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Original research
Rebleeding following aneurysmal subarachnoid hemorrhage before ‘endovascular first’ treatment: a retrospective case-control study of published scoring systems
  1. Arosha S Dissanayake1,
  2. Emalee Burrows1,
  3. Kwok M Ho2,
  4. Timothy J Phillips3,
  5. Stephen Honeybul1,
  6. Graeme J Hankey4
  1. 1 Department of Neurosurgery, Sir Charles Gairdner Hospital, Nedlands, Perth, Western Australia, Australia
  2. 2 Department of Intensive Care Medicine, Royal Perth Hospital, Perth, Western Australia, Australia
  3. 3 Neurological Intervention and Imaging Service of Western Australia, Sir Charles Gairdner Hospital, Nedlands, Western Australia, Australia
  4. 4 School of Medicine, The University of Western Australia, Perth, Western Australia, Australia
  1. Correspondence to Dr Arosha S Dissanayake, Neurosurgery, Sir Charles Gairdner Hospital, Perth, Western Australia 6009, Australia; arosha.d{at}


Background Pre-treatment re-bleeding following aneurysmal subarachnoid hemorrhage (aSAH) affects up to 7.2% of patients even with ultra-early treatment within 24 hours. We retrospectively compared the utility of three published re-bleed prediction models and individual predictors between cases who re-bled matched to controls using size and parent vessel location from a cohort of patients treated in an ultra-early, ‘endovascular first’ manner.

Methods On retrospective analysis of our 9-year cohort of 707 patients suffering 710 episodes of aSAH, there were 53 episodes of pre-treatment re-bleeding (7.5%). Forty-seven cases who had a single culprit aneurysm were matched to 141 controls. Demographic, clinical and radiological data were extracted and predictive scores calculated. Univariate, multivariate, area under the receiver operator characteristic curve (AUROCC) and Kaplan–Meier (KM) survival curve analyses were performed.

Results The majority of patients (84%) were treated using endovascular techniques at a median 14.5 hours post-diagnosis. On AUROCC analysis the score of Liu et al. had minimal utility (C-statistic 0.553, 95% confidence interval (CI) 0.463 to 0.643) while the risk score of Oppong et al. (C-statistic 0.645 95% CI 0.558 to 0.732) and the ARISE-extended score of van Lieshout et al. (C-statistic 0.53 95% CI 0.562 to 0.744) had moderate utility. On multivariate modeling, the World Federation of Neurosurgical Societies (WFNS) grade was the most parsimonious predictor of re-bleeding (C-statistic 0.740, 95% CI 0.664 to 0.816).

Conclusions For aSAH patients treated in an ultra-early timeframe matched on size and parent vessel location, WFNS grade was superior to three published models for re-bleed prediction. Future re-bleed prediction models should incorporate the WFNS grade.

  • Aneurysm
  • Hemorrhage
  • Statistics
  • Subarachnoid

Data availability statement

Data are available upon reasonable request.

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Data availability statement

Data are available upon reasonable request.

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  • Contributors ASD was responsible for study conceptualization, design, result interpretation, manuscript writing

    and is the overall guarantor of the manuscript contents. EB was responsible for data collection. KMH was responsible for statistical analysis and interpretation. TJP was responsible for data provisioning. SH and GH were responsible for clinical and scientific oversight.

  • Funding The authors have not declared a specific grant for this research from any funding agency in the public, commercial or not-for-profit sectors.

  • Competing interests None declared.

  • Provenance and peer review Not commissioned; externally peer reviewed.