Analysis of risk factors associated with massive hemorrhage and rebleeding in small intracranial aneurysms
Objective Analyze the risk factors associated with severe subarachnoid hemorrhage(SAH)and rebleeding in small intracranial aneurysms.Methods From July 2014 to January 2020,patients with SAH caused by small ruptured intracranial aneurysms admitted to the Neurosurgery Department of the First Affiliated Hospital,Chongqing Medical University were retrospectively and continuously included.Small intracranial aneurysms refer to intracranial aneurysms with a maximum diameter of less than 5 mm.Baseline data and clinical data of patients were collected,including age,gender,past history(hypertension,diabetes,coronary heart disease),smoking history,drinking history,admission Glasgow coma scale(GCS)score and Hunt-Hess grade.Patient imaging data were collected to clarify the characteristics of aneurysms,including the number of aneurysms(single or multiple),the shape of SAH responsible aneurysms(irregular aneurysms with subcapsular,polycystic,or lobulated aneurysms),and their location(anterior communicating artery,posterior communicating artery,middle cerebral artery,anterior cerebral artery,internal carotid artery,and posterior circulation).Based on the CT images of the head at admission,the distribution of SAH in patients was determined.The modified Fisher grading system was used to classify SAH into 1-4 levels,and the Hijdra score was used to assess the bleeding volume of SAH in patients.The treatment methods of patients(interventional embolization,clipping)were collected.All patients were grouped according to the modified Fisher classification,with grades 1-2 being the minor SAH group and grades 3-4 being the massive SAH group.Baseline data and clinical data and aneurysm characteristics were compared between minor SAH group and massive SAH group.Multiple Logistic regression analysis was conducted using the modified Fisher grades 3-4 as the dependent variable,and factors with P＜0.1 in baseline data that may affect SAH bleeding volume as independent variables,the risk factors associated with the massive SAH in small ruptured intracranial aneurysms were analyzed.New bleeding visible on preoperative CT of the patient,with or without neurological deterioration,is defined as rebleeding.All patients are divided into rebleeding group and non-rebleeding group based on the occurrence of rebleeding.Baseline data and aneurysm characteristics between patients with rebleeding and those without rebleeding were compared.Multivariate Logistic regression analysis was conducted with rebleeding as the dependent variable,and factors with P＜0.1 in baseline data and aneurysm characteristics were used as independent variables,the risk factors associated with rebleeding in small aneurysms were analyzed.Results A total of 363 SAH patients with small ruptured aneurysms were included in this study,including 103 males and 260 females;age range from 25 to 85 years old,with an average age of(55±11)years.According to the modified Fisher classification,there were 198 cases in the massive SAH group and 165 cases in the minor SAH group.Compared with patients in the minor SAH group,patients in the massive SAH group were older(P=0.011),with a higher proportion of males,concomitant hypertension,and smoking history(all P＜0.05).The proportion of admitted Hunt Hess grade Ⅳ to V was higher(26.3％vs.2.4％,P＜0.01),the GCS score was lower([13.1±1.8]points vs.[13.9±0.8]points,P＜0.01),and the Hijdra score was higher([19.7±5.4]points vs.[8.4±2.6]points,P＜0.01).There was no statistically significant difference in the number of aneurysms and the location and morphology of responsible aneurysms between the massive and minor SAH groups(all P＞0.05).According to whether patients experienced rebleeding before surgery,there were 30 cases in the rebleeding group and 333 cases in the non-rebleeding group.Compared with the non-rebleeding group,patients in the rebleeding group had a higher proportion of concomitant hypertension(83.3％vs.49.2％,P＜0.01)and a higher proportion of admitted Hunt Hess grades Ⅳ-V(43.3％vs.12.9％,P＜0.01),lower GCS scores(12[9,14]points vs.14[13,14]points,P＜0.01),and higher Hijdra scores(18[9,26]points vs.14[9,18]points,P=0.024).There was no statistically significant difference in the number of aneurysms,responsible aneurysm morphology,and location between the rebleeding group and the non-rebleeding group(all P＞0.05).There was no statistically significant difference between the coiling and clipping in the two group(both P＞0.05).Multiple Logistic regression analysis was conducted using modified Fisher grading 3-4 and rebleeding as dependent variables respectively.The results showed that age(OR,1.027,95％CI 1.006-1.049,P=0.012)and hypertension(OR,1.858,95％CI 1.196-2.886,P=0.006)were independent risk factors associated with massive SAH in small ruptured aneurysms.Hypertension(OR,3.775,95％CI 1.371-10.391,P=0.010)and lower GCS score(OR,0.677,95％CI 0.561-0.816,P＜0.01)were independent risk factors associated with rebleeding in small ruptured aneurysms.Conclusions Older age and concomitant hypertension are risk factors associated with massive SAH in patients with small ruptured aneurysms.Coexisting hypertension and lower GCS score are risk factors associated with rebleeding in patients with small ruptured aneurysms.
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