Can early admission reduce aneurysmal rebleeds? A prospective study on aneurysmal incidence, aneurysmal rebleeds, admission and treatment delays in a defined region.

One-hundred and eighty-five patients sustaining an aneurysmal subarachnoid bleed were detected in a well-defined urban region in Stockholm, during a 3-year period. Of all detected patients, 21% died before coming to neurosurgical attention. In this prospective series 54 of the admitted patients had more than one bleed. In 29 of them rebleed was subsequently verified. There were 25 patients with a clinical history of a minor bleed or a warning leak preceding the major bleed. Of all rebleeds--minor bleeds included--35% occurred in the first 24 h, 5% between days 1 and 3, 19% between days 4 and 7 and 41% after the first week. Although the greatest distance to the hospital was 65 km, not more than 53% of the patients were admitted within the first 12 h post bleed. This delayed admission was attributed almost equally to a patient delay or a referral delay by doctors. The outcome of the patients was more gloomy if referral delay was apparent. A substantial number of rebleeds could have been avoided had the patient not disregarded the first bleed or the first doctor on line had not misunderstood the symptoms. Thus, 35 of the 54 rebleeds were regarded as avoidable, if admitted in time. Hypothetically a better outcome was expected in 20 of these 35 avoidable rebleeds. Substantiated by this study, aiming at early admission and treatment in the first 72 h post bleed, almost 65% of the late (after 72 h) rebleeds could be avoided.