Article

Active and Passive Smoking and the Risk of Subarachnoid Hemorrhage An International Population-Based Case-Control Study

April 2004
Stroke 35(3):633-7

DOI:10.1161/01.STR.0000115751.45473.48

Source
PubMed

Authors:

C. Anderson

The George Institute for Global Health

Valery Feigin

Auckland University of Technology

Derrick A Bennett

University of Oxford

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This study was undertaken to better clarify the risks associated with cigarette smoking and subarachnoid hemorrhage (SAH). The study included 432 incident cases of SAH frequency matched to 473 community SAH-free controls to determine dose-dependent associations of active and passive smoking (at home) and smoking cessation with SAH. Compared with never smokers not exposed to passive smoking, the adjusted odds ratio for SAH among current smokers was 5.0 (95% confidence interval [CI], 3.1 to 8.1); for past smokers, 1.2 (95% CI, 0.8 to 2.0); and for passive smokers, 0.9 (95% CI, 0.6 to 1.5). Current and lifetime exposures showed a clear dose-dependent effect, and risks appeared more prominent in women and for aneurysmal SAH. Approximately 1 in 3 cases of SAH could be attributed to current smoking, but risks decline quickly after smoking cessation, even among heavy smokers. A strong positive association was found between cigarette smoking and SAH, especially for aneurysmal SAH and women, which is virtually eliminated within a few years of smoking cessation. Large opportunities exist for preventing SAH through smoking avoidance and cessation programs.

Risk factor synergism in aneurysmal subarachnoid hemorrhage: a cross-sectional study

Article

Full-text available

Nov 2023
ACTA NEUROCHIR

Background Spontaneous subarachnoid hemorrhage (SAH) accounts for 5–10% of strokes but a disproportionately large amount of stroke-related morbidity. Several risk factors have been described, including smoking, hypertension, increasing age, and female sex. Methods This cross-sectional study examined all patients with aSAH within a nationally representative catchment from 01/01/2017 to 31/12/2020. Patients with aneurysmal SAH were identified from multiple sources, including a prospective database and death records. The population was estimated from projections from a door-to-door census and risk factors from stratified random sampled surveys conducted on a yearly basis. Poisson regression models were used to estimate the incidence and incidence rate ratios (IRRs) for risk factors with 95% confidence intervals (95% CIs). Results We identified 875 cases of aSAH in 11,666,807 patient-years of follow-up, which corresponded to a crude incidence of 7.5 per 100,000 patient-years (95% CI 7–8) and a standardized incidence of 6.1/100,000 (95% CI 5.6–6.5). Smoking was the strongest individual risk factor, with a standardized incidence of 24/100,000 (95% CI 20–27) in smokers compared with 2.6/100,000 (2.1–3.2) in non-smokers (age-adjusted IRR 9.2, 95% CI 6.3–13.6). Hypertension (age-adjusted IRR 3.1, 95% CI 2.2–4.3) and female sex (age-adjusted IRR 1.8, 95% CI 1.4–2.3) were also associated with increased incidence. The highest incidence was observed in hypertensive smokers (standardized incidence 63/100,000, 95% CI 41–84), who had a lifetime risk of aSAH of 6.7% (95% CI 5.4–8.1) after age 35. Compared with participants who were non-smokers without hypertension, the age-adjusted IRR in hypertensive smokers was 27.9 (95% CI 15.9–48.8). Conclusion Smoking is the most prominent individual risk factor for aSAH. Smoking and hypertension appear to interact to increase the risk of aSAH synergistically.

The role of physical activity in primary stroke prevention

Article

Full-text available

Dec 2019

Physical inactivity is a known risk factor for stroke. The interaction between exercise and risk of stroke is complex. Physical activity has a beneficial effect on most risk factors for stroke, which may show reciprocal potentiation (e.g. obesity, sleep apnea, atrial fibrillation). Advice on physical activity is of importance in primary prevention of stroke. Hereby, type, amount and intensity of physical activity may be distinguished and adjusted according to comorbidities (e.g. in case of heart failure).

Communities of Practice: A systematic review and meta‐synthesis of what it means and how it really works among nursing students and novices

Article

Nov 2019

Aims and objectives: To evaluate the enablers, barriers and impact that communities of practice have on novice nurses and students learning to become registered nurses. Background: Communities of practice have formed the basis for conceptualising the process of learning that occurs among groups of people within a place of work-a mainstay of healthcare practice. There is a dearth of literature that focuses specifically on the outcomes from student and novice engagement with existing communities of practice. Design: Systematic review and Meta-synthesis. Methods: MEDLINE, PubMed, EMBASE, CINAHL, ProQuest, Scopus and PsycINFO databases were accessed between 1997-2019. The screening and selection of studies were based on eligibility criteria and methodological quality assessment using the Critical Appraisal Skills Programme tool for qualitative research. Meta-synthesis was grounded in the original experiences and collectively synthesised into meaningful themes. The review follows the PRISMA reporting guidelines and PRISMA checklist. Results: The findings highlight three major themes and included enablers for successful communities of practice, barriers to successful communities of practice, and success in action as described by students and novice nurses. Discussion: We suggest successful communities of practice occur when safe and supported spaces ensure students and novices feel comfortable to experiment with their learning, and we emphasise the benefits of having more novice nurses situated within close proximity and under the direct influence of the established practices of more experienced or core group of peers. Relevance to clinical practice: Communities of practice that function successfully create an environment that prioritises the embedding of novices into the broader group. In so doing, students and novice nurses feel supported, welcomed, empowered, and able to make the transition from student to colleague and novice nurse to more experienced nurse. It allows them to experiment with ever new ways of fulfilling the role, while aiding better clinical outcomes.

Normal Ranges of Left Ventricular Strain by Three-Dimensional Speckle-Tracking Echocardiography in Adults: A Systematic Review and Meta-Analysis

Article

Full-text available

Oct 2019
J AM SOC ECHOCARDIOG

Background: Establishing normal values and associated variations of three-dimensional speckle-tracking echocardiography- (3DSTE-) derived left ventricular (LV) strain is necessary for accurate interpretation and comparison of measurements. We aimed to perform a meta-analysis of normal ranges of LV global longitudinal strain (GLS), global circumferential strain (GCS), global radial strain (GRS), and global area strain (GAS) measurements derived by 3DSTE and to identify confounding factors that may contribute to variance in reported measures. Methods: The authors searched four databases, PubMed, Scopus, Embase, and Cochrane Library, through January 2019 using the key terms "left ventricular/left ventricle/left ventricles", "strain/deformation/speckle tracking", and "three dimensional/three-dimensional/three-dimension/three dimension/3D". Studies were included if the articles reported LV strain using 3DSTE in healthy normal subjects, either in the control group or comprising the entire study cohort. The weighted mean was estimated by using the random effects model with a 95% CI. Heterogeneity across studies was assessed using the I2 test. Effects of demographic (age), clinical, and vendor variables were assessed in a metaregression. The National Institutes of Health tools were used to assess the quality of included articles. Publication bias was examined by Begg's funnel plot and Egger's regression test. Results: The search yielded 895 articles. After abstract and full-text screening we included 33 data sets with 2,346 patients for meta-analysis. The reported normal mean values of GLS among the studies varied from -15.80% to -23.40% (mean, -19.05%; 95% CI, -18.18% to -19.93%; I2 = 99.0%), GCS varied from -15.50% to -39.50% (mean, -22.42%; 95% CI, -20.96% to -23.89%, I2 = 99.7%), GRS varied from 19.81% to 86.61% (mean, 47.48%; 95% CI, 41.50%-53.46%; I2 = 99.8%), and GAS varied from -27.40% to -50.80% (mean, -35.03%; 95% CI, -33.19% to -36.87%; I2 = 99.3%). Software for strain analysis was consistently associated with variations in normal strain values (GLS: P = .016; GCS: P < .001; GRS: P < .001; GAS: P < .001). Conclusions: Variations in the normal ranges across studies were significantly associated with the software used for strain analysis, emphasizing that this factor must be considered in the interpretation of strain data.

Sex differences in risk factors for aneurysmal subarachnoid haemorrhage: Systematic review and meta-analysis

Article

Aug 2019
J NEUROL SCI

Background: Aneurysmal subarachnoid haemorrhage (aSAH) disproportionally affects women. We conducted a systematic review and meta-analysis to explore sex differences in aSAH risk factors. Methods: Case-control/cohort studies were searched to November 2017 with sex-specific risk factors for aSAH. Meta-analysis was performed when a risk factor was reported in ≥2 studies. Results: Of 31 studies, 22 were eligible for meta-analysis. Female sex was associated with greater odds of aSAH (HRadjusted 1.90 [1.47-2.46]. There was no detectable difference between the sexes for hypertension (ORadjusted: men 3.13 [2.26-4.34]; women 3.65 [2.87-4.63], p = .18), smoking (ORadjusted: men 2.96 [1.68-5.21]; women 3.11 [1.21-7.97], p = .95), aSAH family history, systolic blood pressure, age and some genetic variations. Alcohol (ORadjusted: men 1.50 [1.04-2.17]; women 0.83 [0.48-1.45], p = .003), high alanine aminotransferase levels, and some gene variants increased the risk of aSAH in men. Reproductive factors, divorce and some genetic variations increased the risk in women. High aspartate aminotransferase levels in men and, diabetes (ORadjusted: men 0.57 [0.32-1.01]; women 0.24 [0.13-0.43], p = .01) and parity in women reduced aSAH risk. Conclusion: We recommend sex-specific re-analysis of existing studies of aSAH risk factors. Known aSAH risk factors (hypertension, smoking and alcohol consumption) should be targeted to prevent aSAH in men and women. Registration PROSPERO (ID: CRD42018091521).

