From the Guidelines
The prognosis for a rebleeded brain aneurysm is generally poor, with mortality rates of 50-80% and significant disability in many survivors. Management requires immediate neurosurgical intervention, typically beginning with stabilization of vital functions, securing the airway, and maintaining adequate blood pressure (typically systolic BP between 120-160 mmHg using medications like nicardipine 5-15 mg/hr or labetalol 5-20 mg/hr) 1. Patients should be transferred to a neurosurgical ICU for definitive treatment, which includes surgical clipping or endovascular coiling of the aneurysm within 24-72 hours to prevent further bleeding. Nimodipine 60 mg every 4 hours for 21 days is administered to prevent vasospasm, a common complication 1. Additional management includes strict blood pressure control, seizure prophylaxis with levetiracetam 500-1000 mg twice daily, pain control, and management of increased intracranial pressure using measures like head elevation to 30 degrees, osmotic therapy with mannitol 0.25-1 g/kg IV or hypertonic saline 3% at 30-50 mL/hr. Rebleeding is particularly dangerous because the already damaged brain has less capacity to compensate for additional injury, and the second hemorrhage often causes more extensive damage than the initial event, leading to increased risk of vasospasm, hydrocephalus, and neurological deterioration.
Key Considerations
- Early management of the ruptured aneurysm has been shown to reduce in-hospital rebleeding and allows more aggressive and early management of cerebral vasospasm by hemodynamic therapy and interventional management if indicated 1.
- Low-volume hospitals should consider early transfer of patients with aSAH to high-volume centers with experienced cerebrovascular surgeons, endovascular specialists, and multidisciplinary neuro-intensive care services 1.
- The goal for the management of cerebral vasospasm is to reduce the threat of ischemic neuronal damage by controlling intracranial pressure, decreasing the metabolic rate of oxygen use, and improving CBF.
Management Strategies
- Surgical clipping or endovascular coiling of the ruptured aneurysm should be performed as early as feasible in the majority of patients to reduce the rate of rebleeding after aSAH 1.
- Complete obliteration of the aneurysm is recommended whenever possible 1.
- Determination of aneurysm treatment should be a multidisciplinary decision based on characteristics of the patient and the aneurysm 1.
From the FDA Drug Label
The Canadian study entered much sicker patients, (Hunt and Hess Grades III-V), who had a high rate of death and disability, and used a dose of 90 mg every 4 hours, but was otherwise similar to the first two studies Analysis of delayed ischemic deficits, many of which result from spasm, showed a significant reduction in spasm-related deficits. Among analyzed patients (72 nimodipine, 82 placebo), there were the following outcomes. * p = 0. 001, nimodipine vs placebo Delayed Ischemic Deficits (DID) Permanent Deficits Nimodipine n (%) Placebo n (%) Nimodipine n (%) Placebo n (%) DID Spasm Alone 8 (11) * 25 (31)5 (7)* 22 (27) DID Spasm Contributing18 (25) 21 (26) 16 (22) 17 (21) DID Without Spasm 7 (10) 8 (10)6 (8) 7 (9) No DID39 (54) 28 (34) 45 (63) 36 (44) When data were combined for the Canadian and the United Kingdom studies, the treatment difference on success rate (i.e., good recovery) on the Glasgow Outcome Scale was 25.3% (nimodipine) versus 10.9% (placebo) for Hunt and Hess Grades IV or V.
- p = 0. 045, nimodipine vs placebo Glasgow Outcome *Nimodipine (n=87)Placebo (n=101) Good Recovery 22 (25.3%) 11 (10.9%) Moderate Disability 8 (9.2%) 12 (11.9%) Severe Disability 6 (6.9%) 15 (14.9%) Vegetative Survival 4 (4.6%) 9 (8.9%) Death 47 (54.0%) 54 (53. 5%)
The mortality rates after brain aneurysm rebleeds are not directly stated in the provided drug labels. However, the labels do provide information on the outcomes of patients with subarachnoid hemorrhage from ruptured intracranial berry aneurysms.
- Mortality rates: In the Canadian and United Kingdom studies, the mortality rates were 54.0% for nimodipine-treated patients and 53.5% for placebo-treated patients 2.
- Key points:
- The drug labels do not provide direct information on mortality rates after brain aneurysm rebleeds.
- The labels do provide information on the outcomes of patients with subarachnoid hemorrhage from ruptured intracranial berry aneurysms.
- The mortality rates in the Canadian and United Kingdom studies were similar between nimodipine-treated and placebo-treated patients.
From the Research
Mortality Rates After Brain Aneurysm Rebleeds
- The mortality rate after brain aneurysm rebleeds is high, with one study reporting a mortality rate of 71% 3.
- Rebleeding is a significant factor influencing the outcome after aneurysmal subarachnoid hemorrhage, with a reported frequency of 4% to 6.9% 3, 4.
- The timing of rebleeding is crucial, with most cases occurring within the first 3 to 7 days after the initial hemorrhage 3, 4.
Prognosis and Management
- The prognosis after brain aneurysm rebleeds is generally poor, with a high risk of severe neurologic deficits and mortality 3, 4.
- Management strategies include early surgical or endovascular treatment, as well as pharmacologic therapy to reduce the risk of rebleeding 4.
- Intra-arterial nimodipine has been shown to be effective in reversing angiographic cerebral vasospasm, but its impact on clinical outcome is variable 5, 6, 7.
- Factors predicting poor clinical outcome after intra-arterial nimodipine treatment include increased number of affected vessels, number of procedures carried out per patient, and delay time from symptomatic cerebral vasospasm to treatment 7.
Risk Factors
- Risk factors for rebleeding after aneurysmal subarachnoid hemorrhage include high systolic blood pressure, sentinel headache, initial loss of consciousness, poor Hunt and Hess grade, high Fisher grade on initial CT, large aneurysm size, and performance of angiography 3, 4.
- The size of the aneurysm is also a significant risk factor, with larger aneurysms being more likely to rebleed 4.