Skip to main content
SpringerLink
Log in

Rebleeding After Aneurysmal Subarachnoid Hemorrhage

  • Review
  • Published:
Neurocritical Care Aims and scope Submit manuscript

Abstract

Rebleeding after initial aneurysmal subarachnoid hemorrhage (SAH) can have substantial impact on overall patient outcome. While older studies have suggested rebleeding occurs in about 4% of patients during the first day after initial aneurysmal bleed, these studies may have failed to capture very early rebleeds and, consequently, underestimated the impact of rebleeding. An electronic literature search was performed to identify English-language articles published or available for review from February 1975 through October 2010. A total of 43 articles (40 original research and 3 review articles) focused on rebleeding after initial aneurysmal SAH in humans were selected for review. Although most studies supported an incidence of rebleeding ≤4%, studies investigating ultra-early rebleeding reported bleeding within the first 24 h following aneurysmal SAH in as many as 9–17% of patients, with most cases occurring within 6 h of initial hemorrhage. Overall, studies investigating antifibrinolytic therapy to reduce rebleeding have failed to clearly demonstrate overall therapeutic benefit. Short-course antifibrinolytic therapy may have a role prior to initial aneurysm repair, although insufficient data are currently available.

This is a preview of subscription content, log in via an institution to check access.

Access this article

Log in via an institution

Price excludes VAT (USA)
Tax calculation will be finalised during checkout.

Instant access to the full article PDF.

Institutional subscriptions

Similar content being viewed by others

References

  1. Ameen AA, Illingworth R. Anti-fibrinolytic treatment in the pre-operative management of subarachnoid haemorrhage caused by ruptured intracranial aneurysm. J Neurol Neurosurg Psychiatry. 1981;44:220–6.

    Article  PubMed  CAS  Google Scholar 

  2. Fujii Y, Takeuchi S, Sasaki O, Minakawa T, Koike T, Tanaka R. Ultra-early rebleeding in spontaneous subarachnoid hemorrhage. J Neurosurg. 1996;84:35–42.

    Article  PubMed  CAS  Google Scholar 

  3. Hillman J, Fridriksson S, Nilsson O, Yu Z, Saveland H, Jakobsson KE. Immediate administration of tranexamic acid and reduced incidence of early rebleeding after aneurysmal subarachnoid hemorrhage: a prospective randomized study. J Neurosurg. 2002;97:771–8.

    Article  PubMed  CAS  Google Scholar 

  4. Laidlaw JD, Siu KH. Ultra-early surgery for aneurysmal subarachnoid hemorrhage: outcomes for a consecutive series of 391 patients not selected by grade or age. J Neurosurg. 2002;97:250–8.

    Article  PubMed  Google Scholar 

  5. Larsen CC, Eskesen V, Hauerberg J, Olesen C, Romner B, Astrup J. Considerable delay in diagnosis and acute management of subarachnoid haemorrhage. Dan Med Bull. 2010;57:A4139.

    PubMed  Google Scholar 

  6. Harrigan MR, Rajneesh KF, Ardelt AA, Fisher WS 3rd. Short-term antifibrinolytic therapy before early aneurysm treatment in subarachnoid hemorrhage: effects on rehemorrhage, cerebral ischemia, and hydrocephalus. Neurosurgery. 2010;67:935–9.

    Article  PubMed  Google Scholar 

  7. Jane JA, Winn HR, Richardson AE. The natural history of intracranial aneurysms: rebleeding rates during the acute and long term period and implication for surgical management. Clin Neurosurg 1977;24:176–84.

    PubMed  CAS  Google Scholar 

  8. Kassell NF, Torner JC. Aneurysmal rebleeding: a preliminary report from the Cooperative Aneurysm Study. Neurosurgery. 1983;13:479–81.

    Article  PubMed  CAS  Google Scholar 

  9. Kassell NF, Torner JC, Haley EC Jr, Jane JA, Adams HP, Kongable GL. The international cooperative study on the timing of aneurysm surgery. Part 1. Overall management results. J Neurosurg. 1990;73:18–36.

    Article  PubMed  CAS  Google Scholar 

  10. Kassell NF, Torner JC, Jane JA, Haley EC Jr, Adams HP. The international cooperative study on the timing of aneurysm surgery. Part 2. Surgical results. J Neurosurg. 1990;73:37–47.

