Changing strategies in the treatment of aneurysmal subarachnoid haemorrhage : challenging the second bleed

Abstract: Despite considerable advances in the management of aneurysmal subarachnoid haemorrhage (SAH) over the past decades, the overall outcome is still disappointing. Currently, not more than six patients out of every ten with a ruptured aneurysm, reaching hospital alive, will recover to a normal life. Apart from the direct effects of the initial haemorrhage, vasospasm and rebleeding clearly stand out as the leading causes of unfavourable results in this capricious disease, and both of these factors seem potentially amenable to further improvement in therapeutic intervention.Ever since the concept of early aneurysm surgery gained wider acceptance, the focus of the neurosurgical community has shifted from re bleeding towards the problem of vasospasm and delayed ischaemic neurological deficits (DIND). During recent years, vasospasm has attracted at least five times more attention than rebleeding in terms of published articles, and huge research efforts have been offered in the pursuit of a medical solution to this problem. Although progress has been made in the treatment of vasospasm during the last decades, DIND continues to contribute significantly to unfavourable outcome in the management of aneurysmal SAH victims. Recent series report an average of 13.5% of patients suffering DIND, leading to unfavourable outcome in 7% of all cases reaching hospital for treatment. Contrary to rebleeding, there is a dominance of morbidity (4.5%) over mortality (2.5%).Historically, the efforts aimed at reducing the risk of rebleeding have mostly been related to the controversial question of the timing of surgery. The current performance in many centers, with over 90% of all ruptured aneurysms seen being occluded within 24 hours from the haemorrhage, gives the impression that we have reached the ultimate protection against rebleeding, with little left to improve in that field. However, the term rebleeding, as we are used to defming it, apparently only represents a part of a wider spectrum of recurrent aneurysm ruptures. Index haemorrhages preceeded by warning leaks and intraoperative ruptures occurring after index haemonhages also share the features of devastating impact on clinical condition and on outcome, and from a practical point of view it may be meaningful to consider all these recurrent ruptures as a common entity - the second bleed.In the studies presented in this thesis, the second bleed has shown to have a profound impact on management outcome in aneurysmal SAH. It accounts for morbidity and mortality in at least 12% of all patients receiving treatment, which is roughly one-third of all patients with poor management outcome. Evidently, prevention of most recurrent bleeds are within the reach of current management protocols. Modifications of strategies in use are presented, that include new guidelines for the pre-neurosurgical care to ensure detection of warning leaks and to provide protection against ultra-early rebleeds, that cannot be reached by early aneurysm occlusion. In the neurosurgical phase, modifications of the surgical protocol allowing for a routine application of intraoperative neuroprotection and liberal use of temporary clipping are advocated.By refocusing the second bleed, identification of it's various forms and modification of treatment protocols for ruptured aneurysms aimed at reducing these recurrent bleeds, many losses can be turned into good outcome, at a cost that is much lower than the cost of pursuing the final solution of vasospasm.