Aneurysmal versus "Benign" Perimesencephalic Subarachnoid Hemorrhage

Preprint

Jul 2023

Introduction: The rate of underlying ruptured aneurysm, complications, and outcomes in "benign" perimesencephalic subarachnoid hemorrhage (PMSAH) are not well known and underreported. Methods: Retrospective analysis of patients with PMSAH from a large tertiary care center (2007-2023. Clinical and imaging data were studied. Results: Eighty-one patients were included with mean age of 55.5 ± 10.3 years. Median (IQR) Hunt and Hess grade was 2 (1-2), and modified Fisher grade was 3 (1-3). An underlying ruptured aneurysm was diagnosed in 5 patients (6.2%). The most common complication was vasospasm in 25 patients (31%) with a significantly higher rate of symptomatic vasospasm among patients with underlying aneurysm (40% vs 2.6%; P=0.01). The median (IQR) time of vasospasm detection was 7 (8-9) days. The majority of vasospasm cases (84%) were asymptomatic, which was not associated with poor outcomes (OR= 0.95, [0.22–4.1], P=0.9) compared to the symptomatic vasospasm (OR= 8.6, [1.06-69.88], P= 0.04). Hydrocephalus occurred in 10% of patients within one day, at higher rate in the aneurysmal group (40% vs 8%; P=0.07). A total of 88% of patients had a favorable functional outcome (mRS 0-2) at discharge, but at a significantly higher rate in non-aneurysmal patients (91% vs 40%; P=0.01). An underlying aneurysm and hydrocephalus were associated with poor functional status (OR= 14.7, [2.1–104], P=0.007, and OR= 22.6, [4.2?123.5], P <0.001), respectively. Conclusion: "Benign" PMSAH pattern was associated with a ruptured aneurysm in 6.2% of patients, which highlights the critical value of conventional cerebral angiogram in the workup. Expectedly, an underlying aneurysm was associated with higher rates of symptomatic vasospasm, hydrocephalus, and lower rates of good clinical outcome. Aneurysm and hydrocephalus were independently associated with poorer outcomes, however, these were detected very early during hospitalization. Vasospasm alone was not associated with poor outcomes. Our findings suggest that non-aneurysmal PMSAH patients can safely be managed with less strict monitoring and a shorter hospital stay.

Troponin and non-traumatic subarachnoid haemorrhage: Results from a study of 243 consecutive patients

Article

Jun 2022

Introduction: Subarachnoid haemorrhage (SAH) is a devastating event, with a mortality of up to 50%. Acute cardiac dysfunction is common after such an event, and it is known to have a negative impact on the outcome of these patients. Cardiac troponin release occurs frequently after SAH and represents an early biomarker for neurogenic cardiac dysfunction. Objective: The present study aimed to evaluate the impact of a raised troponin value on the outcome of SAH patients. Methods: This is a prospective observational study held between 2014-2017 at the University Emergency Hospital, Bucharest. Data on clinical admission status, high-sensitivity troponin I, ECG and echocardiographic evaluation results, ICU length of stay and in-hospital mortality rate. Statistical analysis was performed using non-parametrical Mann-Whitney and chi-square tests. The results were considered significant at p<0.05. Results: A total of 335 consecutive patients with non-traumatic SAH were admitted during the study period. 92 of them were excluded and 243 were analyzed, 203 with aneurysmal SAH and 40 with non-aneurysmal, non-traumatic SAH. High-sensitivity troponin I reached its peak level 48 to 72 hours after SAH and was higher in patients with aneurysmal SAH. For all SAH patients, its median and peak values on days 1 and 2 were correlated with the ICU length of stay and inversely correlated with in-hospital length of stay. For the first 3 days, the median and maximum troponin values are higher in patients who died compared with those who survived and were discharged home (p-value < 0.001). Predictors of an elevated troponin on day 1 are loss of consciousness at ictus, a high Hunt and Hess and Fisher Scale grade, intraventricular haemorrhage and cerebral midline shift. Conclusions: The release of cardiac troponin is a valuable marker of neurogenic cardiac dysfunction in the first 3 days after SAH. The study replicates other data in the literature and highlights the association between SAH severity, early troponin elevation and in-hospital death.

Non-Aneurysmal Perimesencephalic Subarachnoid Hemorrhage: A Literature Review

Article

Full-text available

Mar 2023

Spontaneous non-aneurysmal subarachnoid haemorrhage (NAPMSAH) (addressing point 1) is a relatively rare occurrence in clinical settings as it is rarely misdiagnosed and usually involves a significantly better prognosis than the classical aneurysmal pattern. We hereby focused on a comprehensive analysis of this distinct pathological entity with the purpose of analysing possible pathophysiological entities, outcomes and treatment options involving this diagnosis with a focus on demographical, epidemiological and clinical data. The clinical setting includes focal neurological signs related to the anatomical structures, while computer tomography followed by tomographic angiography are the most common diagnosis tools, with a typical hyperdense lesion involving the midbrain, fourth ventricle and subthalamic areas without an angiographic correspondent, such as an aneurysmal pathology. Further investigations can also be used to highlight this diagnosis, such as interventional angiography or magnetic resonance imaging. Given the rarity of this condition and its relatively better prognosis, treatment options usually remain conservative. In the present review, the main characteristics of NAPMSAH are discussed.

Passive smoking may be associated with bleeding of cerebral arteriovenous malformation in non-smoking women: a retrospective analysis

Article

Full-text available

Jun 2022

Background: Smoking has been considered to be a risk factor for cardiovascular disease, cancer, depression and other diseases in previous reports, and active smoking is considered to be a risk factor for hemorrhagic stroke. In addition, a retrospective study showed that male smokers were at increased risk of bleeding from arteriovenous malformation (AVM), compared with non-smokers. However, the effect of passive smoking on rupturing of cerebral AVM in non-smoking women has not been addressed. Objective: This study aimed to assess the impact of tobacco exposure on AVM bleeding risk in non-smoking women. Methods: A total of 393 non-smoking women diagnosed with AVM were included. They were divided into a bleeding group (205 women) and a non-bleeding group (188 women). We conducted univariate and multivariate analysis on these two groups. In univariate analysis, risk factors that might be related to AVM bleeding were analyzed. In multivariate analysis, the relationship between passive smoking and AVM rupture was analyzed by correcting confounding factors. Results: Multivariate analysis showed that the proportion of passive smoking was statistically different between the bleeding group and the non-bleeding group (OR = 1.609; CI = 1.031-2.509; p = 0.036). Conclusion: Passive smoking may increase the risk of AVM bleeding in non-smoking women. This increased risk may be related to the inflammatory response, vascular wall damage, hemodynamic disorders, changes in atherosclerosis and changes in gene expression caused by passive smoking.

Assessment of Left Ventricle Systolic Function by 2D Speckle Tracking Echocardiography in Patients with Subarachnoid Hemorrhage

Article

Full-text available

Apr 2022

Background: Subarachnoid hemorrhage [SAH] is a neurological emergency with high mortality rates; Cardiac dysfunction with unfavorable neurological outcomes is common association.The Aim of The Work: Subclinical left ventricular systolic dysfunction and its association with the outcome of SAH was assessed.Patients and Methods: 120 cases were involved in this study divided in to two groups 60 healthy control group and 60 Patients with non-traumatic aneurysmal SAH. They were scaled according to Hunt & Hess scale and analyzed for age, sex, history of hypertension, diabetes mellitus, and smoking. ECG was done for all cases, Serum cholesterol, LDLc and troponin I were measured. Conventional and 2D speckle tracking echo were done for the following parameters, ejection fraction EF [by both M mode and biplane], LVEDD, LVESD, LVFS, RWMA and LV GLS.Results: Female gender was more affected beside, significant increases hypertension, smoking, s. cholesterol, LDLc, and troponin I. ECG showed significant ST- T wave changes and prolongation in QTc . Conventional echocardiography showed no significant changes regarding EF, FS, LVEDD and LVESD while, there were significant RWMA in the form of anteroseptal hypokinesia. Strain imaging of LV showed significant reduction of LV GLS in SAH cases which indicates subclinical dysfunction. Hunt& Hess scaling showed about 28.3% of cases had 3 grades which indicated bad prognosis of these cases. Positive correlation between Hunt & Hess scale and hypertension, troponin I and LV GLS which confirms the association between myocardial damage and bad clinical outcome of SAH. Conclusion: Subclinical myocardial damage and dysfunction is common complication of SAH, which is associated with poor prognosis SAH.

The relationship between smoking and brain aneurysms: from formation to rupture

Article

Full-text available

Jun 2021
REV ASSOC MED BRAS

Cerebral aneurysms occur in 3–5% of the general population and are characterized by localized structural deterioration of the arterial wall, with loss of the internal elastic lamina and disruption of the media layer. The most dreaded complication of a cerebral aneurysm is its rupture, which is likely related to several modifiable and nonmodifiable risk factors. Cigarette smoking is a major health hazard, with 5.4 mil- lion premature deaths worldwide every year and an average loss of 13–15 years of life expectancy. Understanding how nico- tine exposure impacts IA may have important implications for screening and counseling of patients. Therefore, the aim of this study is to evaluate the effects of smoking on the formation, growth, rupture, and even recurrence of IAs.

Roles of Phytoestrogen in the Pathophysiology of Intracranial Aneurysm

Article

Jun 2021

Background and Purpose The incidences of intracranial aneurysm and aneurysmal subarachnoid hemorrhage are high in postmenopausal women. Although population-based studies suggest that hormone replacement therapy is beneficial for postmenopausal women with intracranial aneurysms, estrogen replacement may no longer be recommended for the prevention of chronic diseases given its association with adverse outcomes, such as cancer and ischemic stroke. The isoflavone daidzein and its intestinal metabolite equol are bioactive phytoestrogens and potent agonists of estrogen receptors. Given their estrogenic properties, we investigated whether the isoflavones daidzein and equol are protective against the formation and rupture of intracranial aneurysms in a mouse model of the postmenopausal state. Methods We induced intracranial aneurysms in ovariectomized adult female mice using a combination of induced systemic hypertension and a single injection of elastase into the cerebrospinal fluid. We fed the mice with an isoflavone-free diet with/without daidzein supplementation, or in a combination of intraperitoneal equol, or oral vancomycin treatment. We also used estrogen receptor beta knockout mice. Results Both dietary daidzein and supplementation with its metabolite, equol, were protective against aneurysm formation in ovariectomized mice. The protective effects of daidzein and equol required estrogen receptor-β. The disruption of the intestinal microbial conversion of daidzein to equol abolished daidzein’s protective effect against aneurysm formation. Mice treated with equol had lower inflammatory cytokines in the cerebral arteries, suggesting that phytoestrogens modulate inflammatory processes important to intracranial aneurysm pathogenesis. Conclusions Our study establishes that both dietary daidzein and its metabolite, equol, protect against aneurysm formation in ovariectomized female mice through the activation of estrogen receptor-β and subsequent suppression of inflammation. Dietary daidzein’s protective effect required the intestinal conversion to equol. Our results indicate the potential therapeutic value of dietary daidzein and its metabolite, equol, for the prevention of the formation of intracranial aneurysms and related subarachnoid hemorrhage.

