Rehemorrhage

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At one time, re-hemorrhage was considered a major cause of morbidity and mortality in patients who had survived the initial hemorrhage; however, a shift to early surgical management has minimized the importance of this complication. If unprotected, 15-20% of patients will re-bleed in the first 2 weeks [21], carrying with it significant mortality and mor bidity. In most studies, there is an initial peak of re-hemorrhage in the first 48 hours of approximately 4%, which rapidly plateaus to 1-2% per day until 40 days post-hemorrhage [21]. After 6 months, there is a long-term risk of further hemorrhage of 3% per year. Approximately half to three-quarters of individuals suffering a re-bleed will die as a direct result and, in the Cooperative Study, re-bleeding was responsible for 25% of all deaths [9,14]. The risk of re-bleed is increased with poor clinical grade, posterior circulation lesions, hypertension, elderly patients and abnormal hemostatic parameters.

Control of blood pressure in order to minimize the risk of re-hemorrhage is a controversial topic. No controlled trial has ever shown that lowering of blood pressure reduces the risk of re-bleeding, although the Cooperative Study revealed that re-bleeds occurred in 16% of patients who had a systolic blood pressure of 170-240 mmHg but only 9% of those with a systolic of 94-169 mmHg. Most clinicians would suggest that extremes of blood pressure should be avoided, high blood pressure being more likely to cause a re-bleed and low blood pressure exacerbating hypoxic or ischemic cerebral damage from vasospasm.

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