Age- and Gender-Specific Time Trend in Risk of Death of Patients Admitted with Aneurysmal Subarachnoid Hemorrhage in the Netherlands

Sex-Related Differences in Mortality, Delayed Cerebral Ischemia, and Functional Outcomes in Patients with Aneurysmal Subarachnoid Hemorrhage: A Systematic Review and Meta-Analysis

Background/Objective: Sex-related differences among patients with aneurysmal subarachnoid hemorrhage (aSAH) and their potential clinical implications have been insufficiently investigated. To address this knowledge gap, we conduct a comprehensive systematic review and meta-analysis. Methods: Sex-specific differences in patients with aSAH, including mortality, delayed cerebral ischemia (DCI), and functional outcomes were assessed. The functional outcome was dichotomized into favorable or unfavorable based on the modified Rankin Scale (mRS), Glasgow Outcome Scale (GOS), and Glasgow Outcome Scale Extended (GOSE). Results: Overall, 2823 studies were identified in EMBASE, MEDLINE, PubMed, and by manual search on 14 February 2024. After an initial assessment, 74 studies were included in the meta-analysis. In the analysis of mortality, including 18,534 aSAH patients, no statistically significant differences could be detected (risk ratio (RR) 0.99; 95% CI, 0.90-1.09; p = 0.91). In contrast, the risk analysis for DCI, including 23,864 aSAH patients, showed an 11% relative risk reduction in DCI in males versus females (RR, 0.89; 95% CI, 0.81-0.97; p = 0.01). The functional outcome analysis (favorable vs. unfavorable), including 7739 aSAH patients, showed a tendency towards better functional outcomes in men than women; however, this did not reach statistical significance (RR, 1.02; 95% CI, 0.98-1.07; p = 0.34). Conclusions: In conclusion, the available data suggest that sex/gender may play a significant role in the risk of DCI in patients with aSAH, emphasizing the need for sex-specific management strategies.

Association between serum creatinine and 30 days all-cause mortality in critically ill patients with non-traumatic subarachnoid hemorrhage: analysis of the MIMIC-IV database

Background

Serum creatinine is a prognostic marker for various conditions, but its significance of spontaneous subarachnoid hemorrhage is still poorly understood. This study aims to elucidate the correlation between admission serum creatinine (sCr) levels and all-cause mortality within 30 days among individuals affected by non-traumatic subarachnoid hemorrhage (SAH).

Methods

This cohort study included 672 non-traumatic SAH adults. It utilized data from the MIMIC-IV database from 2008 to 2019. The patients' first-time serum creatinine was recorded. Subsequently, an examination of the 30-day all-cause mortality was conducted. Employing a multiple logistic regression model, a nomogram was constructed, while the association between sCr and 30-day all-cause mortality was evaluated using Kaplan-Meier survival curves. The calibration curve was employed to assess the model's performance, while subgroup analysis was employed to examine the impact of additional complications and medication therapy on outcomes.

Results

A total of 672 patients diagnosed with non-traumatic subarachnoid hemorrhage were included in the study. The mortality rate within this timeframe was found to be 24.7%. Multiple logistic regression analysis revealed that sCr served as an independent prognostic indicator for all-cause mortality within 30 days of admission for SAH patients [OR: 2(1.18-3.41); p = 0.01]. A comprehensive model was constructed, incorporating age, sCr, white blood cell count (WBC), glucose, anion gap, and partial thromboplastin time (PTT), resulting in a prediction model with an AUC value of 0.806 (95% CI: 0.768, 0.843), while the AUC for the test set is 0.821 (95% CI: 0.777-0.865).

Conclusion

Creatinine emerges as a significant biomarker, closely associated with heightened in-hospital mortality in individuals suffering from SAH.

Evaluation of cholinergic enzymes and selected biochemical parameters in the serum of patients with a diagnosis of acute subarachnoid hemorrhage

Background

Spontaneous subarachnoid hemorrhage (SAH) is the most severe form of hemorrhagic stroke and accounts for 5-7% of all strokes. Several chemical enzymes and cytokines are thought to cause reactions that may affect the mortality and morbidity of SAH patients. This study aimed to examine the possible relationships between these parameters and the occurrence of SAH and the clinical-radiological parameters in patients with acute SAH.

Methods

This study evaluated 44 patients, including 20 with SAH and 24 controls. We obtained blood from the patients and control groups, which was stored in heparinized tubes and used in determining tumor necrosis factor alpha (TNF-α), brain-derived neurotrophic factor (BDNF), acetylcholinesterase (AChE), caspase-3, and butyrylcholinesterase (BChE) enzymes.

Results

TNF-α, BDNF, AChE, and BChE enzyme levels were not related to the Glasgow Coma scale (GCS) score in the patient group (p > 0.05), whereas higher enzyme levels of caspase-3 were associated with lower GCS scores (p < 0.05). The difference between the control and patient groups in terms of mean TNF-α levels was statistically significant (p < 0.01). The BDNF levels were statistically insignificant in the patient groups (p > 0.05). Caspase-3, AChE, and BChE levels were significantly different between the control and patient groups (p < 0.01).

Conclusions

Our results may be valuable for predicting the prognosis, diagnosis, and follow-up of patients with SAH. However, further studies are required to elucidate the relationship between the clinical and radiological results in patients with SAH and certain enzymes, cytokines, and growth factors.

Surveillance of Unruptured Intracranial Aneurysms: Cost-Effectiveness Analysis for 3 Countries

BACKGROUND AND OBJECTIVES

No consensus exists on adequate surveillance of conservatively managed unruptured intracranial aneurysms (UIAs). We aimed to determine optimal MRI surveillance strategies for the growth of UIAs using cost-effectiveness analysis. A secondary aim was to develop a clinical tool for personalizing UIA surveillance.

