CURRENT PATTERN OF IN-HOSPITAL ANEURYSMAL REBLEEDS - ANALYSIS OF A SERIES TREATED WITH INDIVIDUALLY TIMED SURGERY AND INTRAVENOUS NIMODIPINE

The management of aneurysmal subarachnoid haemorrhage has recently cha nged considerably. Emergency admission to specialized centres and earl y surgery have become common practice. In addition, the use of nimodip ine has gained widespread acceptance. Little data are available concer ning the frequency and temporal profile of reruptures under the curren t policies. The case histories of 387 patients treated for aneurysmal subarachnoid haemorrhage between January 1984 and March 1992 were revi ewed with regard to the incidence of in-hospital reruptures. All patie nts were managed according to the same protocol including a policy of individually timed early surgery and intravenous nimodipine. A total o f 44 first in-hospital rebleeds were observed during the waiting perio d. Two percent of the patients admitted on the day of haemorrhage had a rebleed on the same day after admission to the hospital. No rebleeds were observed on the day after subarachnoid haemorrhage. Rebleed rate s on day 2 and 3 were also low with 0.6 and 0.8% of the population wit h an unclipped aneurysm. For the following 10 days, the daily rate of rerupture increased. A further peak was observed during the 4th week. Using life-table methods, the cumulative rate of rebleeds was calculat ed as 23% within 2 weeks and 42% within 4 weeks. Although patients suf fering rebleeds differed in several respects from patients without reb leeds. most of the differences could be identified to be a consequence of a selection bias resulting in a longer period of exposure to the r isk of rerupture for certain subgroups. Only patients suffering a loss of consciousness after the initial subarachnoid haemorrhage were defi nitively exposed to a higher daily risk of rerupture. Comparison with other series suggests that nimodipine treatment may add to the protect ive effect of bedrest, control of blood pressure and stress deprivatio n during the first days after subarachnoid haemorrhage. However, it ca nnot be excluded that withdrawal of nimodipine together with the gener al precautions in patients with unclipped aneurysms is responsible for the late peak of rebleeds. With regard to the timing of surgery, the low rebleed rates between days 1 and 3 justify semi-elective timing wi thin this interval. On the other hand. in patients in whom aneurysm el imination has been deferred because of bad neurological condition or c oncomittant medical problems, surgery should be performed prior to the 4th week, unless the prognosis is considered hopeless at this time.