J Neurol
DOI 10.1007/s00415-014-7365-0
ORIGINAL COMMUNICATION
Time intervals from subarachnoid hemorrhage to rebleed
M. R. Germans • B. A. Coert • W. P. Vandertop •
D. Verbaan
Received: 5 March 2014 / Revised: 25 April 2014 / Accepted: 26 April 2014
Ó Springer-Verlag Berlin Heidelberg 2014
Abstract The most threatening early complication and
predictor of poor outcome after an aneurysmal subarach-
noid hemorrhage (aSAH) is a rebleed. To evaluate what
proportion of rebleeds might be prevented by early treat-
ment, we assessed the time interval from the initial hem-
orrhage to rebleed, and the location of the patient at the
time of rebleed. Patient characteristics, World Federation
of Neurological Surgeons grade on admission and modified
Rankin Scale outcome scores, referring hospitals and time
intervals from initial hemorrhage to treatment of 293
patients treated between 2008 and 2011 were evaluated.
Time intervals to rebleeds and location of the patients at
the time of rebleed were retrieved. Rebleeds were con-
firmed by CT in 12 % of patients, and an additional 4 % of
patients was diagnosed as having a possible rebleed. Sixty
percent of rebleeds occurred after admission to the treat-
ment center. Almost all rebleeds occurred within 24 h, with
a median time interval between initial hemorrhage and
rebleed of 180 min. A significantly shorter time to treat-
ment and a higher mortality were seen in the group of
patients with a rebleed. Approximately, one in six patients
with an aSAH had a rebleed, of which a majority might
have been preventable because they occurred after admis-
sion to the treatment center. A reduction in the rebleed rate
seems feasible by securing the aneurysm as soon as
possible by improving in-hospital logistics for early aneu-
rysm treatment. Alternative options, such as immediate
M. R. Germans (&)
B. A. Coert
W. P. Vandertop

D. Verbaan
Department of Neurosurgery, H2-241, Neurosurgical Center
Amsterdam, Academic Medical Center (AMC), Meibergdreef 9,
1105 AZ Amsterdam, The Netherlands
e-mail: mrgermans@hotmail.com
administration of antifibrinolytics, are being explored in a
multicenter trial.
Keywords Subarachnoid hemorrhage
Cerebrovascular
disorders
Rebleed
Intracranial aneurysm
Time to
treatment
Introduction
Recurrent bleeding after aneurysmal subarachnoid hemor-
rhage (aSAH) is an early and devastating complication and
a major cause of poor outcome [3, 18]. The reported
incidence of rebleeds is 4–22 % and its risk is highest
within the first hours after the initial hemorrhage [4, 6, 8, 9,
20, 26].
The only proven treatments to reduce the risk for re-
bleeds are obliteration of the aneurysm [11, 16] and
administration of antifibrinolytics [1]. Since antifibrinolytic
treatment does not improve outcome due to a concurrent
increase in delayed cerebral ischemia (DCI) [1], the focus
lies on decreasing the time interval between the initial SAH
and aneurysm treatment. Therefore, recent international
guidelines advise aneurysm treatment as early as feasible to
prevent rebleeds; if possible, it should be aimed to inter-
vene at least within 72 h after onset of first symptoms [5,
21]. Although changes in treatment policies altogether have
resulted in improved functional outcome over the years
[11, 16, 25, 26], the percentage of patients with a poor
outcome is still higher than desirable. An important con-
tributing factor is an ultra-early rebleed [6, 8, 9], occurring
within the first hours after the initial hemorrhage, which
apparently cannot be prevented by the current policy of
aneurysm treatment [11, 16, 26]. To evaluate which pro-
portion of rebleeds could be prevented by reducing the time
123

interval to aneurysm treatment towards only several hours
after the initial hemorrhage, more insight into the time
intervals between initial hemorrhage and rebleed is nec-
essary. Literature about time intervals between initial
hemorrhage and rebleed is sparse, and does not specifically
elucidate the location of the patient at the time of rebleed
[4, 6, 16, 20, 26].
The aim of this study was to assess as accurately as
possible the time interval between initial hemorrhage and
rebleed and the location of the patient at the time of
rebleed.
Methods
Patient population
The patients for this study were selected from our SAH
database, and include 300 patients admitted between
November 2008 and July 2011 with an aSAH to the neu-
rosurgical department of the Academic Medical Center,
Amsterdam (AMC), a tertiary referral center for SAH
patients in a region of approximately 1.3 million people.