METHODS

We designed a microsimulation model from a health care perspective simulating 100,000 55-year-old women to estimate costs and quality-adjusted life years (QALYs) over a lifetime horizon in the United States, the United Kingdom, and the Netherlands, using literature-derived model parameters. Country-specific costs and willingness-to-pay thresholds ($100,000/QALY for the United States, £30,000/QALY for the United Kingdom, and €80,000/QALY for the Netherlands) were used. Lifetime costs and QALYs were annually discounted at 3% for the United States, 3.5% for the United Kingdom, or 4% (costs) and 1.5% (QALYs) for the Netherlands. Strategies were no follow-up surveillance, follow-up with MRI in the first and fifth year after UIA discovery, every 5 years, every 2 years, or annually, or immediate intervention (i.e., clipping or coiling). Using the microsimulation model, we developed a tool for personalizing UIA surveillance for men and women, with different ages and varying aneurysm characteristics. Uncertainty in the input parameters was modeled with probabilistic sensitivity analysis.

RESULTS

Among 55-year-old women, 2,222 individuals in the United States, 1,910 in the United Kingdom, and 2,040 in the Netherlands needed to undergo an annual MRI scan to prevent 1 case of subarachnoid hemorrhage per year. No surveillance MRI was most cost-effective in the United States (in 47% of the simulations) and United Kingdom (in 54% of simulations), whereas annual MRI was most cost-effective in the Netherlands (in 53% of simulations). In the United States and United Kingdom, annual surveillance or surveillance in the first and fifth year after discovery was cost-effective in patients <60 years and at increased risk of aneurysm growth. The optimal, personalized, surveillance strategies were summarized in a look-up table for use in clinical practice.

DISCUSSION

Generally, the US and UK physicians should refrain from assigning patients, particularly older patients and those with few risk factors for aneurysm growth or rupture, to frequent MRI surveillance. In the Netherlands, annual follow-up is generally most cost-effective.

Long-term vascular events after subarachnoid hemorrhage

BACKGROUND

Spontaneous subarachnoid hemorrhage (SAH) long-term risk is not well known. Our aims are: describing long-term vascular event (VE) incidence rates in SAH survivors; describing VE: ischemic and/or hemorrhagic; identifying independent association of factors related to VE; and analyzing the usefulness of factors to increase predictive ability.

METHODS

A prospective cohort study of consecutive patients admitted to Hospital del Mar with a diagnosis of SAH (n = 566) between January 2007 and January 2020 was carried out. They were followed up until January 2021. The study endpoint was a new VE in the follow-up. We calculated both incidence rates and cumulative rates at 5 years. Cox regression survival models including vascular risk factors with and without specific data of SAH disease were developed. We analyzed ROC curves of all multivariate models.

RESULTS

The analyzed cohort included 423 non-fatal SAH cases. Total patient-years were 2468.16 years. The average follow-up was 70.03 ± 43.14; range: 1-180 months. There were 49 VE detected in 47 patients, as 2 of them had more than 1 VE. Incidence rate was 0.020 events_per_patient/year, cumulative incidence at 5 years was 11.11%. The more frequent VE that we found were cerebrovascular (28/49), mainly ischemic (21/28). Disability after SAH and the presence of multiple aneurysms were independently associated with a VE risk and improved the predictive capacity of multivariate models (AUC 0.679 vs 0.764; p = 0.0062).

CONCLUSIONS

We reported a low vascular risk after SAH. We have shown the usefulness of SAH factors to identify patients with a higher risk of VE.

Admission rate-pressure product as an early predictor for in-hospital mortality after aneurysmal subarachnoid hemorrhage

Early prediction of in-hospital mortality in aneurysmal subarachnoid hemorrhage (aSAH) is essential for the optimal management of these patients. Recently, a retrospective cohort observation has reported that the rate-pressure product (RPP, the product of systolic blood pressure and heart rate), an objective and easily calculated bedside index of cardiac hemodynamics, was predictively associated with in-hospital mortality following traumatic brain injury. We thus wondered whether this finding could also be generalized to aSAH patients. The current study aimed to examine the association of RPP at the time of emergency room (ER) admission with in-hospital mortality and its predictive performance among aSAH patients. We retrospectively included 515 aSAH patients who had been admitted to our ER between 2016 and 2020. Their baseline heart rate and systolic blood pressure at ER presentation were extracted for the calculation of the admission RPP. Meanwhile, we collected relevant clinical, laboratory, and neuroimaging data. Then, these data including the admission RPP were examined by univariate and multivariate analyses to identify independent predictors of hospital mortality. Eventually, continuous and ordinal variables were selected from those independent predictors, and the performance of these selected predictors was further evaluated and compared based on receiver operating characteristic (ROC) curve analyzes. We identified both low (< 10,000; adjusted odds ratio (OR) 3.49, 95% CI 1.93-6.29, p < 0.001) and high (> 15,000; adjusted OR 8.42, 95% CI 4.16-17.06, p < 0.001) RPP on ER admission to be independently associated with in-hospital mortality after aSAH. Furthermore, after centering the admission RPP by its median, the area under its ROC curve (0.761, 95% CI 0.722-0.798, p < 0.001) was found to be statistically superior to any of the other independent predictors included in the ROC analyzes (all p < 0.01). In light of the predictive superiority of the admission RPP, as well as its objectivity and easy accessibility, it is indeed a potentially more applicable predictor for in-hospital death in aSAH patients.

