What is the prognosis and management of a rebleeded brain aneurysm?

From the Guidelines

The prognosis for a rebleeded brain aneurysm is generally poor, with mortality rates of 50-70% 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 (systolic 120-160 mmHg) 1. Patients should be transferred to a neurosurgical intensive care unit where definitive treatment involves either surgical clipping or endovascular coiling to prevent further bleeding.

Key Management Strategies

• 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.
• External ventricular drainage may be required for hydrocephalus.
• Complications like vasospasm may be treated with hypertensive therapy, maintaining euvolemia, and in some cases, endovascular interventions. Some key points to consider in the management of rebleeded brain aneurysms include:
• The risk of early aneurysm rebleeding is high and is associated with very poor outcomes, making urgent evaluation and treatment critical 1.
• The initial clinical severity of aSAH should be determined rapidly by use of simple validated scales, as it is the most useful indicator of outcome after aSAH 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. Rebleeding occurs due to instability of the initial blood clot at the rupture site, with the highest risk in the first 24 hours, making urgent intervention critical to prevent this catastrophic complication.

From the Research

Mortality Rates After Brain Aneurysm Rebleeds

• The mortality rate after a brain aneurysm rebleed is significantly high, with one study indicating that rebleeding is associated with a markedly reduced chance of survival with functional independence 2.
• A study published in the Archives of Neurology found that rebleeding occurred in 6.9% of patients with subarachnoid hemorrhage, and was associated with a poor outcome, including a high mortality rate 2.
• Another study published in The Lancet Neurology found that the risk of death at 5 years was significantly lower in patients who underwent coiling compared to those who underwent clipping, with a relative risk of 0.77 3.
• The mortality rate at 3 months was reported to be 16% in one study, and 20% at 1 year 4.
• A more recent study published in The Neuroradiology Journal found that 4 out of 48 patients (8%) died within 30 days of treatment with intra-arterial nimodipine for cerebral vasospasm after aneurysmal subarachnoid hemorrhage 5.

Prognosis and Management of Rebleeded Brain Aneurysm

• The prognosis for patients with a rebleeded brain aneurysm is generally poor, with a high risk of mortality and morbidity 2.
• Management of rebleeded brain aneurysm typically involves early surgical or endovascular treatment to prevent further rebleeding and improve outcomes 2.
• Intra-arterial nimodipine has been shown to be effective in treating cerebral vasospasm after aneurysmal subarachnoid hemorrhage, with some studies suggesting that continuous infusion may be more effective than bolus injection 5, 6.
• The use of intra-arterial verapamil and other vasodilators may also be effective in treating cerebral vasospasm, but the optimal treatment strategy is not yet clear 6.
• Further research is needed to determine the best management strategy for patients with rebleeded brain aneurysms and to improve outcomes for these patients 3, 4, 2, 5, 6.