Patterns of Use and Discontinuation of Secondary Prevention Medications After Stroke

OBJECTIVE

To investigate whether certain patient, acute care, or primary care factors are associated with medication initiation and discontinuation in the community after stroke or TIA.

METHODS

This is a retrospective cohort study using prospective data on adult patients with first-ever acute stroke/TIA from the Australian Stroke Clinical Registry (April 2010 to June 2014), linked with nationwide medication dispensing and Medicare claims data. Medication users were those with ≥1 dispensing in the year postdischarge. Discontinuation was assessed among medication users and defined as having no medication supply for ≥90 days in the year postdischarge. Multivariable competing risks regression, accounting for death during the observation period, was conducted to investigate factors associated with time to medication discontinuation.

RESULTS

Among 17,980 registry patients with stroke/TIA, 91.4% were linked to administrative datasets. Of these, 9,817 adults with first-ever stroke/TIA were included (45.4% female, 47.6% aged ≥75 years, and 11.4% intracerebral hemorrhage). While most patients received secondary prevention medications (79.3% antihypertensive, 81.8% antithrombotic, and 82.7% lipid-lowering medication), between one-fifth and one-third discontinued treatment over the subsequent year postdischarge (20.9% antihypertensive, 34.1% antithrombotic, and 28.5% lipid-lowering medications). Prescription at hospital discharge (sub-hazard ratio [SHR] 0.70; 95% confidence interval [CI] 0.62-0.79), quarterly contact with a primary care physician (SHR 0.62; 95% CI 0.57-0.67), and prescription by a specialist physician (SHR 0.87; 95% CI 0.77-0.98) were all inversely associated with antihypertensive discontinuation.

CONCLUSIONS

Patterns of use of secondary prevention medications after stroke/TIA are not optimal, with many survivors discontinuing treatment within 1 year postdischarge. Improving postdischarge care for patients with stroke/TIA is needed to minimize unwarranted discontinuation.

Assuming one dose per day yields a similar estimate of medication adherence in patients with stroke: An exploratory analysis using linked registry data

PURPOSE

Prescribed daily dose (PDD), the number of doses prescribed to be taken per day, is used to calculate medication adherence using pharmacy claims data. PDD can be substituted by (i) one dose per day (1DD), (ii) an estimate based on the 75th percentile of days taken by patients to refill a script (PDD₇₅ ) or (iii) the World Health Organization's defined daily dose (DDD). We aimed to compare these approaches for estimating the duration covered by medications and whether this affects calculated 1-year adherence to antihypertensive medications post-stroke.

METHODS

We conducted a retrospective review of prospective cohort data from the ongoing Australian Stroke Clinical Registry linked with pharmacy claims data. Adherence was calculated as the proportion of days covered (PDC) for 1DD, PDD₇₅ and DDD. Differences were assessed using Wilcoxon rank-sum tests.

RESULTS

Among 12 628 eligible patients with stroke, 10 057 (80%) were prescribed antihypertensive medications in the year after hospital discharge (78.2% aged ≥65 years, 45.2% female). Overall, the 75th percentile of patient time until next medication refill was 39 days. The greatest variations in dose regimens, estimated using person- and dose-level refill times, were for beta blockers (11.4% taking two tablets/day). There were comparable levels of adherence between 1DD and the PDD₇₅ (median PDC 91.0% vs 91.2%; P = 0.70), but adherence was slightly higher using DDD (92.3%; both P < 0.001). However, this would represent a clinically nonsignificant difference.

CONCLUSION

Adherence to antihypertensive medications shows similar estimates across standard measures of dosage in patients during the first year after an acute stroke.

THU0070 DEFINING SYNOVIAL SIGNATURES IN THE RAT CIA MODEL: WHAT CAN WE LEARN ABOUT RA PROGRESSION?

Background:

Patients showing inadequate or no response to current therapies represent a key unmet need in rheumatoid arthritis (RA). To address this, novel or combination therapies are of high clinical interest. Identification of novel therapeutic targets requires a greater understanding of the pathogenic molecular drivers in the RA synovium. However, our current knowledge of human molecular patterns that emerge as a result of disease progression is complicated by patient-to-patient heterogeneity and access to synovial tissue.

Objectives:

Here we use the current knowledge of human synovial heterogeneity to conduct a longitudinal study of global molecular responses in the rat collagen-induced arthritis (CIA) model to better understand synovial biology, improve the preclinical modeling of human disease, and discover novel targets for RA.