    Article  PubMed  CAS  Google Scholar 

  11. Leipzig TJ, Redelman K, Horner TG. Reducing the risk of rebleeding before early aneurysm surgery: a possible role for antifibrinolytic therapy. J Neurosurg. 1997;86:220–5.

    Article  PubMed  CAS  Google Scholar 

  12. Molyneux A, Kerr R, Stratton I, et al. International subarachnoid aneurysm trial (ISAT) of neurosurgical clipping versus endovascular coiling in 2143 patients with ruptured intracranial aneurysms: a randomised trial. Lancet. 2002;360:1267–74.

    Article  PubMed  Google Scholar 

  13. Molyneux AJ, Kerr RS, Birks J, et al. Risk of recurrent subarachnoid haemorrhage, death, or dependence and standardised mortality ratios after clipping or coiling of an intracranial aneurysm in the International Subarachnoid Aneurysm Trial (ISAT): long-term follow-up. Lancet Neurol. 2009;8:427–33.

    Article  PubMed  Google Scholar 

  14. Molyneux AJ, Kerr RS, Yu LM, et al. International subarachnoid aneurysm trial (ISAT) of neurosurgical clipping versus endovascular coiling in 2143 patients with ruptured intracranial aneurysms: a randomised comparison of effects on survival, dependency, seizures, rebleeding, subgroups, and aneurysm occlusion. Lancet. 2005;366:809–17.

    Article  PubMed  Google Scholar 

  15. Plowman RS, Clarke A, Clarke M, Byrne JV. Sixteen-year single-surgeon experience with coil embolization for ruptured intracranial aneurysms: recurrence rates and incidence of late rebleeding. J Neurosurg. 2011;114:863–74.

    Article  PubMed  Google Scholar 

  16. Starke RM, Kim GH, Fernandez A, et al. Impact of a policy of early antifibrinolytic therapy for the prevention of acute rebleeding after aneurysmal subarachnoid hemorrhage. Stroke. 2008;39:2617–21.

    Article  PubMed  CAS  Google Scholar 

  17. Cha KC, Kim JH, Kang HI, Moon BG, Lee SJ, Kim JS. Aneurysmal rebleeding: factors associated with clinical outcome in the rebleeding patients. J Korean Neurosurg Soc. 2010;47:119–23.

    Article  PubMed  Google Scholar 

  18. Tong Y, Gu J, Fan WJ, Yu JB, Pan JW, Wan S, Zhou YQ, Zheng XJ, Zhan RY. Patients with supratentorial aneurysmal subarachnoid hemorrhage during the intermediate period: waiting or actively treating. Int J Neurosci. 2009;119:1494–506.

    Article  PubMed  Google Scholar 

  19. Ruigrok YM, Slooter AJ, Rinkel GJ, Wijmenga C, Rosendaal FR. Genes influencing coagulation and the risk of aneurysmal subarachnoid hemorrhage, and subsequent complications of secondary cerebral ischemia and rebleeding. Acta Neurochir (Wien). 2010;152:257–62.

    Article  Google Scholar 

  20. Tanno Y, Homma M, Oinuma M, Kodama N, Ymamoto T. Rebleeding from ruptured intracranial aneurysms in North Eastern Province of Japan. A cooperative study. J Neurol Sci. 2007;258:11–6.

    Article  PubMed  Google Scholar 

  21. Heelingman CA, van den Bergh WM, Beijer IS, et al. Risk of rebleeding after treatment of acute hydrocephalus in patients with aneurysmal subarachnoid hemorrhage. Stroke. 2007;38:96–9.

    Article  Google Scholar 

  22. Machiel Pleizier C, Algra A, Velthuis BK, Rinkel GJ. Relation between size of aneurysms and risk of rebleeding in patients with subarachnoid haemorrhage. Acta Neurochir. 2006;148:1277–9.

    Article  CAS  Google Scholar 

  23. Beck J, Raabe A, Szelenyi A, et al. Sentinel headache and the risk of rebleeding after aneurysmal subarachnoid hemorrhage. Stroke. 2006;37:2733–7.

