Life Events and Risk of Subarachnoid Hemorrhage

Clinical Outcomes of Primary Subarachnoid Hemorrhage: An Exploratory Cohort Study from Sudan

Background

Although Subarachnoid Hemorrhage (SAH) is an emergency condition, its epidemiology and prognosis remain poorly understood in Africa. We aim to explore the clinical presentations, outcomes, and potential mortality predictors of primary SAH patients within 3 weeks of hospitalization in a tertiary hospital in Sudan.

Methods

We prospectively studied 40 SAH patients over 5 months, with 3 weeks of follow-up for the symptomatology, signs, Glasgow coma scale (GCS), CT scan findings, and outcomes. The fatal outcome group was defined as dying within 3 weeks.

Results

The mean age was 53.5 years (SD, 6.9; range, 41–65), and 62.5% were women. One-third (30.0%) were smokers, 37.5% were hypertensive, two-thirds (62.5%) had elevated blood pressure on admission, 37.5% had >24 hours delayed presentation, and 15% had missed SAH diagnosis. The most common presenting symptoms were headache and neck pain/stiffness, while seizures were reported in 12.5%. Approximately one-quarter of patients (22.5%) had large-sized Computed Tomography scan hemorrhage, and 40.0% had moderate size. In-hospital mortality rate was 40.0% (16/40); and 87.5% of them passed away within the first week. Compared to survivors, fatal outcome patients had significantly higher rates of smoking (50.0%), hypertension (68.8%), elevated presenting blood pressure (93.8%), delayed diagnosis (56.2%), large hemorrhage (56.2%), lower GCS scores at presentation, and cerebral rebleeding ( P < 0.05 for each). The primary causes of death were the direct effect of the primary hemorrhage (43.8%), rebleeding (31.3%), and delayed cerebral infarction (12.5%).

Conclusions

SAH is associated with a high in-hospital mortality rate in this cohort of Sudanese SAH patients due to modifiable factors such as delayed diagnosis, hypertension, and smoking. Strategies toward minimizing these factors are recommended.

Stress in Patients With (Un)ruptured Intracranial Aneurysms vs Population-Based Controls

BACKGROUND

Stress is associated with increased risk of stroke and might predispose to presence and rupture of intracranial aneurysms.

OBJECTIVE

To study the association of recent and lifelong stress with unruptured intracranial aneurysm (UIA) and aneurysmal subarachnoid hemorrhage (ASAH).

METHODS

In 227 UIA patients (mean age 61 ± 11 yr), 490 ASAH patients (59 ± 11 yr), and 775 controls (51 ± 15 yr) who were randomly retrieved from the general population, we assessed occurrence of major life events and perceived stress during the preceding 12 mo and the entire life. With multivariable logistic regression analysis, we calculated odds ratios (ORs) with 95% confidence intervals (95% CIs) for 4 categories of life events (financial-related, work-related, children-related, and death of family members) and for periods of perceived stress at home and at work (never vs sometimes, often, or always). We adjusted for sex, age, alcohol consumption, smoking, and hypertension.

RESULTS

The 4 categories of life events and perceived stress at work had ORs ranging from 0.4 to 1.7, of which financial stress for UIA was statistically significant (95% CI: 1.1-2.5). ORs for chronic perceived stress at home in the previous year were 4.3 (95% CI: 1.8-10.3) for UIA and 2.5 (1.2-5.5) for ASAH, and for lifelong exposure 5.7 (2.2-14.5) for UIA and 3.0 (1.3-7.0) for ASAH.

CONCLUSION

For some components of stress, there may be a relation with UIA and ASAH. The mechanisms underlying this relation should be unraveled; strategies to improve coping with stress may reduce the risk of rupture in patients with unruptured aneurysms.

Diagnosis and Management of Subarachnoid Hemorrhage

PURPOSE OF REVIEW

The purpose of this article is to present the epidemiology, clinical presentation, and management of patients with subarachnoid hemorrhage (SAH). SAH is a neurologic emergency that carries high morbidity and mortality. Patients with SAH are at risk for several significant neurologic complications, including hydrocephalus, cerebral edema, delayed cerebral ischemia, rebleeding, seizures, and neuroendocrine abnormalities that lead to impaired body regulation of sodium, water, and glucose.

RECENT FINDINGS

The incidence of SAH has remained stable, but mortality of hospitalized patients has significantly declined over the past 3 decades. Many common therapies for SAH have created controversy, and various recent neuroprotective clinical trials have produced negative results. However, the publication of two consensus guidelines by the American Heart Association/American Stroke Association and the Neurocritical Care Society have provided a clarification for what should constitute best practice for patients with SAH. The most important of those recommendations include the following: admission of patients to high-volume centers (defined as more than 35 patients with SAH per year) under the management of a specialized and multidisciplinary team; early identification and management of the bleeding source; evaluation and treatment decision for unsecured aneurysms by a multidisciplinary team made up of cerebrovascular neurosurgeons, endovascular practitioners, and neurointensivists; management of patients in the neurocritical care unit with oral nimodipine, blood pressure control, euvolemia, and frequent monitoring for neurologic and systemic complications; and delayed cerebral ischemia secondary to cerebral vasospasm should be treated with induced hypertension and endovascular therapies once confirmed.