Methods:

A rat CIA model was performed as previously described.1RNA-Seq was performed on 56 knee synovial tissues collected at multiple time points throughout the course of disease. Differential gene expression was determined at each individual time point and longitudinally with disease progression. Published human synovial datasets were used to categorize these genes into myeloid, lymphoid, fibroid, and low inflammatory signatures.2Differentially expressed genes (DEGs) at each time point were compared to human synovial datasets of RA patients before and after treatment. In addition, we compared disease-driven genes in CIA to genes in RA patients that are unchanged following therapy to identify possible combination therapies.

Results:

Disease pathology in the rat CIA natural history study progressed as expected: significant decreases were seen in body weight, as well as increases in ankle diameter, paw weight, and histopathology scores of joints in collagen-injected vs noninjected rats. There were 1900 DEGs identified between diseased and naïve rats over the course of disease, representing disease-induced gene signatures (Fig. 1). Comparing these DEGs to reported human RA synovial signatures, both the lymphoid and myeloid signatures were found to be highly upregulated. Interestingly, there were no significant DEGs representing the human fibroid and low inflammatory synovial signatures identified in the CIA rat model. This suggests that the rat CIA model most closely models RA patients with an immune synovial phenotype. In addition, we examined the overlap between disease-driven genes in CIA and genes in RA patients that are unchanged following therapy to identify signaling pathways that may be of utility in combination therapy. Of genes that were upregulated in CIA, 94% of genes that mapped to extracellular matrix-receptor pathways remained unchanged in the synovial tissue of RA patients following tocilizumab treatment.

Conclusion:

Previous studies have shown that nearly 30% of treatment-naïve early RA patients exhibit a strong fibroid phenotype that correlates with less severe disease and a relatively poor response to disease-modifying anti-rheumatic drugs.3These data indicate that the synovial biology associated with such patients (fibroid or pauci-immune) is not well captured in CIA, the most common preclinical RA model. To assess potential new therapies targeting these patients, it will be necessary to develop alternative animal models with more intact fibroid signatures. In addition to these findings, we also characterized the global molecular changes that occur with disease progression in the CIA rat and made a comparison to RA patients on treatment, providing an overall understanding of disease-relevant pathways in the synovium that may point to possible combination therapies.

References:

[1]Trentham DE, et al.J Exp Med. 1977;146(3):857-868.

[2]Dennis G Jr, et al.Arthritis Res Ther. 2014;16(2):R90.

[3]Humby F, et al.Ann Rheum Dis. 2019;78(6):761-772.

Disclosure of Interests:

Debbie Ruelas Employee of: Gilead, Ruidong Li Employee of: Gilead, Christian Franci Employee of: Gilead, Victor Lira Employee of: Gilead, David Lopez Employee of: Gilead, Li Li Employee of: Gilead, Gundula Min-Oo Employee of: Gilead, Julie A. Di Paolo Employee of: Gilead

169 Comparison of pregnancy outcomes in dairy heifers artificially inseminated with sexed semen deposited in the uterine horns versus the uterine body

