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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    • "As a result, neurovascular centres have adapted services to expedite patient care and this approach is recognised as contributing to the reduction in mortality rates following aSAH over the last three decades [6] [12]. Despite these improvements, the literature reports a fairly unchanging incidence of rebleeding. "
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    ABSTRACT: Re-haemorrhage is a negative, prognostic predictor of outcome in aneurysmal subarachnoid haemorrhage (aSAH). The process of aSAH care has changed however, and most reports on re-haemorrhage are from a time when aneurysms were treated predominantly by open microneurosurgery. The current frequency and impact of re-haemorrhage on outcome in the 'post-ISAT' era is therefore unknown. The aim of this study was to review current outcome, risk factors and causes for inpatient re-haemorrhage in aSAH patients. The departmental aSAH database was reviewed between Jan 2008 and March 2014 (N=1008) to identify cases of re-haemorrhage. Re-haemorrhage was defined as inhospital deterioration in neurological status with CT confirmation of rebleeding. Binary logistic regression was used to (a) determine the impact of re-haemorrhage on outcome adjusted for age and injury severity and (b) to identify any independent predictors of its occurrence. Re-haemorrhage occurred in 55 (5.4%) of patients and most cases had occurred within 24h of ictus (32, 58.1%). Re-haemorrhage was an independent predictor of death (AOR 10.0, p<0.0005, 95%CI 4.9, 20.2) and unfavourable outcome (AOR 5.8 p<0.0005, 95%CI 2.4, 14.0). Only WFNS grade on admission was an independent predictor (AOR 1.7, p<0.0005, 95%CI 1.4, 1.9) of re-haemorrhage. Of the patients who re-bled, in 20 there was no intention to treat due to severe brain injury and in the remainder, the majority occurred early (<24h) (19/35, 54%), or had complicated aneurysm morphology (10/35, 31%) which necessitated a delayed treatment strategy. Re-haemorrhage remains a poor prognostic predictor in aSAH and the grade of SAH is an independent risk factor. Earlier treatment of complex aneurysms could offer the most immediate improvements in its incidence. Copyright © 2015 Elsevier B.V. All rights reserved.
    Full-text · Article · May 2015 · Clinical neurology and neurosurgery
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    • "Spontaneous subarachnoid hemorrhage (SAH) is caused by rupture of an intracranial aneurysm in 80–90% [1] [2] of cases. The mortality for untreated aneurismal SAH is up to 43– 67% [3] [4] [5] in the first month. Therefore, early diagnosis and early treatment are the most effective way to prevent the death of patients. "
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    ABSTRACT: Objective: The aim of this study is to investigate the value of cerebral CT angiography (CTA) with low tube voltage in detection of intracranial aneurysms. Materials and methods: A total of 294 consecutive patients with spontaneous subarachnoid hemorrhage (SAH) were enrolled in this study and randomly assigned into conventional voltage CTA (C-CTA) group and low voltage CTA (L-CTA) group. The objective and subjective image qualities were analyzed and compared between C-CTA and L-CTA groups. With the results of 3D-DSA as "gold standard," the sensitivity, specificity, and accuracy of C-CTA and L-CTA in diagnosis of aneurysms were calculated and compared with each other. Results: Compared with group C-CTA, the CT dose index volume (CTDIvol) of group L-CTA reduced by 35.65%. There were no significant differences between C-CTA and L-CTA groups regarding objective and subjective image qualities. The sensitivity, specificity, and accuracy of L-CTA in diagnosis of aneurysms were 95.16%, 99.72%, and 99.42%, respectively. There were no significant differences in sensitivity, specificity, and accuracy between the C-CTA and L-CTA groups. Conclusion: The value of cerebral CTA with 100 kV low tube voltage in detection of intracranial aneurysms is significant, and it should be recommended as a routine scan method.
    Full-text · Article · Feb 2015
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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.
    Full-text · Article · Feb 2014 · Advances in Hematology
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