There On the contrary several in other studies,

There have been various attempts to isolate the
predictors of anresymal rebleed and natural history . Early intervention and
guided management based on recognition of these risk factors  should improve patient outcome.

Demographic: Although
there is disagreement is present in literature regarding the effect of age and
sex on the risk of rebleed in aneurysmal SAH. Steiger’s 4  and the cooperatve study 1,2,3  reported old age and female
prepodrance .  Similarly in this study there was a female
preponderance noted while the mean age of bleed was 52 years.Majority of the
patients were in the above 50 age group.

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 Time of
rebleed: Rebleeds tend to be within the 1to 2 weeks of haemorrhage as mentioned
in various studies .Our study showed similar findings with the median period to
rebleed being 7 days(1-80 days ). On the contrary several in other studies,
rebleed happened within the first 24 hours while there are with reports of
ultra early rebleeds within 6 hours.This pattern on inhospital rebleeds at 2
weeks was also observed by Solanki et al


In hospital rebleed in our previously published study
was 2.14 percent while currently it is 1.1 percent. This is not reflected in
any parameters regarding decrease in bleed to admission time or admission to
intervention time even though the metrics have improved.Other indian studies
also report similar findings with rates of 4.4 % again attributable to delay in
referral to tertiary centre. The referral pattern continued to be same in both
the 1999- 2007 group and the current study  group with non significant diference in bleed
to admission times.This was also reflected in the control group where no
difference was noted.

Activity before rebleed: The mean admission to rebleed
time was 1 day.Seven patients had rebleed within 6 hours of admission.This was
echoed in findings by park et al where admission to rebleed times were 1.3 to
2.3 hours on average.

The transport of such patients from distant centres or
transport to ICU may play an important role in such situations. This patter was observed  by Hijdra and coworkers, 8 who
showed a 2% rebleed rate on the first day and attributable to additional stress
with transportation to a specialized center, movement of the patient for
imaging studies along with ventriculostomies.Two patients in this group had
ictus during shifting for imaging while 2 had rupture while undergoing DSA .


Risk factors for rebleed:As compared to our previous
study relation between hypertension and a high MAP did not corelate with
rebleed.Others authors have shown relation of the same and lowering of MAP may
lead to reduced incidence of stroke.Loss of consciousness  was associated with rebleeds in almost all
cases although was statistically significant univariate predictor.Other authors
have also isolated LOC as a risk factor associated with rebleed with average
times of 28 minutes of LOC.


Hypertension:Juvelea et al reported the association of
high SBP while Solanki et al reported high Diastolic blood pressure as
independent risk factors .This was not observed in this study and no difference
was found between the two groups.


Aneurysm morphology: Size  is directly related with the risk of
rebleeding. Pleizier et al. 10 reported
that larger aneurysms have a risk of rebleeding, mostly within the first 3 days
of primary haemorrhage.Our study showed larger
aneurysm as a positive risk factor in the rebleed subgroup.In a study by Guo et
al aneurysms larger than 10mm were associated with higher risk,similar to our
study where mean size was 10mm.The study did not show any relation with

               In contrast to other studies
where irregularity of vessel wall and multiplicity was associated with risk of
rebleed.Location as a risk is to be studied as many contrasting reports mention
either anterior or posterior locations as risk for
rebleed6This  series shows a preference for anterior
circulation aneurysms, particularly anterior communicating artery aneurysms but
was not statistically significant. .

Ventriculostomy was also not associated with any higher risk in our
study as with other studies.While Pare et al reported loss of pressure gradient
leading to rupture.

Contrary to studies by Steiger et al where clinical
grade at presentation was associated with rebleed Our study  did not show any relation between the control
and rebleed group in terms of Fisher grade and WFNS scores this was similar to
a study by Park et al where 84 perecent of patients were good WFNS grade.This
is contrast to other studies where rebleed is associated with bad wfns
grade.While Park et al had early admissions on an average while our study had a
delayed admission . Solanki et al reported Fisher grade to be an independent
risk factor for rebleed.There was significant change in both the clinical WFNS
scale status and fisher grade after rupture signifying a grave outcome in most

                  The ideal protocol remains yet to
be ascertained once rebleed had occurred.Both the conservative and surgically
managed groups had bad outcomes which was similar to the 1999 to 2007 study. Mangement
can be done on a case by case basis keeping in mind the poor outcome.





Aneurysmal Rebleed is a potentially fatal complication of aneurysmal SAH.Persistant
delayed referral patterns resulted in  continued
low incidence in this study .Loss of consciousness and larger aneurysm were the
only two variables  consistent with rebleed
. The rationale for aggressive management practices following a rebleed is
doubtful. Prevention can be sought out for by streamlining  transport practices ,early interventions and recognition
of high risk factors along with early referral to high volume centres.