The use of sexed semen (SS) for AI of cattle has resulted in lower pregnancy per timed AI (P/TAI) compared with conventional semen. This has been attributed to lower sperm dose and cell damage during the cell sorting-freezing process. Horn AI is a common practice in equines and canines to improve pregnancy rate when using low sperm doses. The objective was to compare P/TAI and pregnancy loss (PL) in dairy heifers inseminated with SS deposited in the uterine horn (UH) ipsilateral to the ovary containing the preovulatory follicle (POF) versus TAI in the uterine body (UB). This study was performed on two dairy farms in Georgia (A and B). On farm A, 74 Holstein heifers (12 months old) received a 5-day Cosynch + controlled internal drug release (CIDR) protocol including an intravaginal insert (Eazi-Breed CIDR, Zoetis Animal Health) containing 1.38g of progesterone for 5 days and a dose of gonadotrophin-releasing hormone (GnRH) intramuscularly (100µg, 2mL of Factrel, Zoetis Animal Health). At CIDR removal, heifers received a dose of prostaglandin F2α (PGF2α) intramuscularly (25mg, 5mL of Lutalyse, Zoetis Animal Health) and again 24h later; 72h after CIDR removal, heifers received 100µg of GnRH intramuscularly and TAI with frozen-thawed SS. On farm B, 237 Holstein×Jersey heifers (12 months old) received a modified 5-day Cosynch + CIDR. This protocol was similar to that on farm A but did not include GnRH at the time of CIDR insertion or a second dose of PGF2α 24h after CIDR removal. Immediately before TAI, heifers were examined using transrectal ultrasonography (TRUS) to determine on which ovary the POF was present. Each heifer was randomly assigned to TAI using SS in either the UH ipsilateral to the ovary containing the POF (n=150; farm A, n=32; farm B, n=118) or the UB regardless of where the POF was identified (n=161; farm A, n=42; farm B, n=119). Pregnancy was diagnosed 32 days after TAI using TRUS to determine P/TAI. Heifers diagnosed pregnant were re-examined using TRUS at 60 days of gestation to assess PL. Data were analysed using PROC LOGISTIC and the chi-square test of SAS (SAS Institute Inc.). Heifers that received SS in the UH had adequate P/TAI (50.6% (76/150); farm A: 50.0% (16/32); farm B: 50.8% (60/118)), which tended to be numerically greater (P=0.12) than that observed in heifers receiving SS in the UB (43.4% (70/161); farm A: 40.5% (17/42); farm B: 44.5% (53/119)). In addition, PL was not different between groups and was within normal ranges for dairy heifers (10.0 and 9.4% for UH and UB, respectively). In conclusion, TAI of dairy heifers with SS deposited in the UH ipsilateral to the ovary containing the POF resulted in adequate P/TAI, which was 7.2% greater than TAI in the UB. Horn AI with SS might become a valuable tool for optimising reproductive efficiency and genetic selection of dairy herds.

Assessment of neurocognitive decline in cancer patients, except brain cancer, under long-term treatment with bevacizumab

PURPOSE

We performed a cross-sectional study of neurocognitive function in non-brain cancer patients treated with long-term bevacizumab.

METHODS/PATIENTS

From 2015 to 2017, we included patients with different types of cancer treated with bevacizumab with or without chemotherapy (BEV; N = 20) or only chemotherapy (ChT; N = 19) for at least 34 weeks, patients who received non-brain radiotherapy (RxT; N = 19), and healthy controls (HC; N = 19) were assessed once at week 34 of treatment (BEV and ChT) or at completion of radiotherapy. Neurocognition was evaluated with the Hopkins Verbal Learning Test-Revised (HVLT-R) total and delayed recall, the Trail Making Test A and B, and the Controlled Oral Word Association Test in the four groups. Non-parametric tests were used to assess differences between groups.

RESULTS

The BEV, ChT, and RxT groups scored significantly lower than the HC group on all tests and especially on the HVLT-R total recall. In no case were the mean scores of the BEV group significantly lower than those of the ChT or RxT groups.

CONCLUSIONS

Neurocognitive impairment was seen even in patients treated with local non-brain radiotherapy. Treatment with bevacizumab for a long period of time does not seem to worsen neurocognitive function to a greater extent than chemotherapy.

Comparative trends in coronary heart disease subgroup hospitalisation rates in England and Australia

Background

Population-based coronary heart disease (CHD) studies have focused on myocardial infarction (MI) with limited data on trends across the spectrum of CHD. We investigated trends in hospitalisation rates for acute and chronic CHD subgroups in England and Australia from 1996 to 2013.

Methods

CHD hospitalisations for individuals aged 35–84 years were identified from electronic hospital data from 1996 to 2013 for England and Australia and from the Oxford Region and Western Australia. CHD subgroups identified were acute coronary syndromes (ACS) (MI and unstable angina) and chronic CHD (stable angina and ‘other CHD’). We calculated age-standardised and age-specific rates and estimated annual changes (95% CI) from age-adjusted Poisson regression.

Results

From 1996 to 2013, there were 4.9 million CHD hospitalisations in England and 2.6 million in Australia (67% men). From 1996 to 2003, there was between-country variation in the direction of trends in ACS and chronic CHD hospitalisation rates (p<0.001). During 2004–2013, reductions in ACS hospitalisation rates were greater than for chronic CHD hospitalisation rates in both countries, with the largest subgroup declines in unstable angina (England: men: −7.1 %/year, 95% CI −7.2 to –7.0; women: −7.5 %/year, 95% CI −7.7 to –7.3; Australia: men: −8.5 %/year, 95% CI −8.6 to –8.4; women: −8.6 %/year, 95% CI −8.8 to –8.4). Other CHD rates increased in individuals aged 75–84 years in both countries. Chronic CHD comprised half of all CHD admissions, with the majority involving angiography or percutaneous coronary intervention.

