Secondary hemorrhagic complications in aneurysmal subarachnoid hemorrhage: when the impact hits hard

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  • 1 Department of Neurosurgery, University Hospital, University of Duisburg–Essen; and
  • 2 Institute for Diagnostic and Interventional Radiology, University Hospital, University of Duisburg–Essen, Germany
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Clinical data on secondary hemorrhagic complications (SHCs) in patients with aneurysmal subarachnoid hemorrhage (SAH) are sparse and mostly limited to ventriculostomy-associated SHCs. This study aimed to elucidate the incidence, risk factors, and impact on outcome of SHCs in a large cohort of SAH patients.


All consecutive patients with ruptured aneurysms treated between January 2003 and June 2016 were eligible for this study. Patients’ charts were reviewed for clinical data, and imaging studies were reviewed for radiographic data. SHCs were divided into those associated with ventriculostomy and those not associated with ventriculostomy, as well as into major and minor bleeding forms, depending on clinical impact.


Sixty-two (6.6%) of the 939 patients included in the final analysis developed SHCs. Ventriculostomy-associated bleedings (n = 16) were independently predicted by mono- or dual-antiplatelet therapy after aneurysm treatment (p = 0.028, adjusted odds ratio [aOR] = 10.28; and p = 0.026, aOR = 14.25, respectively) but showed no impact on functional outcome after SAH. Periinterventional use of thrombolytic agents for early effective anticoagulation was the only independent predictor (p = 0.010, aOR = 4.27) of major SHCs (n = 38, 61.3%) in endovascularly treated patients. In turn, a major SHC was independently associated with poor outcome at the 6-month follow-up (modified Rankin Scale score > 3). Blood thinning drug therapy prior to SAH was not associated with SHC risk.


SHCs present a rare sequela of SAH. Antiplatelet therapy during (but not before) SAH increases the risk of ventriculostomy-associated bleedings, but without further impact on the course and outcome of SAH. The use of thrombolytic agents for early effective anticoagulation carries relevant risk for major SHCs and poor outcome.

ABBREVIATIONS aOR = adjusted odds ratio; DAPT = double-antiplatelet therapy; DCI = delayed cerebral ischemia; DSA = digital subtraction angiography; EVD = external ventricular drain; ICH = intracerebral hemorrhage; IVH = intraventricular hemorrhage; MAPT = mono-antiplatelet therapy; mRS = modified Rankin Scale; SAH = subarachnoid hemorrhage; SHC = secondary hemorrhagic complication; TCD = transcranial Doppler; WFNS = World Federation of Neurosurgical Societies.

Supplementary Materials

    • Supplemental Tables E1–E3 (PDF 462 KB)

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Contributor Notes

Correspondence Marvin Darkwah Oppong: University Hospital Essen, Germany.

INCLUDE WHEN CITING Published online January 25, 2019; DOI: 10.3171/2018.9.JNS182105.

Disclosures The authors report no conflict of interest concerning the materials or methods used in this study or the findings specified in this paper.


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