Intracranial pressure changes following aneurysm rupture. Part 3: Recurrent hemorrhage.

Continuous monitoring of intraventricular pressure (IVP) was performed before and during 13 recurrent hemorrhages occurring in 10 patients between the 3rd and 14th day after the initial rupture of an intracranial saccular aneurysm. Before re-rupture, nine patients were of Hunt and Hess' clinical Grade III of IV. Severe angiographic vasospasm was demonstrated in six patients. In the period between ruptures, IVP and mean arterial blood pressure were significantly increased compared to pressures in patients who did not rebleed. Ventricular drainage of cerebrospinal fluid (CSF) to a level of 25 mm Hg did not increase the rate of rebleeding (17% of patients). On the other hand, the use of drainage while the repeat rupture was taking place seemed to exert a deleterious effect on the natural mechanisms that lead to arrest of hemorrhage. In five patients with CSF drainage during their rebleed, the steady-state IVP level after the repeat rupture was significantly increased, and four patients died from large intracerebral hemorrhages. These results suggest that drainage of CSF should be avoided during recurrent hemorrhage, and should not be resumed until a steady-state IVP level has been reached.