Conclusions

Since 2004, rates of all CHD subgroups have fallen, with greater declines in acute than chronic presentations. The slower declines and high proportion of chronic CHD admissions undergoing coronary procedures requires greater focus.

Needs and priority areas for building capacity for working with linked data in the Australian pharmacoepidemiology workforce

IntroductionLinked data are increasingly used in pharmacoepidemiology studies to enhance value beyond that which can be achieve from stand-alone pharmaceutical data. The complexity of pharmaceutical data can make any linked data analysis challenging and it is imperative that this is matched by the human capacity to perform this work. Objectives and ApproachResearch is needed to understand the state of the current pharmacoepidemiology workforce and to prioritise its capacity building needs. We aim to profile the Australian pharmacoepidemiology workforce to explore views, needs, priority areas and perspectives relevant to capacity building. Participants are the regular pharmacoepidemiology workforce (Group 1) and senior medicines stakeholders (Group 2). Following a literature review and consultation with a group of key informants, we developed survey and interview instruments for each group. We piloted the instruments in February 2018 and study data collection is planned for March 2018. We will use a mixed-methods approach to analyse the data. ResultsWe conducted a review of existing literature and identified workforce views, needs and priorities at four levels: personal, team, organisation and wider community. During the consultative process, the informants highlighted the multidisciplinary nature of the pharmacoepidemiology workforce including many with non-health related backgrounds. They also raised concerns about attracting applicants with suitable skills and experience, job satisfaction, career progression and workforce retention. We developed instruments to (i) further explore these issues, (ii) ascertain their experience with linked health data, (iii) determine their training needs, and, (iv) learn about their future intentions. We will present findings on issues pertinent to the Australian pharmacoepidemiology landscape and suggest priorities for building workforce capacity. Conclusion/ImplicationsThis study will provide empirical evidence to support and prioritise capacity building in the Australian pharmacoepidemiology workforce to improve their ability to work with linked data. The instruments that we developed and findings may be relevant to phamacoepidemiology workforce in other countries and other emerging fields that use linked data.

Oblique "Scotty dog" versus antero-posterior (AP) views in performing x-ray guided facet joint injections

BACKGROUND

Facet joint pain contributes significantly to lower back pain. Image intensifier x-ray guidance is used to locate the facet joints. This can either be in the oblique "Scotty dog" or antero-posterior views. The aim is to investigate whether improved visualisation of facet joints using the oblique method would increase the accuracy of the injection and hence lead to enhanced pain relief effect when compared to AP views in Lumbar facet joints.

METHODS

Single centre, single blinded. A total of 42 consecutive patients were recruited between December 2014 and March 2015 at Colchester General Hospital. Patients randomly allocated into facet joint injections using the oblique or AP projection. Pre-operatively the patients were asked to rate their back pain using a numerical 11 point pain rating scale in the questionnaire. Post-operatively patients were seen at 6 weeks and once again were asked to fill out the afore mentioned questionnaire. The results were collated and statistical analysis performed using Microsoft Excel.

RESULTS

29 patients returned their post-op questionnaire at approximately 6 weeks post-op. 12 patients had oblique view and 17 patients had AP view. There was a statistically significant difference in the pain scores comparing pre and post op scores for both the Oblique and AP groups. However, there was no significant difference when comparing the post-op pain scores or the absolute changes in pain scores between the two groups.

DISCUSSION

Spinal facet joint injections provide significant relief at the 6 week post-op follow up with no difference between the oblique and AP techniques.

Pharmacogenetics: An Important Part of Drug Development with A Focus on Its Application

Since the human genome project in 2003, the view of personalized medicine to improve diagnosis and cure diseases at the molecular level became more real. Sequencing the human genome brought some benefits in medicine such as early detection of diseases with a genetic predisposition, treating patients with rare diseases, the design of gene therapy and the understanding of pharmacogenetics in the metabolism of drugs. This review explains the concepts of pharmacogenetics, polymorphisms, mutations, variations, and alleles, and how this information has helped us better understand the metabolism of drugs. Multiple resources are presented to promote reducing the gap between scientists, physicians, and patients in understanding the use and benefits of pharmacogenetics. Some of the most common clinical examples of genetic variants and how pharmacogenetics was used to determine treatment options for patients having these variants were discussed. Finally, we evaluated some of the challenges of implementing pharmacogenetics in a clinical setting and proposed actions to be taken to make pharmacogenetics a standard diagnostic tool in personalized medicine.