Our policy is to transfer all patients whose SAH is diag-
nosed in one of the referring centers to our center, inde-
pendent of their clinical condition. Five patients were
excluded because of atypical presentation, leading to a
patient delay of more than 1 week. One patient was
excluded because the clinical features were so unclear that
it took more than a week to diagnose the SAH. A seventh
patient was excluded as extensive neurological and radio-
logical evaluation had led to a diagnosis of posterior
reversible encephalopathy syndrome. In 278 patients, the
SAH was confirmed by a computed tomography (CT) scan
and in 15 patients by lumbar puncture (LP) and the pre-
sence of an aneurysm was diagnosed by CT angiography
and/or digital subtraction angiography.
Data collection
The medical records, radiological investigations, ambu-
lance data and referral letters of the patients with a rebleed
were reviewed retrospectively after approval of the Medi-
cal Ethics Committee of the AMC. Lacking data of refer-
ring hospitals were retrieved. We recorded patient
demographics, referring hospital, World Federation of
Neurological Surgeons (WFNS) grade [22] on admission,
date and time-points (time of the initial hemorrhage, pri-
mary presentation, diagnosis, treatment and rebleed on a
24-h scale) and location of the patient during the rebleed.
When no time-point could be retrieved, it was recorded as
‘irretrievable’ and not used for the analysis of the time
interval.
123
J Neurol
Clinical outcome was assessed by two independent
reviewers after reviewing the medical records, the outpa-
tient clinic records at follow-up, and the letter from the
rehabilitation center, if present. All patients were scored
according to the modified Rankin Scale score (mRS) [17].
Any inconsistencies between outcome assessments were
cleared after discussion with the first author. In case of
insufficient information for a reliable mRS assessment, the
patient was excluded from the outcome analysis. We
decided to use only dichotomized mRS scores to make the
retrospective outcome assessment as reliable as possible.
A rebleed was defined as a sudden spontaneous neuro-
logical deterioration with the presence of more subarach-
noid blood, intraventricular or intracerebral hemorrhage on
a plain CT scan compared to a previous investigation (i.e.
confirmed rebleed), or a sudden spontaneous neurological
deterioration with loss of consciousness, hypertension and
bradycardia, stated as being suggestive of a rebleed (i.e.
possible rebleed). The instances of possible rebleeds were
selected by the first author (MRG) and reviewed by a
second author (BAC); both experienced in treating SAH
patients. In a consensus meeting, taking into account the
reports of the clinical team in charge at the time of the
suspected rebleed, and also the follow-up of patients, both
authors decided whether the deterioration was based on a
possible rebleed or more likely on other causes, such as
electrolyte disturbances, a seizure or hydrocephalus. Re-
bleeds during endovascular or surgical treatment (n = 6)
were not selected for analysis because they were not con-
sidered as a spontaneous rebleed.
Clinical management
All patients were treated according to our standardized
protocol which closely follows international guidelines [5,
21] with an adequate blood pressure to optimize cerebral
perfusion but avoidance of severe hypertension (i.e. mean
arterial blood pressure above 135 mmHg) to reduce the
risk of rebleed. Patients with a suspected rebleed were
taken to the CT scan as soon as they were clinically stable
for transport. All ruptured aneurysms were treated as early
as feasible (preferably within 24 h), and a rebleed was an
indication for emergency treatment as it illustrates insta-
bility of the bloodclot [6, 12]. The choice of treatment
modality (clipping, coiling or none) was made in consensus
between neurologist, neurosurgeon and interventional
neuroradiologist.
Statistical analysis
Time intervals were computed by calculating the difference
between the retrieved time-points of the variables. When
one of the time-points was missing, the patient was
J Neurol

excluded from calculation of that specific time interval. Table 1 Patient characteristics
The WFNS grades and mRS scores were dichotomized into Patient With Without Total p value
groups with a good (WFNS grade 1–3) or poor grade characteristics rebleed rebleed patients
(WFNS grade 4–5), and a favorable (mRS 0–3) or poor (n = 48) (n = 245) n = (293)
outcome (mRS 4–6), respectively. Normally distributed
Age, years; 55 ± 11 56 ± 13 56 ± 13 0.53a
variables were expressed as means with standard deviations mean ± SD
(SD) and tested with the Student’s T test (two-group Female 28 (58) 159 (65) 179 (61) 0.41b
comparison), and unequally distributed variables as medi- CT confirmation of rebleed
ans with interquartile ranges (IQR 25–75 %) and tested Yes 36 (75) n/a 36 (12) –
with the Mann–Whitney U test (two-group comparison) or No 12 (25) 12 (4)
Kruskal–Wallis (multiple group comparison). The Chi- WFNS at first presentation
square test was used to assess differences in proportions. A
1–3 28 (58) 158 (64) 185 (63)
p value \0.05 was considered significant. All analyses
4–5 20 (42) 87 (36) 108 (37) 0.42b
were performed using PASW version 20.0.
