Cerebral aneurysm

Objectives: The 'warning leak', a smaller bleeding event from an aneurysm, which sometimes occurs before an acute massive subarachnoidal hemorrhage (SAH), was first described in 1967. The present study was performed to compare the complications and prognosis for 214 patients with and without a warning leak; aneurysm clipping had been performed in all.

Methods: The interval between the warning headache and the actual SAH was calculated. The following complications were examined: preoperative hemorrhage, intra-operative rupture of the aneurysm, postoperative re-bleeding, symptomatic vasospasm, shunt-requiring hydrocephalus, ventriculitis, postoperative wound infection, and outcome according to the Glasgow Outcome Scale (GOS).

Results: Sixty-seven (31%) out of the 214 patients had a warning leak with a median distance of 11 days before suffering from major SAH. Preoperative angiographie vasospasms occurred more frequently in the group with a warning bleeding (22.4 versus 6.1%; p

Discussion: To give patients the chance to start their treatment in a better clinical condition it is important to recognize the early warning signs. [Neurol Res 2005; 27: 620-624]

Keywords: Cerebral aneurysm; complications; outcome; subarachnoidal hemorrhage; warning leak

INTRODUCTION

Spontaneous subarachnoidal hemorrhage (SAH) is, with an incidence of ~5-10 cases/100,000 per year, a frequent disease1-8. SAH is with 22-25% a major constituent of cerebrovascular mortality9. The most frequent cause of SAH is a ruptured aneurysm of the intracranial brain-supplying arteries. The percentage of ruptured aneurysms as the cause of SAH varies in the literature between 72 and 95%10.

Despite modern microsurgical techniques and intensive care medicine, there still is high morbidity and mortality resulting from SAH. In several investigations a total mortality of 25% is described in SAH patients and a significant morbidity in 50% of the surviving patients11. It is generally accepted that the outcome correlates with the preoperative clinical status12,13. To improve the outcome, it is therefore important to diagnose endangered patients early and perform the operation while they are in a good clinical state. The aneurysmal SAH in most cases presents with a sudden event of severe headache, accompanied by meningism, photophobia, nausea and/or vomiting, and frequently by loss of consciousness14. Classically, the patients describe a sudden headache of an intensity that they had never experienced before.

Already in 1967, Gillingham15 described the phenomenon of the 'warning leak', a smaller bleeding event from an aneurysm, which sometimes occurs prior to an acute massive SAH. The warning leak is frequently recognizable as a headache14,16-18. As the symptomatology is not as impressive as with actual SAH, the symptoms are misinterpreted more frequently19. The aim of this investigation was to answer the following question: do patients with a "warning leak" differ in complications and outcome after SAH compared with patients without such a warning leak?

PATIENTS AND METHODS

Patients

In the period from 1 January 1986 to 30 May 1997 the senior author (J.R.) performed aneurysm clipping in a total of 273 patients. Of these, 252 patients had suffered from SAH. In 214 patients we were able to explore retrospectively whether or not a warning leak had existed. The authors established a database on the patients with SAH. For each patient the following data were analysed: age, sex, and clinical status according to the Hunt and Hess grading scale20. The pattern of hemorrhage on computed tomography (CT) was described according to Fisher et al.21. The localization of the ruptured aneurysm was identified by a transfemoral selective four-vessel cerebral angiography. The patients themselves or their relatives were questioned about a warning headache event. The quality of pain of the warning headache had to be different from the headache these patients were familiar with. In general, the warning leak was characterized as a sudden headache, rather less intensive than in the major bleeding, but also of sudden and short time quality. The interval between the warning headache and the actual SAH was calculated. We defined the actual SAH as the headache event that led to the diagnosis and hospitalization.

The following complications were checked: preoperative hemorrhage, intra-operative rupture of the aneurysm, symptomatic vasospasm (defined as impaired vigilance and/or a new neurological deficit such as a hemiparesis or aphasia), hydrocephalus requiring the implantation of a shunt, ventriculitis, postoperative wound infection, and re-bleeding. The outcome was examined according to the Glasgow Outcome Scale (GOS)22 at the time of dismissal and in the follow-up.