Exome sequencing study revealed novel susceptibility loci in subarachnoid hemorrhage (SAH)

Article

Full-text available

Dec 2020

Aim: To expand our current understanding of the genetic basis of subarachnoid hemorrhage (SAH), and reveal the susceptibility genes in SAH risk. Methods: We conducted whole-exome sequencing (WES) in a cohort of 196 individuals, including 94 SAH patients and 94 controls, as well as 8 samples that belong to two pedigrees. Systematically examination for rare variations (through direct genotyping) and common variations (through genotyping and imputation) for SAHs were performed in this study. Results: A total of 16,029 single-nucleotide polymorphisms (SNPs) and 108,999 short indels were detected in all samples, and among them, 30 SNPs distributed on 17 genes presented a strong association signal with SAH. Two novel pathogenic gene variants were identified as associated risk loci, including mutation in TPO and PALD1. The statistical analysis for rare, damaging variations in SAHs identified several susceptibility genes which were involved in degradation of the extracellular matrix and transcription factor signal pathways. And 25 putative pathogenic genes for SAH were also identified basic on functional interaction network analysis with the published SAH-associated genes. Additionally, pedigree analysis revealed autosomal dominant inheritance of pathogenic genes. Conclusion: Systematical analysis revealed a key role for rare variations in SAH risk and discovered SNPs in new complex loci. Our study expanded the list of candidate genes associated with SAH risk, and will facilitate the investigation of disease-related mechanisms and potential clinical therapies.

To clip or coil? Proposal of individual decision making

Article

Full-text available

May 2019

Background: Once the decision is made to treat the intracranial aneurysm, we should consider between two competing treatment options; open surgery or endovascular therapy. The rationale underlying the choice of treatment modality is usually unclear, as there is little good quality evidence available. Methods: We discuss here the patient, risk factors and the aneurysm related factors for decision making in management of intracranial aneurysm between endovascular and microsurgical modalities of management. Results: The relevance of age of patient, modifiable and nonmodifiable risk actors, family history, rupture status of aneurysm, aneurysm related factors like morphology of aneurysm and multiplicity are discussed here. Perceived differences in efficacy and safety of the two different treatment approaches are commonly used in an attempt to justify treatment choices. Difficulties with treatment selection and case to case management plan should be considered. Conclusion: Properly designed and randomized controlled trials need to be done to address these issues for choosing best management to the patient and definitive guidelines must be made to solve this confusion.

Exploring the causal links between cigarette smoking, alcohol consumption, and aneurysmal subarachnoid hemorrhage: a two-sample Mendelian randomization analysis

Article

Full-text available

Sep 2024

Background Aneurysmal subarachnoid hemorrhage (aSAH) represents a critical health concern characterized by elevated mortality and morbidity rates. Although both genetic predisposition and lifestyle choices influence aSAH susceptibility, understanding the causative associations between cigarette smoking, alcohol consumption, and aSAH risk remains imperative. Mendelian randomization (MR) offers a robust methodological framework for dissecting these associations, leveraging genetic variants as instrumental variables. Objective In this study, a two-sample Mendelian randomization (TSMR) approach was employed to elucidate the causal connections between genetically determined cigarette smoking, alcohol consumption, and aSAH risk. Methods Genetic instruments associated with cigarette smoking and alcohol consumption were sourced from the genome-wide association study (GWAS) and Sequencing Consortium of Alcohol and Nicotine use (GSCAN). Using a genome-wide association study (GWAS) dataset that encompassed aSAH cases and controls of European ancestry, TSMR, which utilized the inverse variance weighting (IVW) method, was employed to estimate the causal effects. Rigorous criteria were applied for selecting instrumental variables to ensure a robust Mendelian randomization analysis. Results A significant causal association was found between genetically determined cigarette smoking and an increased risk of aSAH, with a 1-standard deviation (SD) increase in cigarette use genetically linked to a 96% relative risk elevation [OR-IVW = 1.96, 95% confidence interval (CI) = 1.28–3.01, p = 0.0021]. However, genetically determined alcohol consumption did not exhibit a statistically significant association with aSAH risk (OR-IVW = 1.22, 95% CI = 0.61–2.45, p = 0.578). Conclusion The Mendelian randomization analysis revealed a causal nexus between cigarette smoking and an increased risk of aSAH, advocating for targeted smoking cessation interventions within genetically predisposed cohorts. The results regarding the relationship between alcohol consumption and aSAH were affected by insufficient statistical power. A prudent interpretation of the findings highlights the limitations of Mendelian randomization in elucidating intricate genetic epidemiological relationships. Ongoing research involving larger cohort sizes and advanced methodological approaches is essential for comprehending the genetic underpinnings of aSAH.

Risk factors of cerebral aneurysms rupture in an Indonesian population

Article

Jul 2024

Background: The demographic, clinical, and angiographic features of ruptured aneurysms compared to unruptured cerebral aneurysms in Indonesia are still limited. This study aims to determine risk factors for rupture according to clinical patterns and morphological features in the Indonesian population. Method: We retrospectively reviewed all cerebral aneurysm registries at the largest comprehensive stroke center in Indonesia from January 2019 to January 2022. We compared demographic and vascular risk factors as well as angiographic features between patients with ruptured and unruptured aneurysms with univariate and multivariate analyses. Results: Of 275 patients, 231 (84%) had ruptured cerebral aneurysms. We found a significant difference between the ruptured and unruptured groups in variables such as age, hypertension, dyslipidemia, smoking, location, and type of aneurysm. It was found that only the anterior circulation site (OR 4.91, 95% CI 1.47-16.48; p < 0.01) and saccular type (OR 5.45, 95% CI 1.42-20.93; p = 0.01) were significantly linked to ruptured aneurysms. Conclusion: Our findings revealed that anterior location and saccular type were substantially linked with ruptured aneurysms in the Indonesian population.

Can Specific Dietary Patterns and Lifestyle Habits Influence the Progression of Intracranial Aneurysm Lesions?

Article

May 2024

The progression of intracranial aneurysm (IA) lesions involves complex mechanisms influenced by various factors, including inflammation, oxidative stress, and endothelial dysfunction. This comprehensive review delves into the intricate interplay between specific dietary patterns and the progression of intracranial aneurysm (IA) lesions. Understanding the impact of these dietary factors on inflammation, oxidative stress, and endothelial dysfunction offers valuable insights into noninvasive strategies for managing IA progression, addressing a critical gap in current therapeutic approaches.

Aneurysmal Versus “Benign” Perimesencephalic Subarachnoid Hemorrhage

Article

Feb 2024

BACKGROUND The rate of underlying ruptured aneurysms, complications, and their relevance to outcomes in “benign” perimesencephalic subarachnoid hemorrhage are not well known and underreported. METHODS Retrospective analysis of patients with perimesencephalic subarachnoid hemorrhage from a large tertiary care center (2007–2022). RESULTS Eighty‐one patients were included with mean age of 55.5 ± 10.3 years. An underlying ruptured aneurysm was diagnosed in 5 patients (6.2%); 3 (60%) had negative computed tomography angiography and they were detected only in digital subtraction angiography (2 on initial digital subtraction angiography and 1 on follow‐up digital subtraction angiography). The most common complication was vasospasm in 25/81 patients (31%), and the majority 21/25 (84%) were asymptomatic. Symptomatic vasospasm occurred at a significantly higher rate among patients with underlying aneurysm (40% versus 2.6%; P = 0.01). Hydrocephalus occurred in 10% of patients, all within 1 day, but at a higher rate in the aneurysmal group (40% versus 8%; P = 0.07). A total of 88% of patients had modified Rankin scale score 0–2 at discharge, but at a significantly higher rate in nonaneurysmal patients (91% versus 40%; P = 0.01). An underlying aneurysm, hydrocephalus, and symptomatic vasospasm were associated with poor functional status (odds ratio [OR] = 14.7 [2.1–104]; P = 0.007, OR = 22.6 [4.2–123.5]; P <0.001, OR = 8.6 [1.06–69.88]; P = 0.04), respectively. CONCLUSION “Benign” perimesencephalic subarachnoid hemorrhage pattern was associated with a ruptured aneurysm in 6.2% of patients, and 3.7% were detected only on cerebral angiogram. Underlying aneurysm, symptomatic vasospasm, and hydrocephalus were associated with lower rates of good clinical outcome. All hydrocephalus cases were symptomatic and occurred very early. Asymptomatic vasospasm alone was not associated with poor outcomes. Our findings suggest that patients with nonaneurysmal perimesencephalic subarachnoid hemorrhage without hydrocephalus can safely be managed with less strict monitoring and a shorter hospital stay.

Health effects associated with exposure to secondhand smoke: a Burden of Proof study

Article

Full-text available

Jan 2024
NAT MED

Despite a gradual decline in smoking rates over time, exposure to secondhand smoke (SHS) continues to cause harm to nonsmokers, who are disproportionately children and women living in low- and middle-income countries. We comprehensively reviewed the literature published by July 2022 concerning the adverse impacts of SHS exposure on nine health outcomes. Following, we quantified each exposure–response association accounting for various sources of uncertainty and evaluated the strength of the evidence supporting our analyses using the Burden of Proof Risk Function methodology. We found all nine health outcomes to be associated with SHS exposure. We conservatively estimated that SHS increases the risk of ischemic heart disease, stroke, type 2 diabetes and lung cancer by at least around 8%, 5%, 1% and 1%, respectively, with the evidence supporting these harmful associations rated as weak (two stars). The evidence supporting the harmful associations between SHS and otitis media, asthma, lower respiratory infections, breast cancer and chronic obstructive pulmonary disease was weaker (one star). Despite the weak underlying evidence for these associations, our results reinforce the harmful effects of SHS on health and the need to prioritize advancing efforts to reduce active and passive smoking through a combination of public health policies and education initiatives.