Comparison of Sex Differences in Outcomes of Patients With Aneurysmal Subarachnoid Hemorrhage: A Single-Center Retrospective Study

Background

Sex differences in the outcomes of patients with aneurysmal subarachnoid hemorrhage (aSAH) remain controversial. The aim of this study was to evaluate sex differences in the outcomes of patients with aSAH.

Method

This study retrospectively analyzed the clinical data of consecutive patients with aSAH, admitted to the Department of Neurosurgery, Wuhan University Zhongnan Hospital, from May 1, 2020 to December 31, 2020. The modified Rankin Scale (mRS) score was used to evaluate the prognosis of patients at discharge. Outcome indicators included cerebral ischemia, hydrocephalus, and mRS ≥ 2 at discharge.

Results

The majority (65%) of the 287 patients with aSAH included in the study were females. Patients were divided into female (n = 184) and male (n = 99) groups; the female patients were significantly older than the male patients (61.3 ± 8.5 years vs. 60.0 ± 8.5 years, p = 0.032). The incidence of comorbidities (hypertension, diabetes, and heart disease) was higher in the female group than in the male group, but the difference was not statistically significant. Although more female patients than male patients underwent endovascular treatment, there was no statistical difference in the treatment approach between the two groups. Comparison of post-operative complications and mRS scores at discharge revealed that the rate of cerebral ischemia and mRS ≥ 2 at discharge were significantly higher among female patients than among male patients. Moreover, this difference persisted after propensity adjustment for age and treatment approach. Analysis of risk factors for poor prognosis at discharge in both pre- and post-adjustment patients revealed cerebral ischemia and high mFisher score (mFisher = 3/4) to be independent risk factors.

Conclusion

Female patients with aSAH have a worse prognosis than male patients, and this difference may be because women are more susceptible to cerebral ischemia.

Trends in Mortality after Intensive Care of Patients with Aneurysmal Subarachnoid Hemorrhage in Finland in 2003-2019: A Finnish Intensive Care Consortium study

Background

Previous studies suggest that case mortality of aneurysmal subarachnoid hemorrhage (aSAH) has decreased during the last decades, but most studies have been unable to assess case severities among individual patients. We aimed to assess changes in severity-adjusted aSAH mortality in patients admitted to intensive care units (ICUs).

Methods

We conducted a retrospective, register-based study by using the prospectively collected Finnish Intensive Care Consortium database. Four out of five ICUs providing neurosurgical and neurointensive care in Finland participated in the Finnish Intensive Care Consortium. We extracted data on adult patients admitted to Finnish ICUs with aSAH between 2003 and 2019. The primary outcome was 12-month mortality during three periods: 2003–2008, 2009–2014, and 2015–2019. Using a multivariable logistic regression model—with variables including age, sex, World Federation of Neurological Surgeons grade, preadmission dependency, significant comorbidities, and modified Simplified Acute Physiology Score II—we analyzed whether admission period was independently associated with mortality.

Results

A total of 1,847 patients were included in the study. For the periods 2003–2008 and 2015–2019, the mean number of patients with aSAH admitted per year increased from 81 to 123. At the same time, the patients’ median age increased from 55 to 58 years (p = 0.001), and the proportion of patients with World Federation of Neurological Surgeons grades I–III increased from 42 to 58% (p < 0.001). The unadjusted 12-month mortality declined from 30% in 2003–2008 to 23% in 2015–2019 (p = 0.001), but there was no statistically significant change in severity-adjusted mortality.

Conclusions

Between 2003 and 2019, patients with aSAH admitted to ICUs became older and the proportion of less severe cases increased. Unadjusted mortality decreased but age and case severity adjusted–mortality remained unchanged.

Supplementary Information

The online version contains supplementary material available at 10.1007/s12028-021-01420-z.

Decreased Superoxide Dismutase Concentrations (SOD) in Plasma and CSF and Increased Circulating Total Antioxidant Capacity (TAC) Are Associated with Unfavorable Neurological Outcome after Aneurysmal Subarachnoid Hemorrhage

Background: Subarachnoid hemorrhage (SAH) is a devastating disease with high morbidity and mortality. Hypoxia-induced changes and hemoglobin accumulation within the subarachnoid space are thought to lead to oxidative stress, early brain injury, and delayed vasospasm. This study aimed to evaluate the antioxidant status and its impact on neurological outcome in patients with aneurysmal SAH. Methods: In this prospective observational study, 29 patients with aneurysmal SAH were included (mean age 54.7 ± 12.4). Blood and cerebrospinal fluid (CSF) samples were collected on days (d) 1, 3, and 7. In addition, 29 patients without intracranial hemorrhage served as controls. The antioxidant system was analyzed by glutathione peroxidase (GSH-Px; U/L) and total and free glutathione-sulfhydryl (GSH; mg/L) in the plasma. Superoxide dismutase (SOD, U/mL) and total antioxidant capacity (TAC, µmol/L) were measured in the serum and CSF. Clinical data were compiled on admission (Hunt and Hess grade, Fisher grade, and GCS). Neurological and cognitive outcome (modified Rankin scale (mRS), Glasgow Outcome Scale Extended (GOSE) and Montreal Cognitive Assessment (MoCA)) was assessed after 6 weeks (6 w) and 6 months (6 m). Results: Plasma levels of SOD increased from day 1 to 7 after SAH (d1: 1.22 ± 0.36 U/L; d3: 1.25 ± 0.33 U/L, p = 0.99; d7: 1.52 ± 0.4 U/L, p = 0.019) and were significantly higher compared to controls (1.11 ± 0.27 U/L) at day 7 (p < 0.001). Concordantly, CSF levels of SOD increased from day 1 to 7 after SAH (d1: 1.22 ± 0.41 U/L; d3: 1.77 ± 0.73 U/L, p = 0.10; d7: 2.37 ± 1.29 U/L, p < 0.0001) without becoming significantly different compared to controls (1.74 ± 0.8 U/L, p = 0.09). Mean plasma TAC at day 1 (d1: 77.87 ± 49.72 µmol/L) was not statistically different compared to controls (46.74 ± 32.42 µmol/L, p = 0.25). TAC remained unchanged from day 1 to 7 (d3: 92.64 ± 68.58 µmol/L, p = 0.86; d7: 74.07 ± 54.95 µmol/L, p = 0.8) in plasma. TAC in CSF steeply declined from day 1 to 7 in patients with SAH becoming significantly different from controls at days 3 and 7 (d3: 177.3 ± 108.7 µmol/L, p = 0.0046; d7: 85.35 ± 103.9 µmol/L, p < 0.0001). Decreased SOD levels in plasma and CSF are associated with a worse neurological outcome 6 weeks (mRS: CSF p = 0.0001; plasma p = 0.027/GOSE: CSF p = 0.001; plasma p = 0.001) and 6 months (mRS: CSF p = 0.001; plasma p = 0.09/GOSE: CSF p = 0.001; plasma p = 0.001) after SAH. Increased plasma TAC correlated with a worse neurological outcome 6 weeks (mRS: p = 0.001/GOSE p = 0.001) and 6 months (mRS p = 0.001/GOSE p = 0.001) after SAH. Conclusion: In our study, a reduction in the antioxidative enzyme SOD and elevated TAC were associated with a poorer neurological outcome reflected by mRS and GOSE at 6 weeks and 6 months after SAH. A lower initial SOD CSF concentration was associated with the late deterioration of cognitive ability. These findings support the mounting evidence of the role of oxidative stress in early brain injury formation and unfavorable outcome after SAH.

