Late recurrence of subarachnoid hemorrhage and intracranial aneurysms
- Robert J Singer, MD
Robert J Singer, MD
- Associate Professor of Neurosurgery
- Neurovascular Therapeutics
- Geisel School of Medicine at Dartmouth
- Christopher S Ogilvy, MD
Christopher S Ogilvy, MD
- Professor of Surgery
- Harvard Medical School
- Guy Rordorf, MD
Guy Rordorf, MD
- Associate Professor of Neurology
- Harvard Medical School
Aneurysmal subarachnoid hemorrhage (SAH) is often a devastating event. However, therapeutic advances have added to the armamentarium for treating this malignant process. As case-fatality rates decline, attention is increasingly turned to the management of long-term complications. One of these is the enduring risk of recurrent SAH, which can occur despite successful endovascular or surgical treatment of the ruptured aneurysm.
This topic discusses the risk of recurrent aneurysm formation and subarachnoid hemorrhage after a patient has been treated for an initial subarachnoid hemorrhage. Other topics address acute aspects of aneurysmal subarachnoid hemorrhage, as well as the management of patients with unruptured intracranial aneurysms, and aneurysm screening in other high risk populations. (See "Clinical manifestations and diagnosis of aneurysmal subarachnoid hemorrhage" and "Treatment of aneurysmal subarachnoid hemorrhage" and "Unruptured intracranial aneurysms" and "Screening for intracranial aneurysm".)
Cumulative 8 to 10 year incidences of late rebleeding (more than one year after initial SAH) vary from 0.1 to 3.2 percent [1-5]. The risk of SAH recurrence has been estimated to be 15 to 22 times higher than the expected rate of a first SAH in a healthy age, sex matched cohort [2,4].
Independent risk factors for recurrent SAH in one study were current smoking, younger age, and multiple aneurysms at the time of the initial SAH . Hypertension was an additional important risk factor for aneurysm regrowth or de novo aneurysm formation in another retrospective study . Cigarette smoking and hypertension are also established risk factors for both unruptured intracranial aneurysms and aneurysmal subarachnoid hemorrhage. (See "Clinical manifestations and diagnosis of aneurysmal subarachnoid hemorrhage" and "Unruptured intracranial aneurysms".)
Recurrent SAH may result from recurrence of the treated aneurysm, rupture of another pre-existing aneurysm in a patient with multiple aneurysms, and de novo aneurysm formation.To continue reading this article, you must log in with your personal, hospital, or group practice subscription. For more information on subscription options, click below on the option that best describes you:
- Molyneux AJ, Kerr RS, Birks J, et al. Risk of recurrent subarachnoid haemorrhage, death, or dependence and standardised mortality ratios after clipping or coiling of an intracranial aneurysm in the International Subarachnoid Aneurysm Trial (ISAT): long-term follow-up. Lancet Neurol 2009; 8:427.
- Wermer MJ, Greebe P, Algra A, Rinkel GJ. Incidence of recurrent subarachnoid hemorrhage after clipping for ruptured intracranial aneurysms. Stroke 2005; 36:2394.
- CARAT Investigators. Rates of delayed rebleeding from intracranial aneurysms are low after surgical and endovascular treatment. Stroke 2006; 37:1437.
- Rinkel GJ, Algra A. Long-term outcomes of patients with aneurysmal subarachnoid haemorrhage. Lancet Neurol 2011; 10:349.
- Tsutsumi K, Ueki K, Usui M, et al. Risk of recurrent subarachnoid hemorrhage after complete obliteration of cerebral aneurysms. Stroke 1998; 29:2511.
- Wermer MJ, van der Schaaf IC, Velthuis BK, et al. Follow-up screening after subarachnoid haemorrhage: frequency and determinants of new aneurysms and enlargement of existing aneurysms. Brain 2005; 128:2421.
- Johnston SC, Dowd CF, Higashida RT, et al. Predictors of rehemorrhage after treatment of ruptured intracranial aneurysms: the Cerebral Aneurysm Rerupture After Treatment (CARAT) study. Stroke 2008; 39:120.
- Campi A, Ramzi N, Molyneux AJ, et al. Retreatment of ruptured cerebral aneurysms in patients randomized by coiling or clipping in the International Subarachnoid Aneurysm Trial (ISAT). Stroke 2007; 38:1538.
- Raymond J, Guilbert F, Weill A, et al. Long-term angiographic recurrences after selective endovascular treatment of aneurysms with detachable coils. Stroke 2003; 34:1398.
- Ferns SP, Sprengers ME, van Rooij WJ, et al. Coiling of intracranial aneurysms: a systematic review on initial occlusion and reopening and retreatment rates. Stroke 2009; 40:e523.
- Murayama Y, Nien YL, Duckwiler G, et al. Guglielmi detachable coil embolization of cerebral aneurysms: 11 years' experience. J Neurosurg 2003; 98:959.
- Naggara ON, White PM, Guilbert F, et al. Endovascular treatment of intracranial unruptured aneurysms: systematic review and meta-analysis of the literature on safety and efficacy. Radiology 2010; 256:887.
- Bederson JB, Connolly ES Jr, Batjer HH, et al. Guidelines for the management of aneurysmal subarachnoid hemorrhage: a statement for healthcare professionals from a special writing group of the Stroke Council, American Heart Association. Stroke 2009; 40:994.