Effect of Smoking Cessation on the Risk of Subarachnoid Hemorrhage: A Nested Case-Control Study in Korean Men

Article

Nov 2023

Background Smoking is a well-established risk factor for subarachnoid hemorrhage (SAH), and current smokers have an increased risk of SAH. However, there are insufficient data on whether smoking cessation in current smokers reduces the risk of SAH. Methods A nested case-control study was conducted based on the National Health Insurance Service-National Health Screening Cohort, which comprises nationwide health claims data and a national health screening program in Korea (2002–2019). We constructed a cohort of current male smokers without a history of stroke at the baseline health screening (2002–2003). From this cohort, cases were defined as individuals who experienced a nontraumatic SAH during the follow-up period up to 2019. Five controls were matched to each case using incidence density sampling. Smoking status (continuation or cessation) before the occurrence of SAH was evaluated using the repeated national health screening program. We conducted a multivariable conditional logistic regression analysis, adjusting for alcohol consumption, physical activity, body mass index, systolic blood pressure, and fasting blood glucose levels, to evaluate the association between SAH risk and smoking cessation. Results At baseline, there were 112 142 current male smokers. After excluding individuals with prior stroke or insufficient data, the cohort consisted of 105 223 eligible participants (mean age, 50.3±8.5 years). Among them, we identified 318 cases of SAH and 1590 matched controls. Those who quit smoking had a significantly lower risk of SAH compared with current smokers (adjusted odds ratio, 0.55 [95% CI, 0.41–0.73]). The risk of SAH decreased with a longer period of smoking cessation. The risk reduction with smoking cessation was consistent even among prior heavy smokers. Conclusions Smoking cessation in current male smokers reduced the risk of SAH, and the risk reduction was greater as the cessation period increased. These findings warrant intensive efforts to encourage smokers, even heavy smokers, to quit.

Intracerebral hemorrhage

Chapter

Nov 2009

This concise and informative textbook is aimed at trainee doctors beginning work on a stroke unit or residents embarking on their postdoctoral training in stroke care. It has a practical approach covering all important issues of prevention, diagnosis and treatment of cerebrovascular diseases. Chapters on the basics of neuropathology and pathophysiology are followed by reviews of clinical issues, including neuroimaging, clinical assessment, diagnosis and treatment, stroke in the young, and stroke-related dementia. Topics of rising importance are covered in chapters on stroke unit management, monitoring and management of complications including infections, recommendations for thrombolysis, interventions and neurosurgical procedures, and clear and balanced recommendations for secondary prevention. Finally, neuropsychological syndromes are explained and an up-to-date view on neurorehabilitation is presented. The authors are all experts in their field and many of them teach on the European Master's Program on Stroke Medicine, which is supported and endorsed by the European Stroke Organization.

Neuroradiology

Chapter

Nov 2009

Management of acute ischemic stroke and its complications

Chapter

Nov 2009

Stroke and dementia

Chapter

Nov 2009

Ischemic stroke in the young and in children

Chapter

Nov 2009

Behavioral neurology of stroke

Chapter

Nov 2009

Acute therapies and interventions

Chapter

Nov 2009

Cerebral venous thrombosis

Chapter

Nov 2009

Jobst Rudolf

Less common stroke syndromes

Chapter

Nov 2009

Wilfried Lang

Stroke units and clinical assessment

Chapter

Nov 2009

Basic epidemiology of stroke and risk assessment

Chapter

Nov 2009

Ultrasound in acute ischemic stroke

Chapter

Nov 2009

László Csiba

Infections in stroke

Chapter

Nov 2009

Common risk factors and prevention

Chapter

Nov 2009

Secondary prevention

Chapter

Nov 2009

Cardiac diseases relevant to stroke

Chapter

Nov 2009

Nicotine Replacement Therapy Does Not Reduce Headaches Following Subarachnoid Hemorrhage: A Propensity Score-Matched Study

Article

Sep 2022

BackgroundA significant number of patients admitted for aneurysmal subarachnoid hemorrhage (aSAH) are active smokers and are at risk of developing nicotine withdrawal symptoms (e.g., cravings, irritability, insomnia, headaches, etc.). This study aimed to evaluate the use of nicotine replacement therapy (NRT) regarding headache severity and analgesics consumption.MethodsA retrospective study was conducted using prospectively collected data from 2014 to 2019 in the neurointensive care unit of the Hospices Civils in Lyon, France. We performed a propensity score matching analysis. The covariables used were age, sex, initial World Federation of Neurosurgical Societies score, Hijdra sum score, and factors associated with pain following aSAH (history of chronic pain, anxiety, or depression). Smokers received NRT through a transdermal device. The primary end point was headache control. Secondary end points were mean numerical pain rating scale score and analgesics consumption.ResultsOne hundred and fifty-five patients were included among 523 patients hospitalized for aSAH. Fifty-one patients underwent nicotine substitution and were matched to 51 unsubstituted patients. The headache control rate was not different between the two groups (43.1% vs. 31.4%, p = 0.736). The mean numeric pain rating scale score in the substituted group was 2.2 (1.1–3.5) and 2.4 (1.6–3.1) in the unsubstituted group (p = 0.533). The analgesics consumption (acetaminophen, tramadol, and morphine) was the same in the two groups.Conclusions The use of NRT in the acute phase of aSAH does not seem to have an impact on the intensity of headaches or analgesics consumption.

Effect of Renin-Angiotensin-Aldosterone System Inhibitors on the Rupture Risk Among Hypertensive Patients With Intracranial Aneurysms

Article

Jul 2022
Hypertension

Background: Mounting experimental evidence supports the concept that the RAAS (renin-angiotensin-aldosterone system) is involved in the pathogenesis of intracranial aneurysm rupture. However, whether RAAS inhibitors could reduce the rupture risk of intracranial aneurysms remains unclear. Methods: We performed a chart review of a multicenter, prospectively maintained database of 3044 hypertensive patients with intracranial aneurysms from 20 medical centers in China. The patients were separated into ruptured and unruptured groups. Univariable and multivariable logistical regression analyses were performed to determine the association between the use of RAAS inhibitors and the rupture risk. Sensitivity analyses and subgroup analyses were performed to verify the robustness of the results. Results: In multivariable analyses, female sex, passive smoking, uncontrolled, or unmonitored hypertension, use of over 2 antihypertensive medications, RAAS inhibitors use, antihyperglycemic agents use, hyperlipidemia, ischemic stroke, and aneurysmal location were independently associated with the rupture risk. The use of RAAS inhibitors was significantly associated with a reduced rupture risk compared with the use of non-RAAS inhibitors (odds ratio, 0.490 [95% CI, 0.402-0.597]; P=0.000). Compared with the use of non-RAAS inhibitors, the use of ACE (angiotensin-converting enzyme) inhibitors (odds ratio, 0.559 [95% CI, 0.442-0.709]; P=0.000) and use of ARBs (angiotensin receptor blockers; odds ratio, 0.414 [95% CI, 0.315-0.542]; P=0.000) were both significantly associated with a reduced rupture risk. The negative association of the rupture risk with RAAS inhibitors was consistent across 3 analyzed data and the predefined subgroups (including controlled hypertension). Conclusions: The use of RAAS inhibitors was significantly associated with a decreased rupture risk independent of blood pressure control among hypertensive patients with intracranial aneurysms.

Cumulative Time of Cigarette Smoking Is Associated with a Greater Risk of Aneurysmal Subarachnoid Hemorrhage and Younger Age at Presentation: A Nationwide Observation Study

Article

May 2022

Background Smoking is known to be associated with an increased risk of intracranial aneurysm rupture, however, the risk in smokers stratified by age, sex and aneurysm location is not clear. Methods A retrospective study of all aneurysmal subarachnoid haemorrhage (aSAH) cases in Australia between 2008 and 2018, was conducted. The relative risk of aSAH in smokers compared to non-smokers was calculated based on nationwide smoking statistics, and was stratified according to sex, age group and aneurysm location. Results Out of 12,915 aSAH patients, 3,249 (25.2%) were active smokers. Across both men and women, smoking increased the risk of aSAH by 2.4 times in 30-39-year-olds (95% CI 2.1 – 2.7), 2.4 times in 40-49-year-olds (95% CI 2.2 – 2.7), 2.3 times in 50-59-year-olds (95% CI 2.1 – 2.4), and 1.8 times in 60-69-year-olds (95% CI 1.7 – 2.0) with less of an effect in smokers younger than 30 years (RR: 1.2, 95% CI 1.0 – 1.5) and older than 70 years (RR: 1.0, 95% CI 0.9 – 1.2). Compared to a non-smoker less than 30-years-old, the relative risk of aSAH increased by an average of 7.2 for every decade spent smoking in women, and an average of 4.0 for every decade spent smoking in men. Additionally, smokers were 5.2 times more likely to present younger than 50 years of age. Conclusion Smoking increased the risk of aSAH by two-fold between the ages of 30 and 60. Smokers experienced aSAH at younger ages.

Influence of socioeconomic status on the incidence of aneurysmal subarachnoid haemorrhage and clinical recovery

Article

Jan 2022
J CLIN NEUROSCI

Background The relevance of socioeconomic status (SES) on the incidence of aneurysmal subarachnoid haemorrhage (aSAH) and discharge functional outcomes following treatment is not clear. Methods A retrospective cross-sectional study was performed on data retrieved from the Nationwide Hospital Morbidity Database for all aSAH cases in Australia between 2012 and 2018. Information on patient characteristics, procedures performed, discharge disposition and SES were extracted. SES data was derived from classifications by the Australian Bureau of Statistics. Putative risk factors were evaluated with univariate and multivariate logistic regression analysis to identify independent predictor of unfavourable discharge outcomes (defined as death or dependency). Results A total of 3,591 low SES patients (49.8%) were identified in our study cohort. Average crude incidence of aSAH was persistently higher among the SES disadvantaged (6.6 cases per 100,000 person-years, 95% CI 6.3 – 6.8), compared to the SES advantaged group (4.1 cases per 100,000 person-years, 95% CI 4.0–4.2) (p < 0.0001). Patients in the Low SES group were more likely to be active smokers, have type 2 diabetes mellitus, or live in non-metropolitan residence, and have overall worse discharge functional outcomes (27.7% versus 24.5%, p = 0.0015). Adjusting for well-established risk factors such as older age, and intracranial bleed (ICH and/or IVH), disadvantaged SES remained a significant predictor of poor discharge outcome following aSAH (p = 0.0003). Conclusion aSAH occurs more frequently among low SES communities, and once ruptured, there is a greater risk of poor recovery..