Associations between socioeconomic status and place of residence with survival after aneurysmal subarachnoid haemorrhage

OBJECTIVES

This study aims to understand early (< 24 h post ictus) and late (up to 12 months) survival post aneurysmal subarachnoid haemorrhage (aSAH), with a focus on rurality and socioeconomic status.

METHODS

A statewide population-based cohort of aSAH cases in Tasmania, Australia, was established from 2010-2014 utilising multiple overlapping sources. Clinical data were collected from medical records and the Tasmanian Death Registry, with area-level rurality and socioeconomic status geocoded to participants' residential address.

RESULTS

From a cohort of 237 (70% women, 36% disadvantaged, 38% rural) individuals over a 5-year period, 12-month mortality was 52.3% with 54.0% of these deaths occurring within 24 h post ictus. In univariable analysis of 12-month survival, outcome was not influenced by socioeconomic status but rural geographical location was associated with a non-significant increase in death (HR 1.22 95% CI 0.85-1.75) along with hypertension (HR 1.78 95% CI 1.07-2.98) and hypercholesterolemia (HR 1.70 95% CI 0.99-2.91). Multivariable analysis demonstrated a statistically significant increase in death to 12 months after aSAH for both hypertension (HR 1.81 95% CI 1.08-3.03) and hypercholesterolemia (HR 1.71 95% CI 1.00-2.94) but not socioeconomic status or geographic location.

CONCLUSION

We found high early death in this population-based aSAH Australian population. Survival to 12 months after aSAH was not related to either geographical location or socioeconomic status but modifiable risk factors increased the risk of death. This article is protected by copyright. All rights reserved.

Sex differences in aneurysmal subarachnoid haemorrhage (aSAH): aneurysm characteristics, neurological complications, and outcome

BACKGROUND

Women are over-represented in aSAH cohorts, but whether their outcomes differ to men remains unclear. We examined if sex differences in neurological complications and aneurysm characteristics contributed to aSAH outcomes.

METHODS

In a retrospective cohort (2010-2016) of all aSAH cases across two hospital networks in Australia, information on severity, aneurysm characteristics and neurological complications (rebleed before/after treatment, postoperative stroke < 48 h, neurological infections, hydrocephalus, seizures, delayed cerebral ischemia [DCI], cerebral infarction) were extracted. We estimated sex differences in (1) complications and aneurysm characteristics using chi square/t-tests and (2) outcome at discharge (home, rehabilitation or death) using multinomial regression with and without propensity score matching on prestroke confounders.

RESULTS

Among 577 cases (69% women, 84% treated) aneurysm size was greater in men than women and DCI more common in women than men. In unadjusted log multinomial regression, women had marginally greater discharge to rehabilitation (RRR 1.15 95% CI 0.90-1.48) and similar likelihood of in-hospital death (RRR 1.02 95% CI 0.76-1.36) versus discharge home. Prestroke confounders (age, hypertension, smoking status) explained greater risk of death in women (rehabilitation RRR 1.13 95% CI 0.87-1.48; death RRR 0.75 95% CI 0.51-1.10). Neurological complications (DCI and hydrocephalus) were covariates explaining some of the greater risk for poor outcomes in women (rehabilitation RRR 0.87 95% CI 0.69-1.11; death RRR 0.80 95% CI 0.52-1.23). Results were consistent in propensity score matched models.

CONCLUSION

The marginally poorer outcome in women at discharge was partially attributable to prestroke confounders and complications. Improvements in managing complications could improve outcomes.

