Rate
- Calculate cumulative risk like AVM
- A. This analysis includes a number of assumptions including: a constant risk of rebleeding even early after an initial bleed, no change in risk during the lifetime (which may not be true in pregnancy), no difference in risk for various AVM locations or age groups
For untreated ruptured aneurysms
- Risk of rebleed
- Note: rebleed mortality is higher than 50%
- 1st day: 4%-13.6%
- 3 hrs of bleed: 1/3 of all rebleeds
- 6 hrs of bleed: 1/2 of all rebleeds
- 1st 13 days: 1.5% daily —> total of 20% in 1st 14 days
- 50% rebleed within 6 months
- 3%/year
- 1%/yr for SAH with unknown aetiology or multiple unruptured aneurysm (same for AVM)
0-24h | 4% |
0-2wk | 20% |
0-6mo | 50% |
>6mo | 3% |
- Mortality
- 2%/yr
- 50% death occur in 1st month
Risk factors
- Increased with hunt and Hess grade
- Increased with decrease in ICP: Spinal drainage/ventriculostomy
Management
- Coil
- Clip
- Hyper dynamic therapy or bed rest do not prevent rebleed
- Platelet transfusion
- Sebök 2023: Given to patients who are on antiplatelet therapy who on thomboelastase testing or about to have a procedure done
- Antifibrinolytic therapy: uncertain role
- Tranexamic acid: binds to plasminogen → prevent formation of plasmin + displaces plasmin from surface of fibrin → inhibiting fibrinolysis
- Decreased early rebleed
- 1g IV asap SAH diagnosed → 1g 6hrsly until secure aneurysm
- Epsilon-aminocaproic acid (Amicar)
- Competitively inhibits activation of plasminogen to plasmin → inhibit fibrinolysis
- Shown to reduce risk of rebleed but also inc. risk of vasospams and hydrocephalus
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