Letter to the Editor. Aneurysm rebleeding after subarachnoid hemorrhage

Lesheng Wang MM and Jincao Chen MD, PhD
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  • Zhongnan Hospital of Wuhan University, Wuhan, China
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TO THE EDITOR: We read with great interest the retrospective cohort study by Horie et al.1 (Horie N, Sato S, Kaminogo M, et al. Impact of perioperative aneurysm rebleeding after subarachnoid hemorrhage [published online September 13, 2019]. J Neurosurg. doi:10.3171/2019.6.JNS19704). The authors found that aneurysm rebleeding after subarachnoid hemorrhage (SAH) has specific characteristics in the preoperative, intraoperative, and postoperative periods, involving aneurysm size, heart disease, aneurysm location, family history, clipping, coiling, etc. According to Horie and colleagues, their study is the first to assess the characteristics and predictors of aneurysmal SAH rebleeding in the preoperative, intraoperative, and postoperative periods. We would like to express our respect for their achievements and to share some comments with the authors.

Firstly, and most importantly, the data were collected from 1 university hospital and 10 affiliated hospitals. The authors did not consider the role of these medical institutions in their analysis. Depending on the different medical levels of doctors in these hospitals, different degrees of surgical instruments and equipment, and different management methods after operation, these factors could affect the probability of aneurysm rupture during and after surgery. Therefore, it is difficult to control bias in data collected from 11 hospitals.

Secondly, their article does not provide inclusion criteria for the study subjects but simply describes exclusion criteria. It only rules out subjects younger than 18 years of age and nonaneurysmal SAH including dissection. However, patients with intracranial hemorrhage and on the verge of death, patients with vital organ diseases, and older patients (> 75 years of age) should also be excluded because the rate of postoperative mortality and disability is probably high in these patients, and it is difficult for surgical intervention to improve the survival rate.

Thirdly, the evaluation of aneurysm rebleeding after operation was defined as new SAH on postoperative CT scans. We think there are some flaws in this definition because postoperative hemorrhage on CT can have false-negative results and will affect the clinical outcome of different aneurysm surgeries (clipping vs endovascular coiling) in terms of postoperative rebleeding.

In addition, as for the diagnosis of postoperative rebleeding, the authors define it as new SAH on postoperative CT scans during the period from the operation to 28 days thereafter. To our knowledge, postoperative rebleeding always occurs from the operation to 7 days thereafter, so we suggest correcting the timescale for postoperative rebleeding.

Finally, the authors concluded that multiple aneurysms are protective factors for preoperative rebleeding. However, in a recent article by Suzuki et al.,2 multiple aneurysms are considered as a risk factor for unruptured aneurysms, so there is somewhat of a controversy.

Disclosures

The authors report no conflict of interest.

References

  • 1

    Horie N, Sato S, Kaminogo M, et al. Impact of perioperative aneurysm rebleeding after subarachnoid hemorrhage [published online September 13, 2019]. J Neurosurg. doi:10.3171/2019.6.JNS19704

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  • 2

    Suzuki T, Takao H, Rapaka S, et al. Rupture risk of small unruptured intracranial aneurysms in Japanese adults. Stroke. 2020;51(2):641643.

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  • Nagasaki University School of Medicine, Nagasaki, Japan

Response

We thank Drs. Wang and Chen for their comments. It is difficult to completely exclude technical or surgical equipment bias in all clinical studies, including ours. In this study, the surgical or endovascular procedure was performed by an experienced, certified physician. Regarding inclusion criteria, we believe it is very important to provide real-world data to assess rebleeding and clinical outcome in the aging population. In this study, most postoperative rebleeding occurred a couple of days after treatment. In terms of the association between multiple aneurysms and rebleeding, it is difficult to explain why the presence of multiple aneurysms negatively affected preoperative rebleeding, a finding contrary to our expectations. Suzuki et al. reported that the presence of multiple aneurysms was a risk factor for the rupture of small intracranial aneurysms, and it is not possible to simply discuss the factor of multiple aneurysms because aneurysm size and aneurysm status (initial rupture or rebleeding) are different.

Illustration from Nelson et al. (pp 1516–1526). Artists: Ethan Tyler, Erina He, and Alan Hoofring. Medical Arts, Office of Research Services, National Institutes of Health.

Contributor Notes

Correspondence Jincao Chen: chenjincao@hotmail.com.

INCLUDE WHEN CITING Published online April 3, 2020; DOI: 10.3171/2019.12.JNS193444.

Disclosures The authors report no conflict of interest.

  • 1

    Horie N, Sato S, Kaminogo M, et al. Impact of perioperative aneurysm rebleeding after subarachnoid hemorrhage [published online September 13, 2019]. J Neurosurg. doi:10.3171/2019.6.JNS19704

    • Search Google Scholar
    • Export Citation
  • 2

    Suzuki T, Takao H, Rapaka S, et al. Rupture risk of small unruptured intracranial aneurysms in Japanese adults. Stroke. 2020;51(2):641643.

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