Exploring the effects of transfers and readmissions on trends in population counts of hospital admissions for coronary heart disease: a Western Australian data linkage study

OBJECTIVES

To develop a method for categorising coronary heart disease (CHD) subtype in linked data accounting for different CHD diagnoses across records, and to compare hospital admission numbers and ratios of unlinked versus linked data for each CHD subtype over time, and across age groups and sex.

DESIGN

Cohort study.

DATA SOURCE

Person-linked hospital administrative data covering all admissions for CHD in Western Australia from 1988 to 2013.

MAIN OUTCOME

Ratios of (1) unlinked admission counts to contiguous admission (CA) counts (accounting for transfers), and (2) 28-day episode counts (accounting for transfers and readmissions) to CA counts stratified by CHD subtype, sex and age group.

RESULTS

In all CHD subtypes, the ratios changed in a linear or quadratic fashion over time and the coefficients of the trend term differed across CHD subtypes. Furthermore, for many CHD subtypes the ratios also differed by age group and sex. For example, in women aged 35-54 years, the ratio of unlinked to CA counts for non-ST elevation myocardial infarction admissions in 2000 was 1.10, and this increased in a linear fashion to 1.30 in 2013, representing an annual increase of 0.0148.

CONCLUSION

The use of unlinked counts in epidemiological estimates of CHD hospitalisations overestimates CHD counts. The CA and 28-day episode counts are more aligned with epidemiological studies of CHD. The degree of overestimation of counts using only unlinked counts varies in a complex manner with CHD subtype, time, sex and age group, and it is not possible to apply a simple correction factor to counts obtained from unlinked data.

Identification of myocardial infarction type from electronic hospital data in England and Australia: a comparative data linkage study

OBJECTIVE

To determine the utility of International Classification of Diseases (ICD) codes in investigating trends in ST-segment elevation myocardial infarction (STEMI) and non-ST-segment elevation myocardial infarction (NSTEMI) using person-linked electronic hospitalisation data in England and Western Australia (WA).

METHODS

All hospital admissions with myocardial infarction (MI) as the principal diagnosis were identified from 2000 to 2013 from both jurisdictions. Fourth-digit ICD-10 codes were used to delineate all MI types-STEMI, NSTEMI, unspecified and subsequent MI. The annual frequency of each MI type was calculated as a proportion of all MI admissions. For all MI and each MI type, age-standardised rates were calculated and age-adjusted Poisson regression models used to estimate annual percentage changes in rates.

RESULTS

In 2000, STEMI accounted for 49% of all MI admissions in England and 59% in WA, decreasing to 35% and 25% respectively by 2013. Less than 10% of admissions were recorded as NSTEMI in England throughout the study period, whereas by 2013, 70% of admissions were NSTEMI in WA. Unspecified MI comprised 60% of all MI admissions in England by 2013, compared with <1% in WA. Trends in age-standardised rates differed for all MI (England, -2.7%/year; WA, +1.7%/year), underpinned by differing age-adjusted trends in NSTEMI (England, -6.1%/year; WA, +10.2%/year).

CONCLUSION

Differences between the proportion and trends for MI types in English and WA data were observed. These were consistent with the coding standards in each country. This has important implications for using electronic hospital data for monitoring MI and identifying MI types for outcome studies.

Impact of family-friendly prison policies on health, justice and child protection outcomes for incarcerated mothers and their dependent children: a cohort study protocol

INTRODUCTION

Female imprisonment has numerous health and social sequelae for both women prisoners and their children. Examples of comprehensive family-friendly prison policies that seek to improve the health and social functioning of women prisoners and their children exist but have not been evaluated. This study will determine the impact of exposure to a family-friendly prison environment on health, child protection and justice outcomes for incarcerated mothers and their dependent children.

