in the first 10 years after clipping of an aneurysm, half of such bleeds being caused by newly developed aneurysms. After endovascular coiling, the long-term risks are unclear, being recorded at 0.7% between one month and one year in ISAT (Molyneaux et al. 2005) and at 2-3% in one month to four years in a Dutch cohort (Sluzewski et al. 2005). 

Hellingman CA, van den Bergh WM, Beijer IS et al. (2007). Risk of rebleeding after treatment of acute hydrocephalus in patients with aneurysmal subarachnoid hemorrhage. Stroke 38 96-99... 

Ruijs AC, Dirven CM, Algra A et al. (2005). The risk of rebleeding after external lumbar drainage in patients with untreated ruptured cerebral aneurysms. Acta Neurochirurgie 147 1157-1161... 

New England Journal of Medicine 336 28-40 Schwartz TH, Solomon RA (1996). Perimesencephalic nonaneurysmal subarachnoid hemorrhage review of the literature. Neurosurgery 39 433-440 Sluzewski M, van Rooij WJ, Beute GN et al. (2005). Late rebleeding of ruptured intracranial aneurysms treated with detachable coils. American Journal of Neuroradiology 26 2542-2549 Smith ER, Carter BS, Ogilvy CS (2002). 

Subarachnoid hemorrhage (SAH) is most commonly caused by rupture of an intracranial aneurysm. It can produce vasospasm that may cause ischemia and infarction. Currently, vasospasm has surpassed rebleeding as the most important complication after rupture of an aneurysm. Vasospasm due to SAH is thought to occur in the majority of cases of SAH (angiographic vasospasm is detectable in perhaps as many as 60-70% of patients after subarachnoid hemorrhage), but is symptomatic only in about a third of this population [81]. Symptomatic vasospasm carries a 15% to 20% risk of stroke or death. Vasospasm peaks around 1 week after SAH, but it can be seen as early as 3 days or as late as 3 weeks after the initial event [82], The underlying mechanisms are not understood, but vasospasm is clearly related to the amount of blood and its location in the subarachnoid space. Clinical symptoms generally develop slowly over a period of several hours to 1 or 2 days however, clinical evolution can be rapid in the onset with a stroke-like presentation [81, 82]. 

In case the subarachnoid hemorrhage or parenchymal hematoma cannot be obviously ascribed to FAA or AVM rupture, the aneurysm should be treated in emergency (Pucheu). The treatment should indeed focus on the lesion presenting the more important risk of rebleeding and likely more severe clinical consequences. 

A wedge position of the tip of the catheter may produce rebleeding as well, because the injection force is directly transmitted to the pseudoaneurysm (Lasjaunias et al. 1988). Glue embolization is performed as usual, with the aim of occluding the nidus and aneurysm at the same shot. 

Hydrocephalus, rebleeding from aneurysmal rerupture and cerebral vasospasm with ischemia are the three major complications following SAH. 

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