SUMMARY

SAH is a devastating neurologic disease. Management of patients with SAH should adhere to currently available treatment guidelines. Several aspects of SAH management remain controversial and need further studies to clarify their role in improving patient outcome.

Working hours and cardiovascular disease in Korean workers: a case-control study

OBJECTIVES

Long working hours can negatively impact a worker's health. The objective of this study was to examine the association between working hours and cardiovascular diseases (CVDs) and compare the degree of risk based on CVD subtypes in Korean workers.

METHODS

This study was a case-control study of the patients registered in the Occupational Cardiovascular Diseases Surveillance 2010. The cases included 348 patients diagnosed with a CVD (123 cerebral infarction, 69 intracerebral hemorrhage, 57 subarachnoid hemorrhage, 99 acute myocardial infarction). Controls were 769 participants with no history of CVDs matched for gender, age, type of occupation, and region. Participants' working hours in the previous week and the average working hours over the past three months were assessed to examine short-term and long-term effects.

RESULTS

After adjusting for confounding factors, the odds ratios (ORs) for CVDs in the short-term were 2.66 (95% Confidence interval (CI) :1.78-3.99) for working ≤40 hours, 1.85 (95% CI: 1.22-2.81) for working 50.1-60 hours and 4.23 (95% CI: 2.81-6.39) for working >60 hours compared with the 40.1-50-hour working group. The ORs in the long-term were 2.90 (95% CI: 1.86-4.52) for working ≤40 hours, 1.73 (95% CI: 1.03-2.90) for working 48.1-52 hours and 3.46 (95% CI: 2.38-5.03) for working >52 hours compared with the 40.1-48-hour working group.

CONCLUSIONS

Long working hours are related to an increased risk of CVDs, and the degree of risk differs based on CVD subtype. Short working hours are also related to an increased risk for CVDs. More prospective studies targeting specific disease risks are required.

Guidelines for the management of aneurysmal subarachnoid hemorrhage: a guideline for healthcare professionals from the American Heart Association/american Stroke Association

PURPOSE

The aim of this guideline is to present current and comprehensive recommendations for the diagnosis and treatment of aneurysmal subarachnoid hemorrhage (aSAH).

METHODS

A formal literature search of MEDLINE (November 1, 2006, through May 1, 2010) was performed. Data were synthesized with the use of evidence tables. Writing group members met by teleconference to discuss data-derived recommendations. The American Heart Association Stroke Council's Levels of Evidence grading algorithm was used to grade each recommendation. The guideline draft was reviewed by 7 expert peer reviewers and by the members of the Stroke Council Leadership and Manuscript Oversight Committees. It is intended that this guideline be fully updated every 3 years.

RESULTS

Evidence-based guidelines are presented for the care of patients presenting with aSAH. The focus of the guideline was subdivided into incidence, risk factors, prevention, natural history and outcome, diagnosis, prevention of rebleeding, surgical and endovascular repair of ruptured aneurysms, systems of care, anesthetic management during repair, management of vasospasm and delayed cerebral ischemia, management of hydrocephalus, management of seizures, and management of medical complications.

CONCLUSIONS

aSAH is a serious medical condition in which outcome can be dramatically impacted by early, aggressive, expert care. The guidelines offer a framework for goal-directed treatment of the patient with aSAH.

Increased incidence of aneurysmal subarachnoid hemorrhage on Sundays and Mondays in 1,862 patients from Eastern Finland

BACKGROUND

Temporal patterns of aneurysmal subarachnoid hemorrhage (aSAH) from saccular intracranial aneurysm (sIA) were studied in a consecutive series of 1,862 patients.

METHODS

Neurosurgery of Kuopio University Hospital (KUH) solely serves a defined catchment population in Eastern Finland. Kuopio's sIA database contains 1,596 sporadic and 266 familial patients admitted to KUH within 72 h from the onset of aSAH between 1980 and 2007. The distributions by the weekday of the onset of aSAH, admission to KUH, and occlusive therapy of the ruptured sIA were analyzed. Logistic regression was used to search for clinical variables (patients, sIA disease, clinical condition) that would independently correlate with each distribution.

RESULTS

The onset of aSAH occurred significantly most often (p < 0.001) on Sundays (n = 330) and Mondays (n = 309) and least frequently on Saturdays (n = 231). None of the clinical variables tested associated significantly and independently with the Sunday and Monday peaks. The admissions to KUH after aSAH were most frequent (p < 0.001) on Mondays (n = 331) and least frequent on Thursdays (n = 221) and Saturdays (n = 221). Overall, 1,655 patients underwent occlusive therapy, most frequently on Mondays (n = 318) and least frequently on Saturdays (n = 189) and Sundays (n = 197).

CONCLUSIONS

Sundays and Mondays were the most frequent and Saturdays the least frequent days of aSAH in a defined Eastern Finnish population. We could not identify any etiology to this temporal pattern. Binge drinking is frequent in Finland, especially among young males, but age and gender did not correlate with the Sunday and Monday peaks.