    Article  PubMed  Google Scholar 

  24. Kitsua Y, Suzuki N, Sugiyama M, Yamamoto I. Changes in level of consciousness and association with hyperglycemia as tool for predicting and preventing re-bleeding after spontaneous subarachnoid hemorrhage. Prehosp Disaster Med. 2006;21:190–5.

    Google Scholar 

  25. Ruijs AC, Dirven CM, Algra A, Beijer I, Vandertop WP, Rinkel G. The risk of rebleeding after external lumbar drainage in patients with untreated ruptured cerebral aneurysms. Acta Neurochir. 2005;147:1157–61.

    Article  CAS  Google Scholar 

  26. Kusumi M, Yamada M, Kitahara T, et al. Rerupture of cerebral aneurysms during angiography—a retrospective study of 13 patients with subarachnoid hemorrhage. Acta Neurochir. 2005;147:831–7.

    Article  CAS  Google Scholar 

  27. Naidech AM, Ianjua N, Kreiter KT, et al. Predictors and impact of aneurysm rebleeding after subarachnoid hemorrhage. Arch Neurol. 2005;62:410–6.

    Article  PubMed  Google Scholar 

  28. McIver JI, Friedman JA, Wijdicks EF, et al. Preoperative ventriculostomy and rebleeding after aneurysmal subarachnoid hemorrhage. J Neurosurg. 2002;97:1042–4.

    Article  PubMed  Google Scholar 

  29. Edner G, Ronne-Engström E. Can early admission reduce aneurysmal rebleeds? A prospective study on aneurysmal incidence, aneurysmal rebleeds, admission and treatment delays in a defined region. Br J Neurosurg. 1991;5:601–8.

    Article  PubMed  CAS  Google Scholar 

  30. Steiger HJ, Fritschi J, Seiler RW. Current pattern of in-hospital aneurysmal rebleeds. Analysis of a series treated with individually timed surgery and intravenous nimodipine. Acta Neurochir. 1994;127:21–6.

    Article  CAS  Google Scholar 

  31. Roos YM, Beenen LM, Goren RM, Albrecht KW, Vermeulen M. Timing of surgery in patients with aneurysmal subarachnoid haemorrhage: rebleeding is still the major cause of poor outcome in neurosurgical units that aim at early surgery. J Neurol Neurosurg Psychiatry. 1997;63:490–3.

    Article  PubMed  CAS  Google Scholar 

  32. Hillman J, von Essen C, Leszniewski W, Johansson I. Significance of “ultra-early” rebleeding in subarachnoid hemorrhage. J Neurosurg. 1988;68:901–7.

    Article  PubMed  CAS  Google Scholar 

  33. Larsen CC, Eskesen V, Hauerberg J, Olesen C, Romner B, Astrup J. Considerable delay in diagnosis and acute management of subarachnoid haemorrhage. Ugeskr Laeger. 2010;172:1442.

    PubMed  Google Scholar 

  34. Girvin JP. The use of antifibrinolytic agents in the preoperative treatment of ruptured intracranial aneurysms. Trans Am Neurol Assoc. 1973;98:150–2.

    PubMed  CAS  Google Scholar 

  35. van Rossum J, Wintzen AR, Endtz LJ, Schoen JH, de Jonge H. Effect of tranexamic acid on rebleeding after subarachnoid hemorrhage: a double-blind controlled clinical trial. Ann Neurol. 1977;2:238–42.

    Article  PubMed  Google Scholar 

  36. Chandra B. Treatment of subarachnoid hemorrhage from ruptured intracranial aneurysm with tranexamic acid: a double-blind clinical trial. Ann Neurol. 1978;3:502–4.

    Article  PubMed  CAS  Google Scholar 

  37. Maurice-Williams RS. Prolonged antifibrinolysis: an effective non-surgical treatment for ruptured intracranial aneurysms? Br Med J. 1978;1:945–7.

    Article  PubMed  CAS  Google Scholar 

  38. Kaste M, Ramsay M. Tranexamic acid in subarachnoid hemorrhage. A double-blind study. Stroke. 1979;10:519–22.

    Article  PubMed  CAS  Google Scholar 

  39. Fodstad H, Forssell A, Liliequist B, Schannong M. Antifibrinolysis with tranexamic acid in aneurysmal subarachnoid hemorrhage: a consecutive controlled clinical trial. Neurosurgery. 1981;8:158–65.