Factors affecting pathological complete response after neoadjuvant chemotherapy in breast cancer: A single-center experience

Article

Full-text available

Oct 2021
REV ASSOC MED BRAS

Objective: The aim of this study was to examine the characteristics of patients admitted to our hospital with a diagnosis of breast cancer who reached pathological complete response after being operated following eight cycles of neoadjuvant chemotherapy. Methods: Between 2015-2020, patients with pathological complete response who were operated on after neoadjuvant chemotherapy and sent to our clinic for radiotherapy were evaluated. Results: The median age of the patients was 51 years. The most common histological type was invasive ductal cancer. The number of pathological complete response patients was 74 (28%), and the number of non-pathological complete response patients was 188 (72%). Patients with pathological complete response had a smaller tumor diameter than the non-pathological complete response group (p=0.001). For pathological complete response, T1 stage, N1 stage, NG 3, Ki-67 >20%, negative estrogen receptor, negative progesterone receptor, positive Cerb-B2, and adding trastuzumab to chemotherapy were statistically significant (p<0.05). Before neoadjuvant chemotherapy, stage T1-T2 (p=0.036), LN0-1 (p=0.026), Cerb-B2 positivity (p=0.025), and an initial nuclear grade of three (p=0.001) were found to be the factors affecting pathological complete response. Conclusions: With neoadjuvant chemotherapy, the size of locally advanced tumors decreases, allowing breast conserving surgery. The neoadjuvant chemotherapy response can be used as an early indicator of the prognosis of patients with breast cancer. Today, neoadjuvant chemotherapy is also used for patients with early-stage, operable breast cancer because it has been shown in many studies that reaching pathological complete response is associated with positive long-term results. If we can identify patients who have reached pathological complete response before neoadjuvant chemotherapy, we think we can also determine a patient-specific treatment plan at the beginning of treatment.

Stroke and Substance Abuse

Chapter

Jan 2022

John C.M. Brust

A number of recreationally used drugs, licit and illicit, have been linked to ischemic and hemorrhagic stroke. In some cases, for example, ethanol and tobacco, epidemiologic data convincingly identify the agents as risk factors without implying direct temporal causality. In the case of psychostimulant drugs-including methamphetamine, 3,4-methylenedioxymetamphetamine ("ecstasy"), cathinone derivatives ("bath salts"), and cocaine, as well as cannabis products-linkage is based on case reports and limited epidemiologic data, but temporal association of use, plus biological plausibility, suggest direct causality. Recreational drug use should be considered in any patient with a stroke, regardless of age.

Healthcare Prometrics in the Era of Redeployment

Article

Full-text available

Jun 2022

Naira Matevosyan

A bid is made to measure health as a value. Continuous and conceptual variables pertaining to healthcare distribution, expenses and outcomes are obtained from 70 studies presenting 4,245,866 patient-population from Finland and 4,304,049 from the USA—clustered for three periods: biennium, lustrum, decade. Two causality loops are sampled per country of interest: prematurity–perinatal mortality (PPM), tobacco consumption–respiratory cancer (TRC). Both in Finland and the USA, attribute risk for hypothyroidism, autoimmune disorders, and cardiomyopathy outstage other predictors of perinatal mortality. Diabetes mellitus, diabetes insipidus, obesity, and urinary tract infections are increasingly dominating PPM risks in the USA. Perinatal and maternal mortality ratios are consistently lower in Finland (RR 1.8–4.35). The mean duration of NICU-stay among the surviving and non-surviving low-weight infants is higher in Finland (RR 1.3–3.0). Regardless the term, cost of one NICU-day is 36–53-fold higher in the USA. The state-sponsored prenatal care is 2.58 times more consumed in Finland where the cost of basic prenatal care (excluding childbirth expenses) is 1.6 times lower. Low income is a substantial contributor to tobacco smoking (OR 5.0–15.6)—with a stronger connection (RR 3.56) in the USA. The US mortality rates from active smoking (R 1.5) and nicotine consumption by non-smoking means (RR 2.22) are higher even when the leading death predictors (COPD, Fanconi anemia, thromboembolism, TP53 gene mutation, KRAS mutation) are significantly higher in Finland (RR 2.57–12.85). High asthma rates among the US smokers (RR 4.21) are distinct predictors of poor survival rates from lung cancer—also reflected in higher Tiffeneau-Pinelli index reduction (RR 3.96). Delays in detection of respiratory cancer inversely relate to the survival rates (r =− 0.56). Where results are chaotic, data are assessed through holomorphic operation, each domain as complex-valued function of differentiable variable(s). Under the Riemannian and Finsler reasoning, each variable is a manifold in a spatial unit where tangent sits with the fourth root of differential expression. Such indexing could interprete functional relationships between healthcare value, demand elasticity, attributable or relative risk, prognosis—in the non-cohort samples, as suggested by the following equation matrix: R = ( [η (t) η (t’)/δ (t−t’) ]−D¹xμ r − D¹[μ xr + μ r x] − D²x(1 − λ s) + D²[λ xs + λ s x])ik (lj Rjikl ll). Due to its inherent dissonance property enabling data triangulation in infinitesimal points, Euclidean reasoning may help devise comprehensive healthcare index to predict perinatal and tobacco mortality. Findings of this study suggest that health value is higher in Finland. The need for health policy reform in the USA is warranted.

Nicotine Addiction

Chapter

Jan 2012

Abdominal aortic aneurysm is associated with subarachnoid hemorrhage

Article

Nov 2020

Background Although intracranial aneurysms (IA) and abdominal aortic aneurysms (AAA) share similar risk factors, little is known about the relationship between them. Previous studies have shown an increased incidence of IA in patients with AAA, though the rate of subarachnoid hemorrhage (SAH) in patients with AAA has not been described. Objective To use claims data with longitudinal follow-up, to evaluate the incidence of aneurysmal SAH in patients diagnosed with AAA. Methods We examined longitudinally linked medical claims data from a large private insurer to determine rates of aneurysmal SAH (aSAH) and secured aSAH (saSAH) in 2004–2014 among patients with previously diagnosed AAA. Results We identified 62 910 patients diagnosed with AAA and compared them 5:1 with age- and sex-matched controls. Both populations were predominantly male (70.9%), with an average age of 70.8 years. Rates of hypertension (69.7% vs 50.6%) and smoking (12.8% vs 4.1%) were higher in the AAA group (p<0.0001) than in controls. Fifty admissions for aSAH were identified in patients with AAA (26/100 000 patient-years, 95% CI 19 to 44) and 115 admissions for aSAH in controls (7/100 000 years, 95% CI 6 to 9), giving an incidence rate ratio (IRR) of 3.6 (95% CI 2.6 to 5.0, p<0.0001) and a comorbidity-adjusted incidence rate ratio (IRR) of 2.8 (95% CI 1.9 to 3.9) for patients with AAA. The incidence of secured aneurysmal SAH was proportionally even higher in patients with AAA, 7 vs 2/100 000 years, IRR 4.5 (95% CI 3.2 to 6.3, p<0.0001). Conclusion SAH rate was elevated in patients with AAA, even after adjustment for comorbidities. Among risk factors evaluated, AAA was the strongest predictor for SAH. The relative contributions of common genetic and environmental risk factors to both diseases should be investigated.

Sex-Specific Associations of Smoking with Spontaneous Subarachnoid Hemorrhage: Findings from Observational Studies

Article

Oct 2020
J Stroke Cerebrovasc Dis

Background Some studies have reported that women are at higher risk for spontaneous subarachnoid hemorrhage (SAH) compared with men, and smoking is the most important lifestyle risk factor for spontaneous SAH. However, it is still unknown whether the risk of SAH from smoking and smoking status is differential for women and men. We performed a meta-analysis to estimate the effect of smoking on SAH in women compared with men. Methods PubMed (January 1, 1966 to February 19, 2020) and EMBASE (January 1, 1980 to February 19, 2020) were systematically searched. Studies that estimated sex-specific relative risks (RRs) of SAH were selected. We pooled sex-specific RRs, comparing women with men using random-effects meta-analysis. Results Data from 20 observational studies that included 1,387,204 participants (563,898 women) and 7,838 SAHs (3,977 women) were analyzed. The combined women-to-men RRs of former smokers versus never smokers for SAH were 1.08 (95% confidence interval [CI] 0.62–1.89, p = 0.78). The pooled women-to-men RRs of current smokers versus never smokers were 1.39 (95% CI 1.05–1.83, p = 0.02). The combined women-to-men RRs of total smokers versus never smokers RRs were 1.15 (95% CI 0.88–1.52, p = 0.30). Conclusions Our study shows there is not enough evidence to suggest that women who smoke have a greater risk for SAH than men; however, women who persistently smoke have a greater risk. Smoking seems to be more susceptible in the increased SAH risk in women.

Is smoking a risk factor for bleeding in adult men with cerebral arteriovenous malformations? A single-center regression study from China

Article

Sep 2020
J Stroke Cerebrovasc Dis

Objective To assess whether smoking increases the risk of bleeding in patients with cerebral arteriovenous malformations (CAVM). Material and methods According to our research plan, 385 CAVM patients admitted to Beijing Tiantan Hospital from December 2015 to January 2018 were included in this study, including 210 bleeding patients and 175 non-bleeding patients. We divided patients into three subgroups of current smokers, ex-smokers (those who quit smoking for one year or more) and non-smokers. The relationship between smoking and the risk of CAVM rupture was assessed by univariate and multivariate regression analysis. Results Multivariate regression analysis showed that there was a statistically significant difference between current smoker and non-smoker (OR = 1.87, p = 0.019). Among the covariates of the multivariate regression analysis, the location, combined with blood flow-related intracranial aneurysms and size were related to the risk of CAVM bleeding. Conclusion Current smoking may increase the risk of CAVM bleeding; however, there was no significant correlation between ex-smoking and CAVM bleeding.

Association between secondhand smoke exposure and hypertension: nearly as large as smoking

Article

May 2020

: Active smoking is a widely accepted risk factor for cardiovascular disease and is recognized as a major public health problem. Passive smoking, also known as secondhand smoke exposure (SHSE), is thought to have similar cardiovascular consequences and the risk has been postulated to be equivalent to that of active smoking. A major component of this risk involves the connection with chronic hypertension. There are several population-based observational studies investigating the relationship between SHSE and chronic hypertension, all of which demonstrate a positive association. Given that SHSE appears to be a risk factor for chronic hypertension, SHSE should also be a risk factor for hypertensive end-organ disease. Many studies have sought to investigate this relationship, but this has yet to be fully elucidated. In this review, we focus on the current evidence regarding the association between SHSE and hypertension as well as exploration of the links between SHSE and hypertensive end-organ damage.