Prediction of Outcome After Aneurysmal Subarachnoid Hemorrhage

Background and Purpose- Early prediction of clinical outcome after aneurysmal subarachnoid hemorrhage (aSAH) is still lacking accuracy. In this observational cohort study, we aimed to develop and validate an accurate bedside prediction model for clinical outcome after aSAH, to aid decision-making at an early stage. Methods- For the development of the prediction model, a prospectively kept single-center cohort of 1215 aSAH patients, admitted between 1998 and 2014, was used. For temporal validation, a prospective cohort of 224 consecutive aSAH patients from the same center, admitted between 2015 and 2017, was used. External validation was performed using the ISAT (International Subarachnoid Aneurysm Trial) database (2143 patients). Primary outcome measure was poor functional outcome 2 months after aSAH, defined as modified Rankin Scale score 4-6. The model was constructed using multivariate regression analyses. Performance of the model was examined in terms of discrimination and calibration. Results- The final model included 4 predictors independently associated with poor outcome after 2 months: age, World Federation of Neurosurgical Societies grade after resuscitation, aneurysm size, and Fisher grade. Temporal validation showed high discrimination (area under the receiver operating characteristic curve, 0.90; 95% CI, 0.85-0.94), external validation showed fair to good discrimination (area under the receiver operating characteristic curve, 0.73; 95% CI, 0.70-0.76). The model showed satisfactory calibration in both validation cohorts. The SAFIRE grading scale was derived from the final model: size of the aneurysm, age, Fisher grade, world federation of neurosurgical societies after resuscitation. Conclusions- The SAFIRE grading scale is an accurate, generalizable, and easily applicable model for early prediction of clinical outcome after aSAH.

Sex differences in stroke

Sex disparities within the field of stroke, including subarachnoid hemorrhages (SAHs), have been in focus during the last 2 decades. It is clear that stroke incidence is higher in men, and also that men have their first stroke earlier than women. On the other hand, women have more severe strokes, mainly because cardioembolic strokes are more common in women. This leads to higher case fatality and worse functional outcome in women. It has often been pointed out that women more often have nontraditional stroke symptoms, and therefore may seek medical help later. After discharge from the hospital, female stroke survivors live alone in many cases and are dependent on external care. Therefore, these women frequently rate their quality of life (QoL) lower than men do. Female spouses more often provide help to their male stroke survivors than the reverse, and they accept a heavier burden. These caregivers are at high risk for depression, low QoL, and low psychologic wellbeing. SAH is a special form of stroke, often caused by a ruptured aneurysm. It is about 20% more common in women. The case fatality is high, but does not differ between the sexes.

Microstructural White Matter Abnormalities and Cognitive Impairment After Aneurysmal Subarachnoid Hemorrhage

Background and Purpose- Aneurysmal subarachnoid hemorrhage (aSAH) may have detrimental effects on white matter microstructure, which may in turn explain the cognitive impairments that occur often after aSAH. We investigated (1) whether the white matter microstructure is altered in patients with aSAH compared with patients with an unruptured intracranial aneurysm and (2) whether these abnormalities are associated with cognitive impairment 3 months after ictus. Methods- Forty-nine patients with aSAH and 22 patients with an unruptured intracranial aneurysm underwent 3T brain magnetic resonance imaging, including a high-resolution diffusion tensor imaging sequence. Patients with aSAH were scanned 2 weeks and 6 months after ictus. Microstructural white matter alterations were quantified by the fractional anisotropy and mean diffusivity (MD). Cognition was evaluated 3 months after ictus. Results- Patients with aSAH had higher white matter MD 2 weeks after ictus than patients with an unruptured intracranial aneurysm (mean difference±SEM, 0.3±0.01×10^-3 mm2/s; P≤0.01), reflecting an abnormal microstructure. After 6 months, the MD had returned to the level of the unruptured intracranial aneurysm group. No between-group differences in fractional anisotropy were found (-0.01±0.01; P=0.16). Higher MD at 2 weeks was associated with cognitive impairment after 3 months (odds ratio per SD increase in MD, 2.6; 95% CI, 1.1-6.7). The association between MD and cognitive impairment was independent of conventional imaging markers of aSAH-related brain injury (ie, cerebral infarction, hydrocephalus, total amount of subarachnoid blood, total brain volume, or white matter hyperintensity severity). Conclusions- Patients with aSAH have temporary white matter abnormalities in the subacute phase that are associated with cognitive impairment at 3 months after ictus.

Meteorological Variation Is a Predisposing Factor for Aneurismal Subarachnoid Hemorrhage: A 5-Year Multicenter Study in Fuzhou, China

OBJECTIVE

The climatic characteristics of aneurysmal subarachnoid hemorrhage (aSAH) have been reported, but consensus has not yet been reached. It is of great significance to elucidate the relationships between meteorological variation and aSAH in regions with specific climate patterns. We analyzed the occurrence of aSAH in the capital city of Fujian Province, China, through a multicenter, 5-year study, and aimed to reveal the meteorological influences on aSAH in the coastal city of eastern Fujian under the subtropical marine monsoon condition.

METHODS

A total of 2555 consecutive patients with aSAH in Fuzhou were collected using specialized stroke admission database from January 2013 to December 2017. Meteorological parameters including temperature, atmospheric pressure, and humidity were obtained from China Surface Meteorological Station during the same period. Poisson regression was used to explore the association between meteorological parameters and aSAH to calculate the incidence rate ratios (IRRs) with corresponding 95% confidence intervals (CIs). Generalized additive model analysis further revealed the nonlinear relationships between weather and aSAH.

RESULTS

Daily minimum temperature (IRR 0.976, 95% CI 0.958-0.996) and maximum pressure (IRR 1.022, 95% CI 1.001-1.042) were independently correlated with the onset of aSAH. Low temperature (below 16°C) and excessive atmospheric pressure (above 1008 hPa) increased the risk of aSAH. In addition, March in spring and December in winter were the 2 ictus peaks in Fuzhou throughout the year.

CONCLUSIONS

Cold and excessive atmospheric pressure are triggers for the occurrence of aSAH; March in spring and December in winter are the predominant onset periods in Fuzhou.