    Article  PubMed  CAS  Google Scholar 

  40. Vermeulen M, Lindsay KW, Murray GD, et al. Antifibrinolytic treatment in subarachnoid hemorrhage. N Engl J Med. 1984;311:432–7.

    Article  PubMed  CAS  Google Scholar 

  41. Tsementzis SA, Hitchcock ER, Meyer CH. Benefits and risks of antifibrinolytic therapy in the management of ruptured intracranial aneurysms. A double-blind placebo-controlled study. Acta Neurochir. 1990;102:1–10.

    Article  CAS  Google Scholar 

  42. Roos Y. Antifibrinolytic treatment in subarachnoid hemorrhage: a randomized placebo-controlled trial. Star study group. Neurology. 2000;54:77–82.

    PubMed  CAS  Google Scholar 

  43. Jane JA, Kassell NF, Torner JC, Winn HR. The natural history of aneurysms and arteriovenous malformations. J Neurosurg. 1985;62:321–3.

    Article  PubMed  CAS  Google Scholar 

  44. Kassell NF, Drake CG. Timing of aneurysm surgery. Neurosurgery. 1982;10:514–9.

    Article  PubMed  CAS  Google Scholar 

  45. Roos, Y.B., Rinkel, G., Vermeulen, M., Algra, A., van Gijn, J.: Antifibrinolytic therapy for aneurysmal subarachnoid haemorrhage. Cochrane Database Syst Rev. 2003;CD001245.

  46. Lylyk P, Miranda C, Ceratto R, et al. Curative endovascular reconstruction of cerebral aneurysms with the pipeline embolization device: the Buenos Aires experience. Neurosurgery. 2009;64:632–42.

    Article  PubMed  Google Scholar 

  47. Nelson PK, Lylyk P, Szikora I, Wetzel SG, Wanke I, Fiorella D. The pipeline embolization device for the intracranial treatment of aneurysms trial. Am J Neuroradiol. 2011;32:34–40.

    Article  PubMed  CAS  Google Scholar 

Download references

Author information

Authors and Affiliations

  1. Department of Neurosurgery, University of Virginia School of Medicine, Charlottesville, VA, USA

    R. M. Starke

  2. Department of Neurosurgery, Columbia University College of Physicians and Surgeons, 710 West 168th Street, New York, NY, 10032, USA

    E. S. Connolly Jr.

Authors
  1. R. M. Starke
    View author publications

    You can also search for this author in PubMed Google Scholar

  2. E. S. Connolly Jr.
    View author publications

    You can also search for this author in PubMed Google Scholar

Consortia

The Participants in the International Multi-disciplinary Consensus Conference on the Critical Care Management of Subarachnoid Hemorrhage

Corresponding author

Correspondence to E. S. Connolly Jr..

Additional information

The Participants in the International Multi-disciplinary Consensus Conference on the Critical Care Management of Subarachnoid Hemorrhage are Michael N. Diringer, Thomas P. Bleck, Nicolas Bruder, E. Sander Connolly, Jr., Giuseppe Citerio, Daryl Gress, Daniel Hanggi, J. Claude Hemphill, III, MAS, Brian Hoh, Giuseppe Lanzino, Peter Le Roux, David Menon, Alejandro Rabinstein, Erich Schmutzhard, Lori Shutter, Nino Stocchetti, Jose Suarez, Miriam Treggiari, MY Tseng, Mervyn Vergouwen, Paul Vespa, Stephan Wolf, Gregory J. Zipfel.

Rights and permissions

Reprints and permissions

About this article

Cite this article

Starke, R.M., Connolly, E.S. & The Participants in the International Multi-disciplinary Consensus Conference on the Critical Care Management of Subarachnoid Hemorrhage. Rebleeding After Aneurysmal Subarachnoid Hemorrhage. Neurocrit Care 15, 241–246 (2011). https://doi.org/10.1007/s12028-011-9581-0

Download citation

  • Published:

  • Issue Date:

  • DOI: https://doi.org/10.1007/s12028-011-9581-0

Keywords

Search

Navigation