- Choi DS, Kim MC, Lee SK, et al. Clinical and angiographic long-term follow-up of completely coiled intracranial aneurysms using endovascular technique. J Neurosurg 2010; 112:575.
- Ferns SP, Sprengers ME, van Rooij WJ, et al. Late reopening of adequately coiled intracranial aneurysms: frequency and risk factors in 400 patients with 440 aneurysms. Stroke 2011; 42:1331.
- Hasan DM, Nadareyshvili AI, Hoppe AL, et al. Cerebral aneurysm sac growth as the etiology of recurrence after successful coil embolization. Stroke 2012; 43:866.
- White PM, Lewis SC, Gholkar A, et al. Hydrogel-coated coils versus bare platinum coils for the endovascular treatment of intracranial aneurysms (HELPS): a randomised controlled trial. Lancet 2011; 377:1655.
- Schaafsma JD, Sprengers ME, van Rooij WJ, et al. Long-term recurrent subarachnoid hemorrhage after adequate coiling versus clipping of ruptured intracranial aneurysms. Stroke 2009; 40:1758.
- Sprengers ME, Schaafsma J, van Rooij WJ, et al. Stability of intracranial aneurysms adequately occluded 6 months after coiling: a 3T MR angiography multicenter long-term follow-up study. AJNR Am J Neuroradiol 2008; 29:1768.
- David CA, Vishteh AG, Spetzler RF, et al. Late angiographic follow-up review of surgically treated aneurysms. J Neurosurg 1999; 91:396.
- Tsutsumi K, Ueki K, Morita A, et al. Risk of aneurysm recurrence in patients with clipped cerebral aneurysms: results of long-term follow-up angiography. Stroke 2001; 32:1191.
- Wermer MJ, Koffijberg H, van der Schaaf IC, ASTRA Study Group. Effectiveness and costs of screening for aneurysms every 5 years after subarachnoid hemorrhage. Neurology 2008; 70:2053.
- van der Schaaf IC, Velthuis BK, Wermer MJ, et al. New detected aneurysms on follow-up screening in patients with previously clipped intracranial aneurysms: comparison with DSA or CTA at the time of SAH. Stroke 2005; 36:1753.
- Ferns SP, Sprengers ME, van Rooij WJ, et al. De novo aneurysm formation and growth of untreated aneurysms: a 5-year MRA follow-up in a large cohort of patients with coiled aneurysms and review of the literature. Stroke 2011; 42:313.
- Sprengers ME, van Rooij WJ, Sluzewski M, et al. MR angiography follow-up 5 years after coiling: frequency of new aneurysms and enlargement of untreated aneurysms. AJNR Am J Neuroradiol 2009; 30:303.
- Kemp WJ 3rd, Fulkerson DH, Payner TD, et al. Risk of hemorrhage from de novo cerebral aneurysms. J Neurosurg 2013; 118:58.
- Juvela S, Poussa K, Porras M. Factors affecting formation and growth of intracranial aneurysms: a long-term follow-up study. Stroke 2001; 32:485.
- Wermer MJ, Buskens E, van der Schaaf IC, et al. Yield of screening for new aneurysms after treatment for subarachnoid hemorrhage. Neurology 2004; 62:369.
- Lavoie P, Gariépy JL, Milot G, et al. Residual flow after cerebral aneurysm coil occlusion: diagnostic accuracy of MR angiography. Stroke 2012; 43:740.
- Schaafsma JD, Velthuis BK, van den Berg R, et al. Coil-treated aneurysms: decision making regarding additional treatment based on findings of MR angiography and intraarterial DSA. Radiology 2012; 265:858.
- Steiger HJ, van Loon JJ. Virtues and drawbacks of titanium alloy aneurysm clips. Acta Neurochir Suppl 1999; 72:81.
- Masaryk AM, Frayne R, Unal O, et al. Utility of CT angiography and MR angiography for the follow-up of experimental aneurysms treated with stents or Guglielmi detachable coils. AJNR Am J Neuroradiol 2000; 21:1523.
- Schaafsma JD, Koffijberg H, Buskens E, et al. Cost-effectiveness of magnetic resonance angiography versus intra-arterial digital subtraction angiography to follow-up patients with coiled intracranial aneurysms. Stroke 2010; 41:1736.
- Farb RI, Nag S, Scott JN, et al. Surveillance of intracranial aneurysms treated with detachable coils: a comparison of MRA techniques. Neuroradiology 2005; 47:507.
- Cottier JP, Bleuzen-Couthon A, Gallas S, et al. Follow-up of intracranial aneurysms treated with detachable coils: comparison of plain radiographs, 3D time-of-flight MRA and digital subtraction angiography. Neuroradiology 2003; 45:818.
- Li YD, Li MH, Gao BL, et al. Endovascular treatment of recurrent intracranial aneurysms with re-coiling or covered stents. J Neurol Neurosurg Psychiatry 2010; 81:74.
- Thornton J, Dovey Z, Alazzaz A, et al. Surgery following endovascular coiling of intracranial aneurysms. Surg Neurol 2000; 54:352.
- Mericle RA, Wakhloo AK, Lopes DK, et al. Delayed aneurysm regrowth and recanalization after Guglielmi detachable coil treatment. Case report. J Neurosurg 1998; 89:142.