Statistical analysis

Contingency analysis was performed by comparing the categorical variables using the Pearson's chisquared test or the Fisher's exact test. Differences with a p

RESULTS

In 214 out of a total of 273 patients, the patients themselves or their relatives were able to precisely describe a warning headache event. In 21 out of 273 patients, elective aneurysm surgery was performed. In 38 patients, no information about a warning leak was available; H&H grade at permission and outcome was similar to the remaining 214 patients. Subsequently, 214 patients were analysed. Sixty-seven (31.3%) out of the 214 patients in whom aneurysm clipping had been performed had had a warning bleeding before the acute SAH. The median interval between the warning leak and the acute SAH amounted to 11 days (Figure 7). Table 1 gives a comparative overview of the patients with and without a warning leak. Twenty-three (34%) of the 67 patients with a warning leak had visited a physician before the acute SAH happened. The following diagnoses without recognition of the aneurysm were stated: seven times cervicocephalgias, seven times cranial nerve disturbances of unclear genesis, twice each an ischemic event, a cerebral convulsion, and a drop attack. Once a trauma was assumed as causal. In one case the warning leak was misinterpreted as cervicocephalgia in combination with a drop attack, and in another case as cervicocephalgia in combination with a cerebral convulsion. The mean interval between acute SAH and aneurysm clipping was 2 days in the group with a warning bleeding. Of these, 43 patients were treated early, i.e. between days 0 and 3, and 24 patients were treated later. In the group without a warning bleeding the mean distance between SAH and clipping of the ruptured aneurysm amounted to 1 day. 113 patients were treated early and 34 patients were treated later.

Fifteen out of the 67 patients with a warning bleeding showed an early preoperative angiographic vasospasm. Of these patients, five had a local vasospasm and five showed an ipsilateral vasospasm over a long distance of the vessels on the side of the ruptured aneurysm. Also, five patients had multiple vasospasms. The mean time between the SAH, which led to hospitalization and the angiography amounted to 1 day. In contrast, only nine of the 147 patients without a warning bleeding had an early angiographie vasospasm. Five patients had a regional vasospasm, four over a long distance of the ipsilateral vessel, and no patient had multiple vasospasms. The mean time between the SAH and submission to hospital was O days. In summary, patients with a warning bleeding showed a statistically significant higher frequency of early preoperative angiographic vasospasms than patients without a warning leak.

Preoperative re-bleeding and intra-operative rupture was statistically significantly more frequent in the warning leak group (see also Table 2).

Hypodensities suspect of ischemic lesions in CT were preoperatively seen in three patients of the group with a warning bleeding. Two of these patients showed the hypodensity in the area supplied by the ruptured aneurysm, the third showed multiple vasospasms in the angiography. Postoperatively, 11 patients with warning bleeding showed hypodensities in the CT scan, nine of them in the area supplied by the vessel with the ruptured aneurysm. Five of these patients had a manifest vasospasm already in the preoperative angiography (two times multiply, two times regionally, one time long distance). In the group without a warning bleeding, seven patients showed hypodensities in the preoperative CT scan, in two cases the hypodensities were located in the territory of the supplying vessel where the ruptured aneurysm was located. Three of the seven patients had angiographically proven vasospasms.

Postoperatively, 31 patients without warning bleeding showed hypodensities in the CCT. Fifteen of these were outside the territory supplied by the vessel of the ruptured aneurysm, the other 16 were within the territory supplied by the vessel of the ruptured aneurysm. In the preoperative angiography only two of these patients had an angiographically proven vasospasm.

Table 2 summarizes the complications. Two patients without a warning bleeding had a re-bleeding after aneurysm clipping. The outcome after a mean time of 22 months according to the GOS is shown in Figure 2. There was no significant difference between the two groups with and without warning bleeding.

