Abdolkarim Rahmanian - Department of Neurosurgery, School of Medicine, Shiraz University of Medical Sciences, Shiraz, Iran
Nima Derakhshan - Department of Neurosurgery, School of Medicine, Shiraz University of Medical Sciences, Shiraz, Iran
Ehsan Ali Alibai - Department of Neurosurgery, School of Medicine, Shiraz University of Medical Sciences, Shiraz, Iran

Background and Aim: In-hospital rebleeding and early aneurysm rupture are major causes of mortality and morbidity in aneurysmal subarachnoid hemorrhage. Rebleeding may occur at the referring hospital, during transfer or at the referral neurovascular center prior to surgical or endovascular treatment. However, there has been no report regarding the rate of in-hospital rebleeding and early aneurysm rupture at the referral centers. This study aims to clarify the incidence, significance, management, and outcome of individuals who suffer in-hospital aneurysmal rebleeding and early aneurysm rupture at the referral hospital due to anterior circulation cerebral aneurysm to the time when its neck is visualized for clipping. Methods and Materials/Patients: Among 617 patients with anterior circulation cerebral aneurysms who underwent operation between September 2010 and September 2017 at Neurovascular Unit of Namazi Hospital (main referral neurovascular center in southern Iran), 22 suffered rebleeding since the time of neuroradiologic diagnosis of aneurysm to intraoperative visualization of aneurysm for neck dissection. A surgical technique for fast access and securing the aneurysm is described in this article, too. The patients’ demographics were collected via hospital records in a retrospective fashion. Six-month functional outcome was obtained via OPD records as well as phone calls. Utilizing Independent t test, 1-way ANOVA, Kruskal-Wallis and Mann-Whitney tests in SPSS22, the effect of each study variable was evaluated during 6 months follow-up period.  Results: Rebleeding occurred at different venues from CT angiography to frontal lobe retraction. Anterior communicating artery was the most common aneurysm to suffer in-hospital rebleeding and male gender was found as a risk factor. These patients have significantly higher bleeding amount and longer operative time (P<0.001), but still have a 68.2% chance of surviving with good functional recovery. Earlier in-hospital rebleedings are used to have worse outcomes (P=0.036 for GOS and 0.028 for mRS, respectively).  Conclusion: Patients with in-hospital rebleeding and early aneurysm rupture at the referral hospitals will have a considerable chance for favorable outcome if they undergo aggressive surgical management emergently.

Cerebral aneurysm, Ruptured aneurysm, Tertiary referral hospital, Outcome, Incidence