Optimisation biologique du traitement endovasculaire des anévrysmes intracrâniens

Thesis

Mar 2017

Aymeric Rouchaud

La genèse d’un anévrysme intracrânien n’est pas uniquement due à un effet mécanique mais à un ensemble d’éléments biologiques. Parmi eux, le thrombus intra-anévrysmal a un rôle majeur car il est le site d’activation de nombreuses métalloprotéinases et d’une protéolyse importante. Cependant, le thrombus du sac anévrysmal est également un substrat indispensable à la cicatrisation des anévrysmes après traitement endovasculaire car il sert de support à la recolonisation de l’anévrysme par des cellules mésenchymateuses. Dans les différents travaux présentés dans cette thèse, nous avons pu analyser une partie des phénomènes biologiques impliqués dans le succès ou l’échec des traitements endovasculaires. Les travaux présentés sont basés sur des expérimentations dans le modèle d’anévrysme à l’élastase chez le lapin et traités par coils, flow-diverters ou dispositifs intra-sacculaires (WEB). Ces travaux permettent de mieux comprendre les mécanismes biologiques mis en jeu par les différents traitements endovasculaires. L’analyse de ces phénomènes est indispensable pour comprendre les causes d’échec, mais aussi afin de développer de nouveaux outils biologiquement actifs pour le traitement des anévrysmes intracrâniens. Nous proposons ainsi le développement de stents flow-diverters biologiquement actifs. Nous proposons également trois approches différentes de thérapie cellulaire par voie endovasculaire, utilisant des cellules souches mésenchymateuses autologues, permettant une recolonisation du thrombus intraanévrysmal et une cicatrisation accélérée de l’anévrysme. Au total, le traitement des anévrysmes intracrâniens ne peut plus être basé uniquement sur des considérations mécaniques. Le développement des futurs dispositifs endovasculaires devra inclure une dimension biologique pour optimiser la cicatrisation complète des anévrysmes intracrâniens.

Specific treatment of aneurysmal subarachnoid hemorrhage

Chapter

Jan 2019

Subarachnoid hemorrhage (SAH) secondary to a ruptured cerebral aneurysm represents a challenging clinical entity with high associated morbidity and mortality rates, for which specific management paradigms can improve outcomes. Systemic and neurological assessment and stabilization in the acute phase and prevention of rebleeding by early and definitive aneurysm treatment are critical. Further intensive care management to address potential sequelae subsequent to SAH, including delayed cerebral ischemia and other neurological and systemic complications, are also paramount to improving outcomes in this patient population.

Cigarette smoking and alcohol consumption as risk factors for aneurysmal subarachnoid hemorrhage

Article

Full-text available

May 1993

Aneurysmal subarachnoid hemorrhage is a serious disease despite recent improvements in medical and surgical treatment. Hence, identification of modifiable risk factors for subarachnoid hemorrhage is important. We compared the smoking and drinking habits of 278 consecutive patients with aneurysmal subarachnoid hemorrhage, aged 15-60 years (145 men and 133 women) with those of 314 hospitalized control patients (164 men and 150 women) who did not differ in regard to age, day of onset of symptoms, and acuteness of disease onset. Multiple logistic regression analysis showed that recent alcohol intake and smoking, but not hypertension, were significant independent risk factors for hemorrhage. After adjustment for age, hypertension, and smoking status, men who had consumed 1-40, 41-120, or > 120 g of alcohol within the 24 hours preceding the onset of illness had a relative risk of hemorrhage of 0.3 (95% confidence interval [CI], 0.1-0.8), 2.5 (95% CI, 1.1-5.5), and 4.5 (95% CI, 1.5-12.9), respectively, compared with men who had consumed 0 g. Women who had consumed 1-40 or > 40 g of alcohol had a risk of hemorrhage of 0.4 (95% CI, 0.2-0.8) and 6.4 (95% CI, 2.3-17.9), respectively, compared with women without use of alcohol. Heavily smoking (> 20 cigarettes per day) men and currently smoking women had adjusted relative risks of hemorrhage of 7.3 (95% CI, 3.8-14.3) and 2.1 (95% CI, 1.2-3.6), respectively, compared with men who had never smoked and with women who were not current smokers. Higher levels of erythrocyte mean corpuscular volume in patients with subarachnoid hemorrhage than in control subjects supported the notion of different smoking and drinking habits. Recent heavy alcohol intake and current smoking seem to be independent risk factors for aneurysmal subarachnoid hemorrhage.

Passive smoking as well as active smoking increases the risk of acute stroke

Article

Full-text available

Jun 1999

To estimate the relative risk of stroke associated with exposure to environmental tobacco smoke (ETS, passive smoking) and to estimate the risk of stroke associated with current smoking (active smoking) using the traditional baseline group (never-smokers) and a baseline group that includes lifelong non-smokers and long-term (> 10 years) ex-smokers who have not been exposed to ETS. Population-based case-control study in residents of Auckland, New Zealand. Cases were obtained from the Auckland stroke study, a population-based register of acute stroke. Controls were obtained from a cross-sectional survery of major cardiovascular risk factors measured in the same population. A standard questionnaire was administered to patients and controls by trained nurse interviewers. Information was available for 521 patients with first-ever acute stroke and 1851 community controls aged 35-74 years. After adjusting for potential confounders (age, sex, history of hypertension, heart disease, and diabetes) using logistic regression, exposure to ETS among non-smokers and long-term ex-smokers was associated with a significantly increased risk of stroke (odds ratio (OR) = 1.82; 95% confidence interval (95% CI) = 1.34 to 2.49). The risk was significant in men (OR = 2.10; 95% CI = 1.33 to 3.32) and women (OR = 1.66; 95% CI = 1.07 to 2.57). Active smokers had a fourfold risk of stroke compared with people who reported they had never smoked cigarettes (OR = 4.14; 95% CI = 3.04 to 5.63); the risk increased when active smokers were compared with people who had never smoked or had quit smoking more than 10 years earlier and who were not exposed to ETS (OR = 6.33; 95% CI = 4.50 to 8.91). This study is one of the few to investigate the association between passive smoking and the risk of acute stroke. We found a significantly increased risk of stroke in men and in women. This study also confirms the higher risk of stroke in men and women who smoke cigarettes compared with non-smokers. The stroke risk increases further when those who have been exposed to ETS are excluded from the non-smoking reference group. These findings also suggest that studies investigating the adverse effects of smoking will underestimate the risk if exposure to ETS is not taken into account.

Risk Factors for Multiple Intracranial Aneurysms

Article

Full-text available

Mar 2000

Seppo Juvela

The presence of multiple intracranial aneurysms may be a sign of significant risk factors for aneurysm formation that differ from those factors that increase risk for aneurysm rupture. Only 2 studies concern independent risk factors for multiple aneurysms, and the results are in part controversial. This study was designed to identify independent risk factors for multiple intracranial aneurysms in patients with subarachnoid hemorrhage. Of 266 patients with aneurysmal subarachnoid hemorrhage (139 men and 127 women, aged 15 to 60 years), 80 (30%) had multiple intracranial aneurysms. The prevalence of several health-related habits, previous diseases, and medications of these patients were compared by multiple logistic regression between those with single and those with multiple aneurysms. On the basis of multivariate statistics, only regular cigarette smoking at any time was a significant risk factor for the presence of multiple aneurysms. The odds ratio (OR) of smoking for multiple aneurysms was 2.10 (95% CI, 1.06 to 4.13) after adjustment for age and sex. After additional adjustment for hypertension, the risk was 2.06 (95% CI, 1. 04 to 4.07). Of other variables, only age (OR, 1.02 per year; 95% CI, 1.00 to 1.05; P=0.09) and female sex (OR, 1.60; 95% CI, 0.90 to 2. 85; P=0.11) showed a tendency to increase the risk for multiple aneurysms after adjustment for smoking. On the other hand, patients with hypertension had significantly (P=0.029) more aneurysms (1. 61+/-1.04) than did those without (1.37+/-0.68), although they did not more frequently have multiple aneurysms. Cigarette smoking and possibly also age and female sex seem to be risk factors for multiple intracranial aneurysms in patients of working age who have suffered a subarachnoid hemorrhage. Patients with hypertension seem to have more aneurysms than those without.

Factors Affecting Formation and Growth of Intracranial Aneurysms : A Long-Term Follow-Up Study

Article

Full-text available

Feb 2001
STROKE

We sought to investigate factors determining growth rate of unruptured intracranial aneurysms as well as formation of new (de novo) aneurysms in patients from a time period when unruptured aneurysms were not treated surgically. Eighty-seven patients (79 had ruptured aneurysms clipped at start of follow-up) with 111 unruptured aneurysms as well as an additional 7 patients (2 with and 5 without unruptured aneurysms) who developed new aneurysms were followed from the 1950s to the 1970s until death or subarachnoid hemorrhage or until the last contact. Patients' cerebral arteries were examined later either with conventional (control) angiography (n=38) and/or, for those alive during 1996-1998, with 3-dimensional CT angiography (n=57). In addition, 10 patients were studied at neuropathological autopsy. Mean+/-SD duration of follow-up was 18.9+/-9.4 years (range, 1.2 to 38.9 years). Unruptured aneurysms increased in size >/=1 mm in 39 of the 87 patients (45%) and >/=3 mm in 31 (36%). New aneurysms were found in 15 of the 89 patients and in 5 without an unruptured aneurysm at the beginning of follow-up. Aneurysm rupture was associated very significantly (P:<0.001) with aneurysm growth during follow-up. Of several potential risk factors tested, only cigarette smoking (odds ratio [OR], 3.92; 95% CI, 1.29 to 11.93) and female sex (OR, 3.36; 95% CI, 1.11 to 10.22) were, after adjustment for age, significant (P:<0.05) independent risk factors for occurrence of aneurysm growth of >/=1 mm. Only cigarette smoking (OR, 3.48; 95% CI, 1.14 to 10.64; P:<0.05) was associated with growth of >/=3 mm. Age- and hypertension-adjusted risk factors for aneurysm formation were female sex (OR, 4.73; 95% CI, 1.16 to 19.38) and cigarette smoking (OR, 4.07; 95% CI, 1.09 to 15.15). Women and cigarette smokers are at increased risk for intracranial aneurysm formation and growth. Cigarette smoking in particular hastens aneurysm growth. Cessation of smoking is important for patients with unruptured aneurysms and possibly also for those with a prior subarachnoid hemorrhage.