Association of Stroke Among Adults Aged 18 to 49 Years With Long-term Mortality

IMPORTANCE

Stroke remains the second leading cause of death worldwide. Approximately 10% to 15% of all strokes occur in young adults. Information on prognosis and mortality specifically in young adults is limited.

OBJECTIVE

To determine short- and long-term mortality risk after stroke in young adults, according to age, sex, and stroke subtype; time trends in mortality; and causes of death.

DESIGN, SETTING, AND PARTICIPANTS

Registry- and population-based study in the Netherlands of 15 527 patients aged 18 to 49 years with first stroke between 1998 and 2010, and follow-up until January 1, 2017. Patients and outcomes were identified through linkage of the national Hospital Discharge Registry, national Cause of Death Registry, and the Dutch Population Register.

EXPOSURES

First stroke occurring at age 18 to 49 years, documented using International Classification of Diseases, Ninth Revision, and International Statistical Classification of Diseases and Related Health Problems, Tenth Revision, codes for ischemic stroke, intracerebral hemorrhage, and stroke not otherwise specified.

MAIN OUTCOMES AND MEASURES

Primary outcome was all-cause cumulative mortality in 30-day survivors at end of follow-up, stratified by age, sex, and stroke subtype, and compared with all-cause cumulative mortality in the general population.

RESULTS

The study population included 15 527 patients with stroke (median age, 44 years [interquartile range, 38-47 years]; 53.3% women). At end of follow-up, a total of 3540 cumulative deaths had occurred, including 1776 deaths within 30 days after stroke and 1764 deaths (23.2%) during a median duration of follow-up of 9.3 years (interquartile range, 5.9-13.1 years). The 15-year mortality in 30-day survivors was 17.0% (95% CI, 16.2%-17.9%). The standardized mortality rate compared with the general population was 5.1 (95% CI, 4.7-5.4) for ischemic stroke (observed mortality rate 12.0/1000 person-years [95% CI, 11.2-12.9/1000 person-years]; expected rate, 2.4/1000 person-years; excess rate, 9.6/1000 person-years) and the standardized mortality rate for intracerebral hemorrhage was 8.4 (95% CI, 7.4-9.3; observed rate, 18.7/1000 person-years [95% CI, 16.7-21.0/1000 person-years]; expected rate, 2.2/1000 person-years; excess rate, 16.4/1000 person-years).

CONCLUSIONS AND RELEVANCE

Among young adults aged 18 to 49 years in the Netherlands who were 30-day survivors of first stroke, mortality risk compared with the general population remained elevated up to 15 years later.

Stroke incidence in young adults according to age, subtype, sex, and time trends

OBJECTIVE

To investigate incidence of stroke and its subtypes in young adults, according to sex and age, and to study trends over time.

METHODS

We established a nationwide cohort through linkage of national registries (hospital discharge, cause of death, and population register) with patients aged 18-50 years and those ≥50 years with first-ever ischemic stroke, intracerebral hemorrhage, or unspecified stroke, using ICD-9/ICD-10 codes between 1998 and 2010 in the Netherlands. Outcomes were yearly incidence of stroke stratified by age, sex, and stroke subtype, its changes over time, and comparison of incidence in patients 18-50 years to patients ≥50 years.

RESULTS

We identified 15,257 patients (53% women; mean age 41.8 years). Incidence increased exponentially with age (R ² = 0.99) and was higher for women than men, most prominently in the youngest patients (18-44 years). The relative proportion of ischemic stroke increased with age (18-24 years: 38.3%; 44-49 years: 56.5%), whereas the relative proportion of intracerebral hemorrhage decreased (18-24 years: 34.0%; 44-49 years: 18.3%). Incidence of any stroke in young adults increased (1998: 14.0/100,000 person-years: 2010: 17.2; +23%; p < 0.001), driven by an increase in those aged over 35 years and ischemic stroke incidence (46%), whereas incidence decreased in those ≥50 years (329.1%-292.2%; -11%; p = 0.009).

CONCLUSIONS

Incidence of any stroke in the young increases with age in patients over 35, is higher in women than men aged 18-44 years, and has increased by 23% in one decade, through an increase in ischemic stroke. Incidence of intracerebral hemorrhage is comparable for women and men and remained stable over time.

Evaluation of the yield of post-clipping angiography and nationwide current practice

BACKGROUND

Surgical treatment of intracranial saccular aneurysms aims to prevent (re)hemorrhage by complete occlusion of the aneurysmal lumen. It is unclear whether routine postoperative imaging, to assess aneurysmal occlusion, is necessary since intraoperative assessment by the neurosurgeon may be sufficient. We assessed routine clinical protocols for post-clipping imaging in the Netherlands and determined whether intraoperative assessment of aneurysm clippings sufficiently predicts aneurysm residuals.

METHODS

A survey was conducted to assess postoperative imaging protocols in centers performing clipping of intracranial aneurysms in the Netherlands (n = 9). Furthermore, a retrospective single-center cohort study was performed to determine the predictive value of intraoperative assessment of aneurysm occlusion in relation to postoperative digital subtraction angiography (DSA) findings, between 2009 and 2017.

RESULTS

No center performed intraoperative DSA in a hybrid OR, routinely. Respectively, four (44.4%), seven (77.8%), and three (33.3%) centers did not routinely perform early postoperative imaging, late follow-up imaging, or any routine imaging at all. Regarding our retrospective study, 106 patients with 132 clipped aneurysms were included. There were 23 residuals ≥ 1 mm (17.4%), of which 10 (43.5%) were unexpected. For the presence of these residuals, intraoperative assessment showed a sensitivity of 56.5%, a specificity of 86.2%, a positive predictive value of 46.4%, and a negative predictive value of 90.4%.