Site of first presentation
Referring 36 (75) 199 (81) 235 (80)
hospital
Results Treatment 12 (25) 46 (19) 58 (20) 0.32b
center
Patient characteristics Type of treatment
Clip 1 (2) 32 (13) 33 (11)
CT-confirmed rebleeds were seen in 36 patients, resulting in Coil 39 (81) 187 (76) 226 (77)
a CT-confirmed rebleed rate of 12 % (95 % CI 9–16 %). A None 8 (10) 26 (11) 34 (12) 0.06b
possible rebleed was diagnosed in 12 additional patients, Outcome c

resulting in an overall rebleed rate of 16 % (95 % CI Favorable 25 (53) 163 (67) 188 (65) 0.06b
12–21 %) (Table 1). Four patients suffered more than one (mRS 0–3)
rebleed and all rebleeds occurred before aneurysm treatment. Death 17 (36) 49 (20) 66 (23) 0.02b
(mRS 6)
Comparison of patients with and without rebleeds Data are shown as n (%) or mean ± SD
n/a not applicable, mRS modified Rankin Scale score
There were no significant differences in age (p = 0.53), a
Student’s T test
WFNS grade (p = 0.42) or hospital of primary presenta- b
Chi-square test
tion (referring hospital or treatment center; p = 0.32) c
n = 290 patients (see text)
between patients with or without rebleeds (Table 1). These
differences remained non-significant when the analyses
were done exclusively on patients with confirmed rebleeds.
Each time interval was calculated using a different number
of patients, due to the inability to retrieve some time-
points, which resulted in different proportions of patients Table 2 Time intervals between patients with and without rebleeds
used for each time interval. The proportions of patients Type of interval With rebleed Without p valuea
used varied between 85 and 95 %. All calculated time rebleed
intervals were significantly shorter in patients with a re- Initial hemorrhage to 60 (50–145) 143 (71–753) \0.01
bleed, compared to patients without a rebleed (p B 0.01 for presentationb
all time intervals; Table 2). Presentationb to diagnosis 20 (7–33) 29 (12–64) 0.01
Three patients were lost to follow-up; therefore, clinical Initial hemorrhage to 106 (66–145) 192 \0.01
outcome was evaluated at a median time interval (IQR) of diagnosis (102–728)
4 (0–7) months in 47 patients with a rebleed, and in 243 Diagnosis to start of 481 1,136 \0.01
patients without a rebleed, respectively. The mortality treatment (140–995) (714–1,527)
percentage was significantly higher in patients with a re- Initial hemorrhage to 626 1,202 \0.01
treatment (242–1,115) (636–1,781)
bleed compared to patients without a rebleed (36 vs. 20 %,
p = 0.02). Poor outcome was also more frequent in Data are shown as median (interquartile range) in minutes
a
patients with a rebleed (47 vs. 33 %, p = 0.06), but this Mann–Whitney U test
b
difference was not significant. Presentation at first hospital

123
 J Neurol

Table 3 Location of patients during rebleed
Location Number
(n = 48)
At site of initial bleeding 3 (6)
Transport to primary hospital 3 (6)
At referring hospital 9 (19)
Transport between referring hospital and treatment 4 (8)
center
In treatment center 29 (60)
Data are shown as n (%). Sum of percentages is not 100, due to
rounding off
Patients with a rebleed: location and time intervals
to the rebleed
Thirteen percent of all rebleeds occurred before primary
presentation at a hospital and 27 % during the stay at the
referring hospital or transportation to the treatment center.
The remaining 60 % of rebleeds occurred after admission
to the treatment center (Table 3).
In 29 patients (60 % of patients with a rebleed), we were
able to retrieve the time-points of initial hemorrhage and
rebleed. The median (IQR) time interval between initial
hemorrhage and rebleed was 180 min (95–531); 83 % of
the rebleeds occurred within the first 12 h after the initial
hemorrhage, and 97 % of the rebleeds occurred within the
first 24 h (Fig. 1). The time intervals in relation to location
of the patient during the rebleed are outlined in Fig. 2 and
show a significant longer interval to rebleed in patients
admitted to the treatment center (p \ 0.05). No significant
association was found between time interval to rebleed and
WFNS grade (p = 0.77), outcome (p = 0.21) or type of
hospital of primary presentation (p = 0.23).