METHODS AND ANALYSIS

A longitudinal retrospective cohort design will be used to compare outcomes for mothers incarcerated at Boronia Pre-release Centre, a women's prison with a dedicated family-friendly environment, and their dependent children, with outcomes for mothers incarcerated at other prisons in Western Australia (that do not offer this environment) and their dependent children. Routinely collected administrative data from 1985 to 2013 will be used to determine child and mother outcomes such as hospital admissions, emergency department presentations, custodial sentences, community service orders and placement in out-of home care. The sample consists of all children born in Western Australia between 1 January 1985 and 31 December 2011 who had a mother in a West Australian prison between 1990 and 2012 and their mothers. Children are included if they were alive and aged less than 18 years at the time of their mother's incarceration. The sample comprises an exposed group of 665 women incarcerated at Boronia and their 1714 dependent children and a non-exposed comparison sample of 2976 women incarcerated at other West Australian prisons and their 7186 dependent children, creating a total study sample of 3641 women and 8900 children.

ETHICS AND DISSEMINATION

This project received ethics approval from the Western Australian Department of Health Human Research Ethics Committee, the Western Australian Aboriginal Health Ethics Committee and the University of Western Australia Human Research Ethics Committee.

Clinical consultations and investigations before and after discontinuation of endocrine therapy in women with primary breast cancer

OBJECTIVE

Although clinical trials recommend that women with hormone-dependent primary breast cancer remain on endocrine therapy for at least 5 years, up to 60% discontinue treatment early. We determined whether these women had consulted with clinicians or had investigations for cancer recurrence or metastasis around the time they discontinued endocrine therapy, and whether clinical contact continued after discontinuation.

METHODS

We performed case-control and cohort studies of women from the 45 and Up Study who were diagnosed with invasive primary breast cancer between January 2003 and December 2008, and who had ≥12 months of anastrozole, exemestane, letrozole or tamoxifen subsequently dispensed.

RESULTS

Women who consulted general practitioners and surgeons/oncologists, and women who had breast ultrasound/mammogram were just as likely to discontinue endocrine therapy within 30 days as those who did not consult these clinicians or have this investigation. In the 6 months after early discontinuation, women who discontinued endocrine therapy were less likely to consult general practitioners (adjusted risk ratio [RRadj] 0.80; 95% confidence interval [CI] 0.75, 0.86) and surgeons/oncologists (RRadj 0.62; 95% CI 0.54, 0.72) than those who remained on therapy.

CONCLUSIONS

For most women, endocrine therapy discontinuation did not appear to follow consultation with doctors managing their breast cancer treatment or investigations for recurrence or metastasis. However, women who discontinued endocrine therapy were less likely to consult their general practitioner or surgeon/oncologist in the 6 months following discontinuation than those who remained on therapy. Of the clinician groups studied, general practitioners are best placed to engage and support women to continue pharmacotherapy. However, mechanisms are needed to prompt clinicians to do this at every visit.

[Causes of hospital mortality due to brain haemorrhage in patients with arteriovenous malformation]

AIM

To determine the causes of mortality in cases of brain haemorrhage among patients with arteriovenous malformations (AVM) treated in a tertiary hospital.

PATIENTS AND METHODS

The patients with AVM who died over the period 1990-2014 were selected from a prospective register of vascular malformations. Demographic aspects, localisation of the AVM, associated aneurysms and previous treatments were reviewed. Three main causes of death were established: initial bleeding/rebleeding, those related with the treatment of the AVM and other causes not related with AVM.

RESULTS

A total of 400 patients were treated for AVM, 216 (54%) with a ruptured AVM, of whom 26 (12.1%) died as a result of a brain haemorrhage. The mean age of the group of patients who died was 48.8 years (range: 8-78 years). Twenty (76.9%) were admitted in coma (Glasgow Coma Scale < 9). In five cases (19.2%), bleeding was due to an associated aneurysm. A very high percentage (38.5%) had the AVM in the posterior fossa. Three patients had previously received non-curative treatments for the AVM in other medical centres. Of the total number, six (23.1%) received endovascular/surgical treatment in our hospital, and we have assumed that, due to the indication or owing to the time in which it was carried out, the cause of death was treatment-related, although two young patients underwent surgery with bilateral mydriasis. One patient died due to an associated glioblastoma, and the others, 19 (76%), due to rebleeding or to the initial brain damage.

CONCLUSION

Knowing the causes of mortality can help improve the clinical outcome, above all in cases in which an early treatment could be indicated.