CONCLUSIONS

There is lack of consensus regarding the post-clipping imaging strategy in the Netherlands. Since intraoperative assessment is shown to be insufficient to predict postoperative aneurysm residuals, we advocate routine postoperative imaging after aneurysm clipping unless this is not warranted on the basis of patient age, clinical condition, and/or comorbidity.

Optical Coherence Tomography for Intracranial Aneurysms: A New Method for Assessing the Aneurysm Structure

BACKGROUND

There is a lack of precise methods for predicting the risk of aneurysm rupture. Therefore, prophylactic treatment is used, which leads to unnecessary potential complications. A new modality enabling a more accurate risk assessment is needed. Optical coherence tomography (OCT) is a new-generation imaging technology that has astonishing resolution for vascular imaging. In this study, OCT was used for the evaluation of intracranial aneurysms.

METHODS

In vivo OCT imaging was performed for aneurysms induced in 6 rabbits and in 9 intracranial aneurysm patients. Catheters were cut short to prevent any extra length from damaging aneurysms and tissues. Images of both the parent artery and the aneurysm at multiple viewing angles were obtained using rotational OCT scanning.

RESULTS

The OCT images of rabbits correlated well with histologic sections. The 3-layered architecture of the parent arteries was explicitly shown. Ruptured intracranial aneurysms manifested complete breakdown of the wall structure; however, this was not observed in any unruptured aneurysms. The OCT images of unruptured intracranial aneurysms demonstrated a trend of degradation by showing the gradual disappearance of the demarcation between the layers or incomplete apoptosis in layer structures.

CONCLUSION

OCT is the most precise imaging modality because it provides detailed information regarding the aneurysm structures, thus enabling more distinct insight into the vascular construction of intracranial aneurysms.

Atmospheric Pressure Variation is a Delayed Trigger for Aneurysmal Subarachnoid Hemorrhage

OBJECTIVE

There is an ongoing search for conditions that induce spontaneous subarachnoid hemorrhage (SAH). The seasonal pattern of SAH is shown in a large meta-analysis of the literature, but its explanation remains undecided. There is a clear need for sound meteorologic data to further elucidate the seasonal influence on SAH. Because of the stable and densely monitored atmospheric situation in the north of the Netherlands, we reviewed our unique cohort on the seasonal incidence of SAH and the association between SAH and local atmospheric changes.

METHODS

Our observational cohort study included 1535 patients with spontaneous SAH admitted to our neurovascular center in the north of the Netherlands between 2000 and 2015. Meteorologic data could be linked to the day of the ictus. To compare SAH incidences over the year and to test the association with meteorologic conditions, incidence rate ratios (IRRs) with corresponding 95% confidence intervals (CIs) were used, calculated by Poisson regression analyses.

RESULTS

Atmospheric pressure variations were significantly associated with aneurysmal SAH. In particular, the pressure change on the second and third day before the ictus was independently correlated to a higher incidence of aneurysmal SAH (IRR, 1.11; 95% CI, 1.00-1.23). The IRR for aneurysmal SAH in July was calculated 0.67 (95% CI, 0.49-0.92) after adjustment for temperature and atmospheric pressure changes.

CONCLUSIONS

Atmospheric pressure variations are a delayed trigger for aneurysmal SAH. Also, a significantly decreased incidence of aneurysmal SAH was noted in July.

Transoceanic Management and Treatment of Aneurysmal Subarachnoid Hemorrhage: A 10-Year Experience

BACKGROUND AND PURPOSE

Because of the small number of yearly cases of ruptured cerebral aneurysms, endovascular treatment is not performed in Martinique. Therefore, patients from Martinique are sent 7000 km to Paris on commercial flights as soon as possible, where treatment is performed. Nontransportable patients are treated locally with either surgery or symptomatic care. The objective of our study was to assess patient outcomes and safety of this treatment strategy.

METHODS

We retrospectively examined all cases of aneurysmal subarachnoid hemorrhage in Martinique diagnosed during 2004 to 2013. Medical case records were searched for the type and location of treatment, clinical status, and transfer duration.

RESULTS

A total of 119 patients had an aneurysmal subarachnoid hemorrhage during the 10-year period. Of these, 91 were transferred to Paris, 12 were surgically treated locally, and 16 received symptomatic treatment. None of the transferred patients experienced any hemorrhagic recurrence, and none suffered a significant complication related to the air transportation. The median time between aneurysmal subarachnoid hemorrhage diagnosis and arrival at the referral center was 32 hours. The 30-day case fatality rate for treated cases was 14.6% (8.8% for those treated in Paris and 58.3% for those treated locally).

CONCLUSIONS

Our treatment strategy for aneurysmal subarachnoid hemorrhage resulted in a 30-day case fatality rate similar to those observed elsewhere, despite an 8-hour flight and a median treatment delay of 32 hours. This strategy therefore seems to be safe and reliable for isolated regions with small populations.

Increased incidence of subarachnoid hemorrhage during cold temperatures and influenza epidemics

OBJECTIVE

This study investigated whether the increased incidence of aneurysmal subarachnoid hemorrhage (SAH) in winter is related to temperature or increased incidence of influenza. Such relationships may elucidate the pathogenesis of intracranial aneurysm rupture.

METHODS

A nationwide sample of 18,714 patients with SAH was linked with weekly temperature and influenza-like illness consultation data. Poisson regression analyses were used to calculate incidence density ratios (IDRs) with corresponding 95% CIs for the association of SAH incidence with temperature and influenza epidemics; IDRs were adjusted for study year (aIDR). In addition, SAH incidence data from 30 European population-based studies were linked with daily temperature data from the European Climate Assessment.