Discussion
This study illustrates the time interval between initial
hemorrhage and rebleed in patients with aSAH, and the
location of the patient at the time of the rebleed to examine
what proportion of rebleeds could possibly be prevented by
reducing the time interval to treatment towards only several
hours after the initial hemorrhage. The rebleed rate in our
cohort was 16 % with a median time interval to rebleed of
180 min. Sixty percent of patients suffer their rebleed after
admission to the treatment center. According to these data,
the current approach of aneurysm treatment as early as
feasible, if possible within 72 h after initial hemorrhage,
might not be fast enough to reduce a large number of re-
bleeds [21]. Even with our protocol, which strives for
treatment within the first 24 h resulting in a median time
interval to treatment of approximately 18 h, a large number
of rebleeds was still not prevented.
Our overall rebleed rate is high (16 %), even if we only
include our CT-confirmed rebleeds (12 %). In older stud-
ies, the rebleed rate was reported to be approximately 4 %
[20], but our rate is more comparable to recent studies,

Fig. 1 Rebleeds in the first

24 h after initial hemorrhage in
29 patients. Reference line at
720 min (12 h)

123
J Neurol
Fig. 2 Time intervals from
initial hemorrhage to rebleed
per location in 29 patients.
Boxes represent IQR. Thick
lines represent median time.
*Kruskal–Wallis test comparing
‘‘in treatment center’’ and other
locations
which report an incidence of close to 12 % [20], with some
studies even reporting rates up to 22 % [4, 6, 8, 9, 20, 26].
Our high rate of rebleeds is probably a result of early
presentation of patients after their initial aSAH because our
region is densely populated with short distances to hospi-
tals and ambulances which are present within 15 min.
Therefore, patients with early rebleeds who might have
died without receiving medical assistance in case of a more
delayed presentation, may have been included. Addition-
ally, we transferred all patients whose SAH was diagnosed
in one of the referring centers to our center, independent of
their clinical condition. In this way, we also included the
poor-grade patients who potentially suffered a rebleed. Our
rate of rebleeds may be underestimated because patients
with fatal early rebleeds may not have been diagnosed with
SAH, because they arrived dead at the hospital or were first
treated for cardiac instability and died afterwards without a
brain CT scan [19, 21].
A remarkably high proportion of rebleeds (60 %)
occurred in patients who were already admitted to the
treatment center. Their time interval to rebleed is signifi-
cantly longer, owing to the waiting time in the treatment
center before the aneurysm is secured. This implies that an
important reduction in the rebleed rate might be achieved
by a more expeditious securement of the aneurysm. The
significantly shorter intervals to treatment in patients with a
rebleed confirm that it is possible to secure the aneurysm
within the first hours after hemorrhage, probably as a result
of emergency management [6, 12]. If this sense of urgency
is applied to all aSAH patients, i.e. also in the patients who
do clinically well and have not yet suffered a rebleed, some
rebleeds might be prevented. This urgent treatment, which
has proven its benefit in the treatment of ischemic stroke by
applying the ‘time-is-brain’ concept [10, 13, 14], would
necessitate an optimization of in-hospital logistics, and
could thus improve outcome [11, 16, 25, 26].
Nevertheless, 40 % of patients still have their rebleed
before admission to the treatment center. Although patient
transfers could be optimized by further education of gen-
eral practitioners and ambulance employees to increase the
awareness for SAH [2], or by the presence of a mobile CT
unit in the ambulance, which has shown to significantly
shorten the time to diagnosis and treatment in ischemic
stroke [24], these measures have appeared difficult to
achieve. Therefore, other options must be examined to
prevent out-of-hospital rebleeds within the first hours after
the initial hemorrhage. One option could be the adminis-
tration of an antifibrinolytic agent. Although this has been
shown to reduce the rebleed rate, standard administration
after aSAH is not recommended because it also increases
DCI [1]. Recently, our group, therefore, has started a
multicenter randomized controlled trial to evaluate the
123

clinical outcome after ultra-early and short-term adminis-
tration of antifibrinolytics [7].
