Sentinel Headaches: Do they Predict Rebleeding after Subarachnoid Hemorrhage?
Sentinel Headaches: Do they Predict Rebleeding after Subarachnoid Hemorrhage?
Abstract & Commentary
By Dara G. Jamieson MD, Associate Professor, Clinical Neurology, Weill Medical College, Cornell University. Dr. Jamieson is a consultant for Boehringer Ingelheim and Merck, and is on the speaker's bureau for Boehringer Ingelheim, Merck, Ortho-McNeil, and Pfizer.
Synopsis: Patients with sentinel headaches occurring in the 4-week period prior to a subarachnoid hemorrhage have a 10-fold increase in early rebleeding. These patients may benefit from ultra-early treatment including aneurysm obliteration.
Source: Beck J, et al. Headache and the risk of rebleeding after aneurysmal subarachnoid hemorrhage. Stroke. 2006;37:2733-2737.
This study investigated whether patients with a sentinel headache (SH) prior to SAH had a higher rate of rebleeding than patients who did not report such a headache. A severe sudden headache occurring in the days to weeks prior to SAH has been reported with frequency varying from 15% to 60%. The clinical significance and mechanism of the SH are unclear. Headache is an almost universal experience, with a large proportion of the population suffering from frequent severe headaches. The report of a headache occurring before a SAH headache could be coincidental or reflect recall bias. On the other hand, a headache prior to the SAH could be due to changes in aneurysmal size or to minor bleeding from the aneurysm.
Information was gathered from 237 consecutive patients with lumbar puncture or computed tomography proven SAH over a 3-year period from 1999 to 2002. The patients underwent aneurysm obliteration by open or endovascular surgery in a 24-48 hour period after the ictus, unless the patient was unstable or moribund. The usual treatment for SAH was instituted, with hypertension-hypervolemia-hemodilution therapy reserved for symptomatic vasospasm. A SH was defined as a sudden, severe, never previously experienced headache, of unknown character and intensity, lasting at least an hour, and occurring in the 4 weeks prior to the index SAH. The information about the SH was acquired from the family, the patient, or the primary care physician within the 3 days after SAH. Rebleeding was CT-proven, occurring prior to aneurysm obliteration.
Hunt-Hess scores on admission were 4 and 5 in 40.5% of patients, and 1 in 10.5% of patients. Of the 237 patients, 23 (9.7%) rebled prior to aneurysm obliteration. A SH was noted in 41 (17.3%) patients. The presence of a SH, increased aneurysm size, and increased number of aneurysms were significantly associated with rebleeding. Trends were seen for an association between less rebleeding in the anterior circulation and more rebleeding with more severe Hunt-Hess scores. The odds of eventually experiencing a rebleeding episode for a patient with a SH, compared with a patient without a SH, was 13.6 (95% CI, 5.2 to 35.1; p < 0.0001) in the univariate model; the relative risk was 9.0 (95% CI, 4.1 to 19.7). After controlling for age, aneurysm size, Hunt-Hess grade, number of aneurysms, and time of risk (time from SAH to aneurysm obliteration), the odds ratio was 10.3 (95% CI, 2.6 to 40.8; p < 0.0001) for rebleeding with a history of a SH. In the 212 patients with 6-month outcome data, rebleeding significantly increased the odds of death and reduced the odds of survival with good or functional outcome.
Commentary
Rebleeding is an important cause of mortality and morbidity after aneurysmal subarachnoid hemorrhage (SAH). Rates vary in the range of 2 to 20 % depending on the definition of rebleeding, the timing of aneurysmal treatment, and the patient population. Ultra-early treatment, including aneurysm obliteration, could be offered to those patients with SAH who appear to be at especially high risk of rebleeding, with the goal of improving outcome after SAH.
Patients in this study, whose aneurysms were obliterated within 48 hours after SAH, still had an almost 10% rebleeding rate. The presence of risk factors for rebleeding such as increased aneurysm size (11.2 ± 9.2 as compared to 6.9 mm ± 4.7 for non-rebleeders), multiple aneurysms, and a SH, can alert those caring for the patient with SAH, that ultra-early intervention may decrease the time of risk of rebleeding. A history of a SH may be used to identify the subgroup of patients who could benefit from ultra-early treatment.
Patients with sentinel headaches occurring in the 4-week period prior to a subarachnoid hemorrhage have a 10-fold increase in early rebleeding. These patients may benefit from ultra-early treatment including aneurysm obliteration.Subscribe Now for Access
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