Lovelock CE, Rinkel GJ, Rothwell PMTime trends in outcome of subarachnoid hemorrhage. Population-based study and systematic review. Neurology 74:1494-1501

University Department of Clinical Neurology, John Radcliffe Hospital, Oxford, UK.
Neurology (Impact Factor: 8.29). 04/2010; 74(19):1494-501. DOI: 10.1212/WNL.0b013e3181dd42b3
Source: PubMed


Treatment of aneurysmal subarachnoid hemorrhage (SAH) has changed substantially over the last 25 years but there is a lack of reliable population-based data on whether case-fatality or functional outcomes have improved.
We determined changes in the standardized incidence and outcome of SAH in the same population between 1981 and 1986 (Oxford Community Stroke Project) and 2002 and 2008 (Oxford Vascular Study). In a meta-analysis with other population-based studies, we used linear regression to determine time trends in outcome.
There were no reductions in incidence of SAH (RR = 0.79, 95% confidence interval [CI] 0.48-1.29, p = 0.34) and in 30-day case-fatality (RR = 0.67, 95% CI 0.39-1.13, p = 0.14) in the Oxford Vascular Study vs Oxford Community Stroke Project, but there was a decrease in overall mortality (RR = 0.47, 0.23-0.97, p = 0.04). Following adjustment for age and baseline SAH severity, patients surviving to hospital had reduced risk of death or dependency (modified Rankin score > 3) at 12 months in the Oxford Vascular Study (RR = 0.51, 0.29-0.88, p = 0.01). Among 32 studies covering 39 study periods from 1980 to 2005, 7 studied time trends within single populations. Unadjusted case-fatality fell by 0.9% per annum (0.3-1.5, p = 0.007) in a meta-analysis of data from all studies, and by 0.9% per annum (0.2-1.6%, p = 0.01) within the 7 population studies.
Mortality due to subarachnoid hemorrhage fell by about 50% in our study population over the last 2 decades, due mainly to improved outcomes in cases surviving to reach hospital. This improvement is consistent with a significant decrease in case-fatality over the last 25 years in our pooled analysis of other similar population-based studies.

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    • "In contrast to the declining incidence of ischaemic stroke in high-income countries, the incidence of ICH has been constant [2]. The 1-month fatality rate after ICH does not appear to have changed over the last few decades with rates of 25–35% in high-income countries and 30–48% in low-/middle-income countries [3]. Computed tomography (CT) is now widely available in the developed world and has become the diagnostic test of choice in ICH to determine the site of the haemorrhage and estimate the volume of the haematoma [4]. "
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    ABSTRACT: Brain contains large amounts of tissue factor, the major initiator of the coagulation cascade. Neuronal apoptosis after intracerebral haemorrhage (ICH) leads to the shedding of procoagulant phospholipids (PPLs). The aim of this study was to investigate the generation of PPL, tissue factor activity (TFa), and D-Dimer (D-Di) in the cerebrospinal fluid (CSF) at the acute phase of ICH in comparison with other brain diseases and to examine the relationship between these factors and the outcome of ICH. CSF was collected from 112 patients within 48 hours of hospital admission. Thirty-one patients with no neurological or biochemical abnormalities were used to establish reference range in the CSF ("controls"). Thirty had suffered an ICH, and 51 other neurological diagnoses [12: ventricular drainage following brain surgery, 13: viral meningitis, 15: bacterial meningitis, and 11 a neurodegenerative disease (NDD)]. PPL was measured using a factor Xa-based coagulation assay and TFa by one home test. PPL, D-Di, and TFa were significantly higher (P < 0.001) in the CSF of patients with ICH than in controls. TFa levels were significantly (P < 0.05) higher in ICH than in patients with meningitides or NDD. Higher levels (P < 0.05) of TFa were observed in patients with ICH who died than in survivors. TFa measurement in the CSF of patients with ICH could constitute a new prognostic marker.
    Advances in Hematology 02/2014; 2014:576750. DOI:10.1155/2014/576750
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    • "Aneurysmal subarachnoid hemorrhage (SAH) accounts for 5% of all strokes. In recent years mortality has decreased to about 10-20% due to improved interventional and surgical techniques allowing early aneurysm occlusion [1]. However, SAH is still associated with significant morbidity. "
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    ABSTRACT: Chronic communicating hydrocephalus is a significant health problem affecting up to 20% of survivors of spontaneous subarachnoid hemorrhage (SAH). The development of new treatment strategies is hampered by the lack of well characterized disease models. This study investigated the incidence of chronic hydrocephalus by evaluating the temporal profile of intracranial pressure (ICP) elevation after SAH, induced by endovascular perforation in rats. Twenty-five adult male Sprague-Dawley rats (260-320g) were subjected to either endovascular perforation or sham surgery. Five animals died after SAH induction. At 7, 14 and 21 days after surgery ICP was measured by stereotaxic puncture of the cisterna magna in SAH (n=10) and SHAM (n=10) animals. On day 21 T-maze test was performed and the number of alterations and latency to decision was recorded. On day 23, samples were processed for histological analyses. The relative ventricle area was evaluated in coronal Nissl stained sections. On day 7 after surgery all animals showed normal ICP. The absolute ICP values were significantly higher in SAH compared to SHAM animals on day 21 (8.26±4.53 mmHg versus 4.38±0.95 mmHg) but not on day 14. Observing an ICP of 10mmHg as cut-off, 3 animals showed elevated ICP on day 14 and another animal on day 21. The overall incidence of ICP elevation was 40% in SAH animals. On day 21, results of T-maze testing were significantly correlated with ICP values, i.e. animals with elevated ICP showed a lower number of alterations and a delayed decision. Histology yielded a significantly higher (3.59 fold increased) relative ventricle area in SAH animals with ICP elevation compared to SAH animals without ICP elevation. In conclusion, the current study shows that experimental SAH leads to chronic hydrocephalus, which is associated with ICP elevation, behavioral alterations and ventricular dilation in about 40% of SAH animals.
    PLoS ONE 07/2013; 8(7):e69571. DOI:10.1371/journal.pone.0069571 · 3.23 Impact Factor
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    • "Therefore, SAH is regarded as the subtype of stroke with the worst prognosis ; due to the relatively young age at which SAH occurs, the loss of potential life before the age of 65 is comparable to that of ischemic stroke, a condition which is more than 20 times more frequent (incidence: 240/100,000 person years) [7]. Despite large technical and procedural achievements in the diagnosis of SAH, in the prevention of rebleedings, and in general intensive care over the past three decades, it is a matter of debate whether the outcome after SAH improved significantly [3] [5] [8] [9]. This disappointing situation may be the mere reflection of the severity of the disease, however, since most sequelae of SAH occur with a delay of several hours and even days, it is generally accepted that a deeper understanding of the pathophysiology of the secondary insults caused by the initial hemorrhage may be the key for the development of novel therapeutic strategies and, hence, for improving patient outcome. "
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    ABSTRACT: Subarachnoid hemorrhage (SAH) is the subtype of stroke with one of the highest mortality rates and the least well-understood pathophysiologies. One of the very early events which may occur after SAH is a significant decrease of cerebral perfusion pressure (CPP) caused by the excessive increase of intracranial pressure during the initial bleeding. A severely decreased CPP results in global cerebral ischemia, an event also occurring after cardiac arrest. The aim of the current paper is to review the pathophysiological events occurring in experimental models of SAH and global cerebral ischemia and to evaluate the contribution and the importance of global cerebral ischemia for the pathophysiology of SAH.
    Stroke Research and Treatment 06/2013; 2013(2):651958. DOI:10.1155/2013/651958
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