Both a worse outcome and higher mortality have been
reported in patients with a rebleed [3, 8, 15, 18], whereas in
our population only mortality was significantly higher. Our
results may have been influenced by the retrospective
analysis of outcome assessment or smaller proportion of
patients with poor outcome compared to other studies with
rebleed rates of 4–22 % and, therefore, have to be inter-
preted with care [4, 6, 8, 9, 20, 26]. This lack of a signif-
icantly worse outcome is possibly a result from our early
aneurysm treatment management and aggressive treatment
of poor-grade aSAH patients [23].
This study has some limitations. First, a quarter of re-
bleeds was not confirmed with consecutive CT scans,
which could have overestimated the overall rebleed rate
and may have influenced the time interval calculations.
However, by assessing all the data at time of the rebleed as
well as the clinical follow-up by two neurosurgeons with
experience in treating SAH patients, we think that the
selected patients very likely had a rebleed. In addition, no
differences in baseline characteristics were seen between
analyses including all rebleeds and exclusively the con-
firmed rebleeds. To our opinion, the inclusion of possible
rebleeds reflects the daily clinical practice where treatment
decisions are made on the presence of possible rebleeds as
well. Second, the time-points were retrieved retrospec-
tively, and this could have led to a less reliable estimation
of the exact (re)hemorrhage time and time intervals. Third,
the amount of patients with a rebleed is relatively small and
important differences in time intervals and outcome
assessment could, therefore, have not been discovered.
Finally, the mRS scores have to be interpreted with care,
because they were based on outpatient clinical records and
rehabilitation letters at different time intervals after the
hemorrhage owing to the retrospective study design.
However, the median mRS evaluation time of 4 months
after hemorrhage is comparable with the outcome assess-
ment at 3 months, which is often used in aSAH studies.
In summary, we found a rebleed rate of 16 % at a
median time interval of 180 min and almost all rebleeds
occurred within 24 h. A rebleed was associated with
increased mortality, with a tendency towards poor out-
come. In 60 %, the rebleed occurred after admission to the
treatment center, so in-hospital logistics for early aneurysm
treatment need to be improved. Faster transportation to the
treatment center with immediate aneurysm treatment or
alternative treatment options such as ultra-early and short-
time antifibrinolytic therapy could prevent a consistent part
of the rebleeds, and this is being further investigated.
Acknowledgments We thank Jantien Hoogmoed and Stéphanie van
Straaten for their help in the collection of data. This research received
123
J Neurol
no specific Grant from any funding agency in the public, commercial
or not-for-profit sectors.
Conflicts of interest On behalf of all authors, the corresponding
author states that there is no conflict of interest.
Ethical standard The author hereby declares that the research
documented in the manuscript has been carried out in accordance with
the ethical standards laid down in the 1964 Declaration of Helsinki.
References
1. Baharoglu MI, Germans MR, Rinkel GJ, Algra A, Vermeulen M,
van Gijn GJ, Roos YB (2013) Antifibrinolytic therapy for aneu-
rysmal subarachnoid haemorrhage. Cochrane Database Syst Rev
8:CD001245
2. Bouckaert M, Lemmens R, Thijs V (2009) Reducing prehospital
delay in acute stroke. Nat Rev Neurol 5:477–483
3. Broderick JP, Brott TG, Duldner JE, Tomsick T, Leach A (1994)
Initial and recurrent bleeding are the major causes of death fol-
lowing subarachnoid hemorrhage. Stroke 25:1342–1347
4. Cha KC, Kim JH, Kang HI, Moon BG, Lee SJ, Kim JS (2010)
Aneurysmal rebleeding : factors associated with clinical outcome
in the rebleeding patients. J Korean Neurosurg Soc 47:119–123
5. Connolly ES Jr, Rabinstein AA, Carhuapoma JR, Derdeyn CP,
Dion J, Higashida RT, Hoh BL et al (2012) Guidelines for the
management of aneurysmal subarachnoid hemorrhage: a guide-
line for healthcare professionals from the American Heart
Association/American Stroke Association. Stroke 43:1711–1737
6. Fujii Y, Takeuchi S, Sasaki O, Minakawa T, Koike T, Tanaka R
(1996) Ultra-early rebleeding in spontaneous subarachnoid
hemorrhage. J Neurosurg 84:35–42
7. Germans MR, Post R, Coert BA, Rinkel GJ, Vandertop WP,
Verbaan D (2013) Ultra-early tranexamic acid after subarachnoid
hemorrhage (ULTRA): study protocol for a randomized con-
trolled trial. Trials 14:143
8. Guo LM, Zhou HY, Xu JW, Wang Y, Qiu YM, Jiang JY (2011)
Risk factors related to aneurysmal rebleeding. World Neurosurg
76:292–298
9. Hillman J, Fridriksson S, Nilsson O, Yu Z, Saveland H, Ja-
kobsson KE (2002) Immediate administration of tranexamic acid
and reduced incidence of early rebleeding after aneurysmal
subarachnoid hemorrhage: a prospective randomized study.
