Critical Care Medicine-Neurologic Disorders>>>>>Cerebrovascular Diseases
Question 3#

A 47-year-old male with untreated hypertension was brought to the emergency department for loss of consciousness while at home and an episode of emesis. A head CT demonstrated a diffuse SAH with intraventricular extension and early signs of hydrocephalus. A CT angiogram demonstrated a 6 mm fusiform aneurysm from the distal right posterior inferior cerebellar artery (PICA). He was admitted to the intensive care unit for ongoing management. Over the course of the evening, there was progressive somnolence and an EVD was placed with an elevated opening pressure. Once placed, the EVD remained clamped. Given the need to delay definitive management of the aneurysm, transexamic acid (TXA) was started. Within 8 hours of admission, there was acute worsening of the examination and an acute increase in the intracranial pressure (ICP), and on opening the EVD, blood actively drained.

What of the following is MOST true of aneurysmal rerupture? 

a. Aneurysm rerupture does not change functional outcome of those who survive
b. Posterior circulation aneurysms are more common to have rerupture than anterior circulation aneurysms
c. The use of TXA decreases the risk of rebleeding and improves clinical outcomes
d. Placement of an EVD increases the risk of rebleeding
e. Rerupture more commonly occurs within the first 3 to 5 days, following the initial aneurysm rupture

Correct Answer is E

Comment:

Correct Answer: E

This SAH patient has suffered a rerupture of his PICA aneurysm. Rebleeding is a major complication of SAH and a major cause of mortality, which can occur at any time during the course. Early rebleeding has been commonly reported to take place between 3 and 5 days, yet the exact period of great risk is still debated. The correlation between risk of rebleeding and predictors such as poor clinical SAH grades, loss of consciousness, external ventricular drainage, and size of aneurysm has been debated. Posterior circulation aneurysms are more likely to rupture, yet overall they are not associated with an increased risk of rerupture.

In an attempt to decrease the risk of rebleeding, TXA has been evaluated in SAH patients and has shown to decrease the rate of early rebreeding; however, it did not associate with improvement in clinical outcome.

References:

  1. Naidech AM, Janjua N, Kreiter KT, et al. Predictors and impact of aneurysmal rebleeding after subarachnoid hemorrhage. Arch Neurol. 2005;62:410-416.
  2. Starke RM, Connolly ES Jr; Participants in the International MultiDisciplinary Consensus Conference on the Critical Care Management of Subarachnoid Hemorrhage. Rebleeding after aneurysmal subarachnoid hemorrhage. Neurocrit Care. 2011;15:24106.