J Cerebrovasc Endovasc Neurosurg.  2022 Mar;24(1):36-43. 10.7461/jcen.2021.E2021.05.006.

Factors associated with rebleeding after coil embolization in patients with aneurysmal subarachnoid hemorrhage

• Kim D
• Pyen J
• Whang K
• Cho S
• Jang Y
• Kim J
• Koo Y
• Choi J

• KMID: 2527593
• DOI: http://doi.org/10.7461/jcen.2021.E2021.05.006

Abstract

Objective
Aneurysmal subarachnoid hemorrhage (aSAH) has a high mortality rate, and hemorrhage amounts and perioperative rebleeding importantly determines prognosis. However, despite adequate treatment, prognosis is poor in many ruptured aneurysm cases. In this study, we identified and evaluated factors related to perioperative rebleeding in patients with aSAH.
Methods
The medical and surgical records of 166 patients that underwent endovascular embolization for a ruptured cerebral aneurysm at a single institution from 2014 to 2016 were retrospectively analyzed to identify risk factors of rebleeding. All patients were examined for risk factors and evaluated for increased hemorrhage by brain computed tomography at 3 days after surgery.
Results
This series included 54 men (32.5%) and 112 women (67.5%) of mean age 58.3±14.3 years. After procedures, 26 patients (15.7%) experienced rebleeding, and 1 of these (0.6%) experienced an intraoperative aneurysmal rupture. External ventricular drainage (EVD) (odds ratio [OR] 5.389, [95% confidence interval (CI) 1.171- 24.801]) and modified Fisher grade (OR 2.037, [95% CI 1.077-3.853]) were found to be independent risk factors of rebleeding, and perioperative rebleeding was strongly associated with patient outcomes (p＜0.001).
Conclusions
We concluded the rebleeding risk after aSAH is greater in patients with large hemorrhage amounts and a high pre-operative modified Fisher grade, and thus, we caution neurosurgeons should take care in such cases.

Keyword

Aneurysmal subarachnoid hemorrhage; Endovascular procedure; Therapeutic Embolization

Figure

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  Fig. 1. Forest plot on the relationship between the rebleeding risk after endovascular treatment and pre/postoperative risk factors.

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  Fig. 2. (A) This patient had a small amount of SAH, but with IVH, and was classified as grade 4 for Fisher grade and grade 2 for modified Fisher grade. (B) This patient showed thick SAH without IVH and was classified as grade 3 in both Fisher and modified Fisher grades. (C) This patient was classified as grade 4 for both Fisher grade and modified Fisher grade as thick SAH with IVH. Compared with (A) and (C), although the absolute amount of hemorrhage shows a remarkable difference, the Fisher grade was all grade 4, and the difference in absolute hemorrhage amount was not distinguishable, but the modified Fisher grade was classified as grade 2 and 4, reflecting the hemorrhage amount. Compared with A and B, the absolute amount of hemorrhage is higher in B, but in Fisher grade, (A) was higher as grade 4, whereas in modified Fisher grade, grade increased as the amount of hemorrhage increases in the order of (A), (B) and (C). SAH, subarachnoid hemorrhage; IVH, intraventricular hemorrhage.

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