From the Guidelines
The prognosis for an aneurysm rebleed is poor, with mortality rates of 50-70% and significant disability in many survivors, as reported in the most recent guideline from the American Heart Association/American Stroke Association 1.
Key Considerations
- Immediate treatment is essential and typically involves securing the aneurysm through surgical clipping or endovascular coiling within 24-72 hours of the initial bleed.
- Medical management includes strict blood pressure control (typically maintaining systolic pressure between 120-160 mmHg) using medications like nicardipine (5-15 mg/hr IV) or labetalol (5-20 mg/hr IV).
- Patients require ICU admission with neurological monitoring, pain control, seizure prophylaxis (levetiracetam 500-1000 mg twice daily), and prevention of complications like vasospasm, which may be managed with nimodipine (60 mg every 4 hours for 21 days).
Rebleeding Risk
- Rebleeding risk is highest within the first 24 hours (4-13%) and remains elevated for about 2-4 weeks after the initial rupture, as noted in guidelines for the management of aneurysmal subarachnoid hemorrhage 1.
- The pathophysiology involves instability of the initial blood clot at the rupture site and ongoing hemodynamic stress on the weakened vessel wall, which is why rapid intervention to secure the aneurysm is critical for improving outcomes.
Treatment Approach
- The goal of initial treatment is complete obliteration of the aneurysm whenever feasible, with partial treatment aimed at securing the putative rupture site during the acute phase being reasonable to reduce the risk of early rebleeding 1.
- Subgroup analysis of posterior circulation aneurysms supports the benefit of coiling over clipping, with a lower risk of death or dependency 1.
- Rapid intervention is supported by observational data indicating significantly shorter time to treatment in patients with large intracerebral hematoma and favorable outcome compared with those with unfavorable outcome 1.
From the Research
Mortality Rates After Aneurysm Rebleeds
- The mortality rate from early rebleeding can be reduced by 80% with tranexamic acid treatment, as shown in a study published in the Journal of Neurosurgery 2.
- A study published in the Archives of Neurology found that rebleeding occurred in 6.9% of patients, with most cases (73%) occurring within 3 days of ictus, and was associated with a markedly reduced chance of survival with functional independence 3.
- The risk of death at 12 months was lower for endovascular coiling compared to neurosurgical clipping, with a risk ratio of 0.80 (95% CI 0.63 to 1.02) 4.
- A long-term follow-up study of the International Subarachnoid Aneurysm Trial (ISAT) cohort found that the risk of death at 5 years was significantly lower in the coiling group than in the clipping group, with a relative risk of 0.77 (95% CI 0.61-0.98) 5.
Prognosis and Treatment
- Early aneurysm repair is crucial in preventing rebleeding, and the use of antifibrinolytic drugs such as tranexamic acid can provide protection against ultraearly rebleeds 2.
- Endovascular coiling is associated with a better outcome compared to neurosurgical clipping for people in good clinical condition with ruptured aneurysms of either the anterior or posterior circulation 4.
- The durability of endovascular coiling versus neurosurgical clipping of ruptured cerebral aneurysms was assessed in an 18-year follow-up of the UK cohort of the ISAT, which found that patients in the endovascular treatment group were more likely to be alive and independent at 10 years than patients in the neurosurgery group 6.
- Rebleeding was more likely after endovascular coiling than after neurosurgical clipping, but the risk was small and the probability of disability-free survival was significantly greater in the endovascular group than in the neurosurgical group at 10 years 6.