van Donkelaar Carlina E, Bakker Nicolaas A, Veeger Nic J G M, Uyttenboogaart Maarten, Metzemaekers Jan D M, Luijckx Gert-Jan, Groen Rob J M, van Dijk J Marc C
From the Department of Neurosurgery (C.E.v.D., N.A.B., J.D.M.M., R.J.M.G., J.M.C.v.D.), Department of Intensive Care Medicine (N.A.B.), Department of Clinical Epidemiology and Trial Coordination Center (N.J.G.M.V.), Department of Neurology (M.U., G.-J.L.), and Department of Radiology (M.U.), University Medical Center Groningen, University of Groningen, Groningen, The Netherlands.
Stroke. 2015 Aug;46(8):2100-6. doi: 10.1161/STROKEAHA.115.010037. Epub 2015 Jun 11.
Aneurysmal subarachnoid hemorrhage (aSAH) is a devastating type of stroke associated with high morbidity and mortality. One of the most feared complications is an early rebleeding before aneurysm repair. Predictors for such an often fatal rebleeding are largely unknown. We therefore aimed to determine predictors for an early rebleeding after aSAH in relation with time after ictus.
This observational prospective cohort study included all consecutive patients admitted with aSAH between January 1998 and December 2014 (n=1337) at our University Neurovascular Center. Clinical predictors for rebleeding ≤24 hours were identified using multivariable Cox regression analyses. Kaplan-Meier analyses were applied to evaluate the time of rebleeding ≤72 hours after aSAH.
A modified Fisher grade of 3 to 4 was a predictor for an in-hospital rebleeding ≤24 hours after ictus (adjusted hazard ratio, 4.4; 95% confidence interval, 2.1-10.6; P<0.001). The numbers needed to treat to prevent 1 rebleeding ≤24 hours was calculated 15 (95% confidence interval, 10-25). Also, the initiation of external cerebrospinal fluid-drainage (adjusted hazard ratio, 1.9; 95% confidence interval, 1.4-2.5; P<0.001) was independently associated with a rebleeding ≤24 hours. Cumulative in-hospital rebleeding rates were 5.8% ≤24 hours, and 1.2% in the time frame 24-72 hours after ictus.
In our opinion, timing of treatment of aSAH patients, especially those with an modified Fisher grade of 3 or 4 in a good clinical condition, should be reconsidered. These aSAH patients might be regarded a medical emergency, requiring aneurysm repair as soon as possible. In this respect, our findings should provoke the debate on timing of aneurysm repair, especially in patients considered to be at high risk for rebleeding.
动脉瘤性蛛网膜下腔出血（aSAH）是一种具有高发病率和死亡率的毁灭性卒中类型。最可怕的并发症之一是在动脉瘤修复前早期再出血。这种往往致命的再出血的预测因素很大程度上尚不清楚。因此，我们旨在确定aSAH后早期再出血与发病后时间相关的预测因素。
这项观察性前瞻性队列研究纳入了1998年1月至2014年12月期间在我们大学神经血管中心连续收治的所有aSAH患者（n = 1337）。使用多变量Cox回归分析确定再出血≤24小时的临床预测因素。应用Kaplan-Meier分析评估aSAH后再出血≤72小时的时间。
改良Fisher分级为3至4级是发病后24小时内院内再出血的预测因素（调整后风险比，4.4；95%置信区间，2.1 - 10.6；P < 0.001）。预防1次24小时内再出血所需治疗的人数计算为15（95%置信区间，10 - 25）。此外，开始进行外部脑脊液引流（调整后风险比，1.9；95%置信区间，1.4 - 2.5；P < 0.001）与24小时内再出血独立相关。发病后24小时内累积院内再出血率为5.8%，24 - 72小时时间段内为1.2%。
我们认为，应重新考虑aSAH患者的治疗时机，尤其是那些改良Fisher分级为3或4级且临床状况良好的患者。这些aSAH患者可能应被视为医疗急症，需要尽快进行动脉瘤修复。在这方面，我们的研究结果应引发关于动脉瘤修复时机的辩论，尤其是在被认为再出血风险高的患者中。