Hormonal factors and risk of aneurysmal subarachnoid hemorrhage: An international population-based, case-control study

Article

Full-text available

Apr 2001
STROKE

Subarachnoid hemorrhage (SAH) is more common in women than in men, but the role of hormonal factors in its etiology remains uncertain. The aim of this study was to examine the relationship between hormonal factors and risk of SAH in women. This was a prospective, multicenter, population-based, case-control study performed in 4 major urban centers in Australia and New Zealand. Two hundred sixty-eight female cases of first-ever aneurysmal SAH occurred during 1995-1998. Controls were 286 frequency-matched women from the general population of each center. Outcome measures included risk of SAH associated with use of oral contraceptive pills (OCPs), hormone replacement therapy (HRT), and various endogenous hormonal factors including menstrual patterns, parity, age at birth of first child, and breast-feeding practices. Cases and controls did not differ with regard to menstrual and reproductive history except in age at birth of first child, where older age was associated with reduced risk of SAH (odds ratio [OR], 0.63; 95% CI, 0.43, 0.91). Relative to never use of HRT, the adjusted OR for ever use of HRT was 0.64 (95% CI, 0.41, 0.98), which did not alter significantly after further adjustment for possible confounding factors. Borderline evidence of an inverse association was detected for past use of HRT (adjusted OR, 0.59; 95% CI, 0.30, 1.13) and current use of HRT (adjusted OR, 0.67; 95% CI, 0.40, 1.13), but there was no evidence of an association for use of OCPs (adjusted OR, 0.97; 95% CI, 0.58, 1.60). The risks of SAH are lower in women whose first pregnancy is at an older age and women who have ever used HRT but not OCPs. The findings suggest an independent etiologic role for hormonal factors in the pathogenesis of aneurysmal SAH and provide support for a protective role for HRT on risk of SAH in postmenopausal women.

Epidemiology of Aneurysmal Subarachnoid Hemorrhage in Australia and New Zealand: Incidence and Case Fatality From the Australasian Cooperative Research on Subarachnoid Hemorrhage Study (ACROSS)

Article

Aug 2000

Background and purpose: More data on the epidemiology of subarachnoid hemorrhage (SAH) are required to increase our understanding of etiology and prevention. This study sought to determine the incidence and case fatality of SAH from 4 prospective, population-based registers in Australia and New Zealand. Methods: We identified all cases of "aneurysmal" SAH from November 1995 to June 1998 in Adelaide, Hobart, Perth (Australia), and Auckland (New Zealand), a total population of approximately 2.8 million, using standard diagnostic criteria and uniform community-wide surveillance and data extraction procedures. Results: A total of 436 cases of SAH were registered, including 432 first-ever events and 4 recurrent events. The mean age of cases was 57 years (range, 16 to 94 years), and 62% were female. From the 400 first-ever events registered over whole years, the crude annual incidence for the total population was 8.1 per 100 000 (95% CI, 7.4, 9.0), with rates higher for females (9. 7; 95% CI, 8.6, 11.0) than for males (6.5; 95% CI, 5.5, 7.6). Age-specific rates showed a continuous upward trend with age, although the shape and strength of this association differed between the sexes. Standardized annual incidence of SAH varied across centers, being highest in Auckland largely because of the high rate in Maori and Pacific people. The 28-day case fatality rate for the total population was 39% (95% CI, 34%, 44%), with little variation in ratios across centers. Conclusions: There is variation in the incidence of SAH in Australia and New Zealand, but the rates are consistently higher for females. A monotonic increase in incidence with age suggests that exposures with cumulative effects and long induction times may be less relevant in the etiology of SAH.

Case Control Studies: Design, Conduct, Analysis

Article

Jan 1982

Case-Control Studies. Design, Conduct, Analysis.

Article

Sep 1983

Occupational Exposure to Environmental Tobacco Smoke

Article

Sep 1995

Sally Katharine Hammond

Objectives. —To measure occupational exposures to environmental tobacco smoke in diverse settings, including offices and production areas, and to evaluate the effectiveness of policies that restrict or ban smoking in the workplace.Design. —Survey. The average weekly concentration of environmental tobacco smoke was measured with passive monitors that sample nicotine. Approximately 25 samplers were placed in each worksite for 1 week.Setting. —Twenty-five Massachusetts worksites, including fire stations, newspaper publishers, textile dyeing plants, and manufacturers of valves, fiberoptics, flight instruments, batteries, adhesives, semiconductor equipment, filters, and tools and dies. Samples were collected in offices and production areas.Main Outcome Measures. —The distribution of nicotine concentrations in various work settings as a function of company smoking policy. These data were interpreted with three approaches: comparing measured concentrations with a published risk assessment; comparing occupational exposures with home exposures; and evaluating the "cigarette equivalents" to which workers were exposed.Results. —Worksite smoking policy had a major effect on the nicotine concentrations, which fell from a median of 8.6 μg/m3 in the open offices at worksites that allowed smoking to 1.3 μg/m3 in sites that restricted smoking, and to 0.3 μg/m3 in worksites that banned smoking. The nonoffice workspaces were affected similarly, with median concentrations of 2.3,0.7, and 0.2 μg/m3 at worksites that allowed, restricted, and banned smoking, respectively.Conclusion. —All three evaluation methods indicated that occupational exposure to environmental tobacco smoke presents a substantial risk to workers in the absence of a policy restricting or banning smoking.(JAMA. 1995;274:956-960)

Smoking Cessation and Decreased Risk of Stroke in Women

Article

Jan 1993

Objective.—To prospectively examine the relationship of time since stopping smoking with risk of stroke in middle-aged women. Design.—An ongoing prospective cohort of women with 12 years’ follow-up data (1976 to 1988), in which information on smoking habits was updated every 2 years by postal questionnaire. Population Studied.—A total of 117 006 female registered nurses aged 30 to 55 years in 1976 and free of coronary heart disease, stroke, and cancer at baseline. Main Outcome Measures.—Incident strokes (fatal and nonfatal), further subdivided into ischemic stroke, subarachnoid hemorrhage, and cerebral hemorrhage. Results.—The age-adjusted relative risk of total stroke among current smokers compared with never smokers was 2.58 (95% confidence interval, 2.08 to 3.19). The corresponding relative risk among former smokers was 1.34 (95% confidence interval, 1.04 to 1.73). For total and ischemic stroke, the excess risks among former smokers largely disappeared from 2 to 4 years after cessation. The same patterns of decline were observed regardless of number of cigarettes smoked, the age at starting, or the presence of other risk factors for stroke. Conclusions.—The risk of suffering a stroke among cigarette smokers declines soon after cessation and the benefits are independent of the age at starting and the number of cigarettes smoked per day.

Cigarette smoking, alcohol use, and subarachnoid hemorrhage

Article

Oct 1992

Subarachnoid hemorrhage remains a devastating disease. Identification of etiologic risk factors would allow the possibility of prevention. We conducted a population-based case-control study in King County, Washington. Patients whose bleeds originated from a source other than an aneurysm were excluded. Two age- and gender-matched control subjects were identified for each case through random digit telephone dialing. A standardized in-person interview was conducted with the patient whenever possible, a proxy respondent for the case in all instances, the two control subjects, and their proxies. Analyses involved conditional logistic regression taking into account matching on age, gender and respondent type. Over 2 years, 169 cases were identified, and 149 participated in the case-control study. Compared with those who never smoked, the odds ratio for current heavy smokers (greater than 20 cigarettes/day) was 11.1 (95% confidence interval [CI], 5.0-24.9); for current light smokers (less than or equal to 20 cigarettes/day), 4.1 (95% CI, 2.3-7.3); and for former smokers, 1.8 (95% CI, 1.0-3.2). The risk associated with smoking was greatest in the 3 hours after a cigarette (odds ratio [OR] = 7.0; 95% CI, 3.7-13.1) and then fell, not reaching the risk in those who had never smoked until more than 10 years had passed since the last cigarette. Heavy alcohol use (greater than 2 drinks/day) was also associated with bleeds (OR = 2.2; 95% CI, 0.9-5.1, after adjusting for smoking status). These associations were not substantially altered after adjusting for several possible confounding factors, including a history of hypertension. Cigarette smoking and heavy alcohol use are associated with the occurrence of subarachnoid hemorrhage.

Passive smoking and heart disease. Epidemiology, physiology, and biochemistry

Article

Feb 1991

The evidence that ETS increases risk of death from heart disease is similar to that which existed in 1986 when the US Surgeon General concluded that ETS caused lung cancer in healthy nonsmokers. There are 10 epidemiological studies, conducted in a variety of locations, that reflect about a 30% increase in risk of death from ischemic heart disease or myocardial infarction among nonsmokers living with smokers. The larger studies also demonstrate a significant dose-response effect, with greater exposure to ETS associated with greater risk of death from heart disease. These epidemiological studies are complemented by a variety of physiological and biochemical data that show that ETS adversely affects platelet function and damages arterial endothelium in a way that increases the risk of heart disease. Moreover, ETS, in realistic exposures, also exerts significant adverse effects on exercise capability of both healthy people and those with heart disease by reducing the body's ability to deliver and utilize oxygen. In animal experiments, ETS also depresses cellular respiration at the level of mitochondria. The polycyclic aromatic hydrocarbons in ETS also accelerate, and may initiate, the development of atherosclerotic plaque. Of note, the cardiovascular effects of ETS appear to be different in nonsmokers and smokers. Nonsmokers appear to be more sensitive to ETS than do smokers, perhaps because some of the affected physiological systems are sensitive to low doses of the compounds in ETS, then saturate, and also perhaps because of physiological adaptions smokers undergo as a result of long-term exposure to the toxins in cigarette smoke. In any event, these findings indicate that, for cardiovascular disease, it is incorrect to compute "cigarette equivalents" for passive exposure to ETS and then to extrapolate the effects of this exposure on nonsmokers from the effects of direct smoking on smokers. These results suggest that heart disease is an important consequence of exposure to ETS. The combination of epidemiological studies with demonstration of physiological changes with exposure to ETS, together with biochemical evidence that elements of ETS have significant adverse effects on the cardiovascular system, leads to the conclusion that ETS causes heart disease. This increase in risk translates into about 10 times as many deaths from ETS-induced heart disease as lung cancer; these deaths contribute greatly to the estimated 53,000 deaths annually from passive smoking. This toll makes passive smoking the third leading preventable cause of death in the United States today, behind active smoking and alcohol.

Modeling and Variable Selection in Epidemiologic Analysis

Article

Apr 1989

Sander Greenland

This paper provides an overview of problems in multivariate modeling of epidemiologic data, and examines some proposed solutions. Special attention is given to the task of model selection, which involves selection of the model form, selection of the variables to enter the model, and selection of the form of these variables in the model. Several conclusions are drawn, among them: a) model and variable forms should be selected based on regression diagnostic procedures, in addition to goodness-of-fit tests; b) variable-selection algorithms in current packaged programs, such as conventional stepwise regression, can easily lead to invalid estimates and tests of effect; and c) variable selection is better approached by direct estimation of the degree of confounding produced by each variable than by significance-testing algorithms. As a general rule, before using a model to estimate effects, one should evaluate the assumptions implied by the model against both the data and prior information.

