Rebleeding following aneurysmal subarachnoid hemorrhage before ‘endovascular first’ treatment: a retrospective case-control study of published scoring systems

Abstract

BackgroundPre-treatment re-bleeding following aneurysmal subarachnoid hemorrhage (aSAH) affects up to 7.2% of patients even with ultra-early treatment within 24 hours. We retrospectively compared the utility of three published re-bleed prediction models and individual predictors between cases who re-bled matched to controls using size and parent vessel location from a cohort of patients treated in an ultra-early, ‘endovascular first’ manner.MethodsOn retrospective analysis of our 9-year cohort of 707 patients suffering 710 episodes of aSAH, there were 53 episodes of pre-treatment re-bleeding (7.5%). Forty-seven cases who had a single culprit aneurysm were matched to 141 controls. Demographic, clinical and radiological data were extracted and predictive scores calculated. Univariate, multivariate, area under the receiver operator characteristic curve (AUROCC) and Kaplan–Meier (KM) survival curve analyses were performed.ResultsThe majority of patients (84%) were treated using endovascular techniques at a median 14.5 hours post-diagnosis. On AUROCC analysis the score of Liuet al.had minimal utility (C-statistic 0.553, 95% confidence interval (CI) 0.463 to 0.643) while the risk score of Opponget al.(C-statistic 0.645 95% CI 0.558 to 0.732) and the ARISE-extended score of van Lieshoutet al.(C-statistic 0.53 95% CI 0.562 to 0.744) had moderate utility. On multivariate modeling, the World Federation of Neurosurgical Societies (WFNS) grade was the most parsimonious predictor of re-bleeding (C-statistic 0.740, 95% CI 0.664 to 0.816).ConclusionsFor aSAH patients treated in an ultra-early timeframe matched on size and parent vessel location, WFNS grade was superior to three published models for re-bleed prediction. Future re-bleed prediction models should incorporate the WFNS grade.

Letter: Clinical Impact and Predictors of Aneurysmal Rebleeding in Poor-Grade Subarachnoid Hemorrhage: Results From the National POGASH Registry

“…We read with interest the recent publication by Panni et al 1 where nearly 18% of high-grade aneurysmal subarachnoid hemorrhage patients suffered rebleeding despite predominantly endovascular, "hyperearly" treatment underscoring the primacy of initial clinical grade for rebleed prediction. 1,2 This study also uncovered several novel statistical associations; the presence of radiological ultra-early vasospasm increased the odds of rebleeding, whereas a history of premorbid hypertension reduced the odds of rebleeding even after covariate adjustment. 1 However, we wish to highlight several methodological limitations in the design and analysis of the study which may account for these findings.…”

“…8 Are the functional outcomes after pretreatment and post-treatment rebleeding in aneurysmal subarachnoid hemorrhage similar? Mortality from pretreatment rebleeding has been estimated in recent studies to be 41%-57%, 2,9 whereas outcomes after post-treatment rebleeding is estimated at 25% mortality, although the remaining 75% of patients have favorable outcomes. 10 When directly compared in a large multicentre study, 25.3% of patients who experienced pretreatment bleeding had a favorable outcome compared with only 9.9% of patients who experienced post-treatment rebleeding.…”