DISCUSSION

The proportion of patients with a warning bleeding previous to SAH varies widely in the literature. Depending upon the examiner it varies between 15 and 58.8%17,18,23,25-28. This great variability may be explained mainly by the anamnestical evaluation of warning bleedings. In our investigation the proportion of patients with warning bleeding was 31.3%, while the true rate might be higher, because warning bleedings in patients with a disturbance of consciousness could not be verified if these patients had not told their relatives about a sudden headache experience. Our data are within the range of proportions reported in the literature. In contrast to previous investigations, objective differences during the acute treatment interval, e.g. incidence of preoperative vasospasm, confirming the difference between the two groups, are demonstrated. The outcome after a mean follow-up time of 22 months did not show any differences between the two groups.

EFFECT ON PREOPERATIVE VASOSPASM AND INTRA-OPERATIVE COMPLICATIONS

Preoperative angiographie vasospasms were more common in the group with a warning bleeding (22.4 versus 6.1%). This might be caused by inducing reactions after a warning bleeding similar to those after SAH. The number of hypodensities in the preoperative CT did not differ between the two groups (see also Table 2).

Intra-operative aneurysm rupture was more frequent in the group of patients with a warning bleeding than in the group without a warning bleeding (28.4 versus 15%). This might be due to a perianeurysmal scar formation by the earlier event, with the local reactions resulting in a higher vulnerability. An example for the intra-operative findings after a warning leak is shown in Figure 3.

EFFECT ON POSTOPERATIVE COMPLICATIONS AND THE OUTCOME

The patients without a warning bleeding did not have postoperative symptomatic vasospasms (15%) more often than the patients with a warning bleeding (14.9%), although in CT scan hypodensities in patients with no warning leak were more frequent (21.1 versus 16.4%). More of the patients with no warning leak developed a shunt-requiring hydrocephalus malresorptivus (18.4 versus 10.5%) corresponding to the varying grades of SAH (see also Table 1). In the postoperative courses no statistically significant differences could be seen.

The outcome of both groups after a follow-up time of nearly 2 years did not vary (Figure 2). This may be explained by the fact that both groups had a similar clinical condition when arriving at the hospital (see Table 1, H&H grade at admission). While patients with a warning leak more frequently had preoperative angiographie vasospasms and intra-operative aneurysm ruptures, CT scans showed more postoperative hypodensities in patients with no warning leak.

Thirty out of the 67 patients with warning bleeding were graded H&H III-V at the time of admission to the hospital. This is 14% of the total number of 214 SAH patients. Comparing the total mortality of the H&H I and Il patients (3.6%) with the total mortality of the H&H UI-V patients (22.1%), the better outcome of the patients with a good initial clinical grading is shown. The difference in prognosis is more clearly shown when the favorable outcome (GOS GR or MD) is separated from the unfavorable (GOS SD, PVS, and D). Here the patients graded H&H I and II in 92% achieved a favorable long time outcome already when dismissed from hospital, whereas only 54% of the H&H III-V patients could achieve this status. Therefore, theoretically 30 more patients (14%) could have been treated under better prognostic conditions if a warning leak had been correctly diagnosed early before major SAH occurred.

CONCLUSION

The warning leak and non-warning leak group differ in early perioperative course. In summary, the warning leak group showed a higher percentage of preoperative angiographically proven vasospasm. In the end, the outcome of both groups did not differ after a period of almost 2 years.

It is important to recognize the warning signs early and to use the nowadays well available diagnostic possibilities such as CT or MR angiography with the aim to perform surgery before the patients suffer from the major bleeding. If this is accomplished, a considerable proportion of aneurysm patients will have the chance to undergo surgery in a better clinical status.

ACKNOWLEDGEMENTS

The authors thank Prof. Dr K. Dietz, Department of Medical Biometry, Eberhard-Karls University Tuebingen, for his assistance with the statistical analysis.

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Rainer Ritz* and Johannes Reif[dagger]

* Department of Neurosurgery, Eberhard-Karls University Tuebingen, 72076 Tuebingen, Germany

[dagger] Department of Neurosurgery, University of Saarland, 66421 Homburg/Saar, Germany

Correspondence and reprint requests to: Rainer Ritz, Department of Neurosurgery, University Hospital Tuebingen, Hoppe-Seyler-Strasse 3, 72076 Tuebingen, Germany. [rainer.ritz@med.uni-tuebingen.de] Accepted for publication September 2004.

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