J Neurosurg 97:771–778
10. Kwan J, Hand P, Sandercock P (2004) Improving the efficiency
of delivery of thrombolysis for acute stroke: a systematic review.
QJM 97:273–279
11. Laidlaw JD, Siu KH (2002) Ultra-early surgery for aneurysmal
subarachnoid hemorrhage: outcomes for a consecutive series of
391 patients not selected by grade or age. J Neurosurg
97:250–258
12. Larsen CC, Sorensen B, Nielsen JD, Astrup J (2012) Reduced
clot-stability during the first 6 hours after aneurysmal subarach-
noid haemorrhage––a prospective case–control study. Thromb
Res 129:e229–e232
13. Lindsberg PJ, Happola O, Kallela M, Valanne L, Kuisma M,
Kaste M (2006) Door to thrombolysis: ER reorganization and
reduced delays to acute stroke treatment. Neurology 67:334–336
14. Mikulik R, Kadlecova P, Czlonkowska A, Kobayashi A, Broz-
man M, Svigelj V, Csiba L et al (2012) Factors influencing in-
hospital delay in treatment with intravenous thrombolysis. Stroke
43:1578–1583
15. Naidech AM, Janjua N, Kreiter KT, Ostapkovich ND, Fitzsim-
mons BF, Parra A, Commichau C et al (2005) Predictors and
J Neurol
impact of aneurysm rebleeding after subarachnoid hemorrhage.
Arch Neurol 62:410–416
16. Phillips TJ, Dowling RJ, Yan B, Laidlaw JD, Mitchell PJ (2011)
Does treatment of ruptured intracranial aneurysms within 24
hours improve clinical outcome? Stroke 42:1936–1945
17. Rankin J (1957) Cerebral vascular accidents in patients over the
age of 60. II. Prognosis. Scott Med J 2:200–215
18. Roos YB, Beenen LF, Groen RJ, Albrecht KW, Vermeulen M
(1997) Timing of surgery in patients with aneurysmal subarach-
noid haemorrhage: rebleeding is still the major cause of poor
outcome in neurosurgical units that aim at early surgery. J Neurol
Neurosurg Psychiatry 63:490–493
19. Skrifvars MB, Parr MJ (2012) Incidence, predisposing factors,
management and survival following cardiac arrest due to sub-
arachnoid haemorrhage: a review of the literature. Scand J
Trauma Resusc Emerg Med 20:75
20. Starke RM, Connolly ES Jr (2011) Rebleeding after aneurysmal
subarachnoid hemorrhage. Neurocrit Care 15:241–246
21. Steiner T, Juvela S, Unterberg A, Jung C, Forsting M, Rinkel G
(2013) European stroke organization guidelines for the
management of intracranial aneurysms and subarachnoid haem-
orrhage. Cerebrovasc Dis 35:93–112
22. Teasdale GM, Drake CG, Hunt W, Kassell N, Sano K, Pertuiset
B, De Villiers JC (1988) A universal subarachnoid hemorrhage
scale: report of a committee of the World Federation of Neuro-
surgical Societies. J Neurol Neurosurg Psychiatry 51:1457
23. van den Berg R, Foumani M, Schroder RD, Peerdeman SM, Horn
J, Bipat S, Vandertop WP (2011) Predictors of outcome in World
Federation of Neurologic Surgeons grade V aneurysmal sub-
arachnoid hemorrhage patients. Crit Care Med 39:2722–2727
24. Walter S, Kostopoulos P, Haass A, Keller I, Lesmeister M,
Schlechtriemen T, Roth C et al (2012) Diagnosis and treatment of
patients with stroke in a mobile stroke unit versus in hospital: a
randomised controlled trial. Lancet Neurol 11:397–404
25. Weil AG, Zhao JZ (2012) Treatment of ruptured aneurysms:
earlier is better. World Neurosurg 77:263–265
26. Wong GK, Boet R, Ng SC, Chan M, Gin T, Zee B, Poon WS
(2012) Ultra-early (within 24 hours) aneurysm treatment after
subarachnoid hemorrhage. World Neurosurg 77:311–315
123