RESULTS

The aIDR for SAH during influenza epidemics was 1.061 (95% CI 1.022–1.101) in the univariable and 1.030 (95% CI 0.989–1.074) in the multivariable analysis. This association declined gradually during the weeks after epidemics. Per 1°C temperature drop, the aIDR was 1.005 (95% CI 1.003–1.008) in the univariable and 1.004 (95% CI 1.002–1.007) in the multivariable analysis. In the European population-based studies, the IDR was 1.143 (95% CI 1.129–1.157) per 1°C temperature drop.

CONCLUSIONS

The incidence of SAH is increased during cold temperatures and epidemic influenza. Future studies with individual patient data are needed to investigate causality between temperature or influenza and SAH.

Prediction of outcome after subarachnoid hemorrhage: timing of clinical assessment

OBJECTIVE Currently, early prediction of outcome after spontaneous subarachnoid hemorrhage (SAH) lacks accuracy despite multiple studies addressing this issue. The clinical condition of the patient on admission as assessed using the World Federation of Neurosurgical Societies (WFNS) grading scale is currently considered the gold standard. However, the timing of the clinical assessment is subject to debate, as is the contribution of additional predictors. The aim of this study was to identify either the conventional WFNS grade on admission or the WFNS grade after neurological resuscitation (rWFNS) as the most accurate predictor of outcome after SAH. METHODS This prospective observational cohort study included 1620 consecutive patients with SAH admitted between January 1998 and December 2014 at our university neurovascular center. The primary outcome measure was a poor modified Rankin Scale score at the 2-month follow-up. Clinical predictors were identified using multivariate logistic regression analyses. Area under the receiver operating characteristic curve (AUC) analysis was used to test discriminative performance of the final model. An AUC of > 0.8 was regarded as indicative of a model with good prognostic value. RESULTS Poor outcome (modified Rankin Scale Score 4-6) was observed in 25% of the patients. The rWFNS grade was a significantly stronger predictor of outcome than the admission WFNS grade. The rWFNS grade was significantly associated with poor outcome (p < 0.001) as well as increasing age (p < 0.001), higher modified Fisher grade (p < 0.001), larger aneurysm size (p < 0.001), and the presence of an intracerebral hematoma (OR 1.8, 95% CI 1.2-2.8; p = 0.002). The final model had an AUC of 0.87 (95% CI 0.85-0.89), which indicates excellent prognostic value regarding the discrimination between poor and good outcome after SAH. CONCLUSIONS In clinical practice and future research, neurological assessment and grading of patients should be performed using the rWFNS to obtain the best representation of their clinical condition.

Time trends in causes of death after aneurysmal subarachnoid hemorrhage: A hospital-based study

OBJECTIVE

To compare causes of in-hospital death after aneurysmal subarachnoid hemorrhage (aSAH) in 2 time periods within the same institution.

METHODS

From a prospectively collected institutional database, we retrieved data on 844 consecutive patients with aSAH admitted ≤3 days after ictus in 1999-2002 and 2009-2012. We assessed case-fatality <90 days and causes of in-hospital death and used Poisson regression analyses to calculate adjusted risk ratios (aRR) with corresponding 95% confidence intervals (CI) for change in individual causes of death, with the first time period as the reference group.

RESULTS

Ninety-day case-fatality declined from 150/381 patients (39%) in 1999-2002 to 140/463 (30%) in 2009-2012 (aRR 0.74 [95% CI 0.62-0.88]). Compared with 1999-2002, the aRR for specific cause of in-hospital death in 2009-2012 was 1.06 (95% CI 0.72-1.56) for death from the initial bleeding, 0.47 (95% CI 0.31-0.71) for death from rebleeding, and 0.91 (95% CI 0.50-1.65) for death from delayed cerebral ischemia. Over time, the proportion of patients with in-hospital rebleeding declined from 90/381 (24%) to 78/463 (17%) (aRR 0.68 [95% CI 0.52-0.90]), median day of rebleeding from day 5 (IQR 1-10) to day 0 (IQR 0-1), and median day of aneurysm treatment from day 4 (IQR 2-13) to day 1 (IQR 1-2).

CONCLUSIONS

An important contributor to the reduction in in-hospital death is the reduction in death from rebleeding, which probably results from earlier aneurysm treatment. Our results stress the need for early occlusion of the aneurysm and the need for other strategies that improve outcome by reducing the risk of rebleeding.

Time intervals from aneurysmal subarachnoid hemorrhage to treatment and factors contributing to delay

In the management of aneurysmal subarachnoid hemorrhage (aSAH), aneurysm treatment as early as feasible is mandatory to minimize the risk of a rebleed and may thus improve outcome. We assessed the different time intervals from the first symptoms of aSAH to start of aneurysm treatment in an effort to identify which factors contribute mostly to a delay in time to treatment. In 278 aSAH patients, time intervals between the different steps from initial hemorrhage to aneurysm treatment were retrospectively reviewed, and delaying factors were determined. Half of the patients presented to a hospital within 115 min (IQR 60-431). The median (IQR) interval from hemorrhage to diagnosis was 169 min (96-513), and from diagnosis to treatment 1,057 min (416-1,428), or 17.6 h. Aneurysm treatment started within 24 h in 76 % of treated patients. Independent factors predicting delay to treatment were primary presentation at a referring hospital and admission to the treatment center later in the day. Delay in treatment was not independently related to poor outcome. The interval to aneurysm treatment might be improved upon by immediate and direct transport to the treatment center combined with optimization of in-hospital logistics, following the 'time-is-brain' concept so successfully adopted in the treatment of ischemic stroke.