Rebleeding from ruptured intracranial aneurysms in North Eastern Province of Japan. A cooperative study.

OBJECT: Rebleeding from ruptured intracranial aneurysms is a major cause of death and disability. With regard to the factors that precipitate the rebleeding and influence the time course after initial bleeding, previous reports differ in their results, and the number of patients investigated was not sufficient for valid conclusions. This study was thus designed to clarify the factors related to rebleeding from ruptured intracranial aneurysms in a large group of patients of the North Eastern Province of Japan. METHODS: We found 181 patients with rebleeding after hospitalization among 5612 cases of ruptured intracranial aneurysms from January 1997 to December 2001 in 33 major hospitals in the North Eastern Province of Japan. We analyzed the data with respect to the time course after bleeding and rebleeding, the arterial blood pressure, the situation when rebleeding occurred, the methods of neuroimaging, the level of consciousness, the treatment and the outcome. RESULTS: Of 181 patients who were hospitalized, rebleeding occurred in 65 (35.9%) within 3 h and 88 (48.6%) within 6 h after the initial subarachnoid hemorrhage (SAH). The consciousness level before the rebleeding varied widely in distribution, but belonged to the drowsiness or less [Japan coma scale (JCS) single-digit] in 83 patients (45.8%), but after rebleeding, JCS triple-digits (semicoma to coma) included 152 patients (84.0%). Systolic arterial blood pressure prior to rebleeding was most commonly between 120 and 140 mmHg. Rebleeding did occur more frequently during angiography (totally 29 patients, 20%) and much less frequently during 3D-CTA and MRA procedures (a single case). Treatment consisted of aneurysm neck clipping in 72 patients (40.0%), endovascular therapy with coils in 4 patients (2.2%) and conservative ones in 103 patients (56.9%). As to outcome, 109 patients with rebleeding (60.2%) died in 3 months following initial SAH. CONCLUSION: Rebleeding occurs more frequently in the earlier period after the initial SAH than previously believed. Thus, more aggressive pharmacologically induced systemic arterial hypotension appears to be important for preventing rebleeding but ultimate outcome of more aggressive hypotension is yet to be determined. If feasible, in order to avoid catheter-angiography related rebleeding, evaluations solely with 3D-CTA and MRA should be in consideration and earlier surgical intervention seems essential as rebleeding does occur often within the first 3 h of onset.

[Postpartum cerebral angiopathy--a case report the vasculopathy associated with co-administration of two vasoconstrictives, methylergometrine maleate and sumatriptan].

A 25-year-old woman (gravida 1, para 0) who had no history indicating the toxemia of pregnancy developed hypertension and severe throbbing headache after the delivery of her first child by the cesarean section. Generalized tonic-clonic seizure ensued 5 days after the delivery, after which she did not fully regain her consciousness. Her head T2-weighted and FLAIR MRIs showed areas of multiple high intensities in the basal ganglia and cerebral white matter. Her cerebral MRA revealed the segmental stenosis and irregular wall of the major vessels, in particular of the right MCA trunk. Three weeks later, these abnormalities in the neuroimages disappeared and she was free of any symptoms. The history disclosed that obstetricians had used methylergometrine maleate for uterine contraction after delivery and then sumatriptan for her throbbing headache. We speculate that these vasoconstrictive agents might have induced the postpartum cerebral angiopathy. Postpartum cerebral angiopathy may be distinct from reversible posterior leukoencephalopathy in that the abnormalities are not restricted to the posterior lobes and that the vascular changes are apparent on neuroimagings. However, this entity might have a common underlying physiology, which is the abnormally elevated blood pressure that occurs in the setting of early postpartum period. Caution should be exercised when vasoconstrictives are to be used in postpartum period.