Occupational exposure to environmental tobacco smoke

Article

Oct 1995

To measure occupational exposures to environmental tobacco smoke in diverse settings, including offices and production areas, and to evaluate the effectiveness of policies that restrict or ban smoking in the workplace. Survey. The average weekly concentration of environmental tobacco smoke was measured with passive monitors that sample nicotine. Approximately 25 samples were placed in each worksite for 1 week. Twenty-five Massachusetts worksites, including fire stations, newspaper publishers, textile dyeing plants, and manufacturers of valves, fiberoptics, flight instruments, batteries, adhesives, semiconductor equipment, filters, and tools and dies. Samples were collected in offices and production areas. The distribution of nicotine concentrations in various work settings as a function of company smoking policy. These data were interpreted with three approaches: comparing measured concentrations with a published risk assessment; comparing occupational exposures with home exposures; and evaluating the "cigarette equivalents" to which workers were exposed. Worksite smoking policy had a major effect on the nicotine concentrations, which fell from a median of 8.6 micrograms/m3 in the open offices at worksites that allowed smoking to 1.3 micrograms/m3 in sites that restricted smoking, and to 0.3 microgram/m3 in worksites that banned smoking. The nonoffice workspaces were affected similarly, with median concentrations of 2.3, 0.7, and 0.2 microgram/m3 at worksites that allowed, restricted, and banned smoking, respectively. All three evaluation methods indicated that occupational exposure to environmental tobacco smoke presents a substantial risk to workers in the absence of a policy restricting or banning smoking.

Completeness and Accuracy of Interview Data from Proxy Respondents: Demographic, Medical, and Life-style Factors

Article

Apr 1994
EPIDEMIOLOGY

To evaluate the quality of exposure data provided by proxy respondents, we used a dual interview protocol in a case-control study of subarachnoid hemorrhage. All control subjects and their proxy respondents were interviewed (N = 283 control-proxy pairs), as were the cases who were able to provide their own information and their proxy respondents (N = 68 case-proxy pairs). The reliability of proxy-derived data was excellent for demographic and body habitus measures (kappa or intraclass correlation range = 0.86-0.99), and all aspects of cigarette smoking history (range = 0.79-0.93). Proxy reliability was somewhat lower for questions regarding medications and hormone preparations (range = 0.55-0.88), alcohol consumption (range = 0.52-0.82), and recreational physical activity (range = 0.55-0.67). Proxy reliability varied according to the relationship of the proxy to the index subject. Relative to the index subjects, proxy respondents tended to underreport the presence or level of exposure. For most exposures, odds ratios computed with proxy-derived data were similar in magnitude to odds ratios obtained with index subject data; important bias due to differential nonresponse or differential misclassification was suggested only for questions regarding hormone replacement therapy. Epidemiologic studies that rely on proxy respondents may require more subjects to offset the effect of nondifferential nonresponse and misclassification on the precision of effect estimates.

Smoking cessation and decreased risk of stroke in women

Article

Feb 1993

To prospectively examine the relationship of time since stopping smoking with risk of stroke in middle-aged women. An ongoing prospective cohort of women with 12 years' follow-up data (1976 to 1988), in which information on smoking habits was updated every 2 years by postal questionnaire. A total of 117,006 female registered nurses aged 30 to 55 years in 1976 and free of coronary heart disease, stroke, and cancer at baseline. Incident strokes (fatal and nonfatal), further subdivided into ischemic stroke, subarachnoid hemorrhage, and cerebral hemorrhage. The age-adjusted relative risk of total stroke among current smokers compared with never smokers was 2.58 (95% confidence interval, 2.08 to 3.19). The corresponding relative risk among former smokers was 1.34 (95% confidence interval, 1.04 to 1.73). For total and ischemic stroke, the excess risks among former smokers largely disappeared from 2 to 4 years after cessation. The same patterns of decline were observed regardless of number of cigarettes smoked, the age at starting, or the presence of other risk factors for stroke. The risk of suffering among cigarette smokers declines soon after cessation and the benefits are independent of the age at starting and the number of cigarettes smoked per day.

Risk Factors for Subarachnoid Hemorrhage : A Systematic Review

Article

Apr 1996

Knowledge of modifiable risk factors for subarachnoid hemorrhage (SAH) is important in terms of prevention. We therefore conducted a systematic review of studies on risk factors for SAH, with emphasis on sufficiently precise criteria for the diagnosis of SAH. To identify studies we performed a Medline search from 1966 to 1994 and searched the reference lists of all relevant publications. Studies were included only if they fulfilled predefined methodological criteria. Case-control studies were included if the diagnosis of SAH was proved by CT, angiography, or autopsy in at least 70% of patients. Longitudinal studies were included if the criteria for SAH were based on a review of the medical records. Nine longitudinal studies and 11 case-control studies were included. Significant risk factors were as follows: (1) smoking (relative risk [RR] for longitudinal studies, 1.9; 95% confidence interval [CI], 1.5 to 2.3; odds ratio [OR] for case-control studies, 3.5; 95% CI, 2.9 to 4.3); (2) hypertension (RR, 2.8; 95% CI, 2.1 to 3.6; OR, 2.9; 95% CI, 2.4 to 3.7) and (3) drinking 150 g or more of alcohol per week (RR, 4.7; 95% CI, 2.1 to 10.5; OR, 1.5; 95% CI, 1.1 to 1.9). Use of oral contraceptives, hormone replacement therapy, hypercholesterolemia, and physical activity were not significantly related to the risk of SAH. We conclude that smoking, hypertension, and alcohol abuse are important risk factors for SAH. Reduction of exposure to these risk factors might result in a decreased incidence of SAH.

Activity of ??1-antitrypsin and cigarette smoking in subarachnoid haemorrhage from ruptured aneurysm

Article

Oct 1996
J NEUROL SCI

An altered equilibrium of protease/protease-inhibitor factors may be involved in the pathogenesis of aneurysm rupture: α1-antitrypsin (α1-AT) represents the most relevant inhibitor of elastase, a proteolytic enzyme enhancing catabolic processes of collagen metabolism. Cigarette smoking has been shown to significantly reduce the inhibitory effect of α1-AT on proteases. In the present study we test the hypothesis whether the activity of α1-AT is altered in patients with subarachnoid haemorrhage (SAH) and if is there any relationship between α1-AT activity and the high risk of aneurysm rupture in smokers. The patients were subdivided in the following groups: (a) patients with unruptured aneurysm (n = 10); (b) patients presenting with SAH admitted within 48 h after the episode (n = 20); (c) patients presenting with SAH admitted >48 h after the episode (n = 14); (d) controls (n = 10): patients with neither cerebrovascular nor acute disease. Blood samples were obtained immediately at admission. Measurement of α1-AT level was determined by immunoturbidimetric method. In order to obtain qualitative data about the anti-protease activity of α1-AT (expressed as collagenase inhibitory percentage capacity (CIC) at different doses) we consider the 20 cases admitted for SAH within 48 h.

Passive Smoking and the Risk of Coronary Heart Disease — A Meta-Analysis of Epidemiologic Studies

Article

Apr 1999

The effect of passive smoking on the risk of coronary heart disease is controversial. We conducted a meta-analysis of the risk of coronary heart disease associated with passive smoking among nonsmokers. We searched the Medline and Dissertation Abstracts Online data bases and reviewed citations in relevant articles to identify 18 epidemiologic (10 cohort and 8 case-control) studies that met prestated inclusion criteria. Information on the designs of the studies, the characteristics of the study subjects, exposure and outcome measures, control for potential confounding factors, and risk estimates was abstracted independently by three investigators using a standardized protocol. Overall, nonsmokers exposed to environmental smoke had a relative risk of coronary heart disease of 1.25 (95 percent confidence interval, 1.17 to 1.32) as compared with nonsmokers not exposed to smoke. Passive smoking was consistently associated with an increased relative risk of coronary heart disease in cohort studies (relative risk, 1.21; 95 percent confidence interval, 1.14 to 1.30), in case-control studies (relative risk, 1.51; 95 percent confidence interval, 1.26 to 1.81), in men (relative risk, 1.22; 95 percent confidence interval, 1.10 to 1.35), in women (relative risk, 1.24; 95 percent confidence interval, 1.15 to 1.34), and in those exposed to smoking at home (relative risk, 1.17; 95 percent confidence interval, 1.11 to 1.24) or in the workplace (relative risk, 1.11; 95 percent confidence interval, 1.00 to 1.23). A significant dose-response relation was identified, with respective relative risks of 1.23 and 1.31 for nonsmokers who were exposed to the smoke of 1 to 19 cigarettes per day and those who were exposed to the smoke of 20 or more cigarettes per day, as compared with nonsmokers not exposed to smoke (P=0.006 for linear trend). Passive smoking is associated with a small increase in the risk of coronary heart disease. Given the high prevalence of cigarette smoking, the public health consequences of passive smoking with regard to coronary heart disease may be important.

Ischemic stroke risk and passive exposure to spouses’ cigarette smoking. Melbourne Stroke Risk Factor Study (MERFS) Group

Article

May 1999

This study investigated the association between ischemic stroke risk and passive exposure to cigarette smoking. Risk factors among 452 hospitalized cases of first-episode ischemic stroke were compared with 452 age- and sex-matched "neighbor-hood" controls. The risk of stroke was twice as high for subjects whose spouses smoked as for those whose spouses did not smoke (95% confidence interval = 1.3, 3.1), after adjustment for the subject's own smoking, heart disease, hypertension, diabetes, and education level. These results were confirmed when analysis was limited to those who never smoked. These findings provide evidence that spousal smoking may be a significant risk factor for ischemic stroke.

Behavioral Risk Factor Prevalence and Lifestyle Change After Stroke : A Prospective Study

Article

Aug 2000

Stroke patients have a 15-fold increased risk of recurrent stroke, and those with > or =1 risk factor have a further increased risk of recurrence. Previous work found management of physiological risk factors after stroke to be unsatisfactory, but there is little information on behavioral risks within the stroke population. This study estimates behavioral risk factor prevalence after stroke and explores lifestyle change. The study used data from the population-based South London Stroke Register, collected prospectively between 1995 and 1998. Main measures included smoking status, alcohol use, and obesity. Logistic regression was used to determine sociodemographic differences in these measures. At 1 year after stroke, 22% of patients still smoked, 36% of patients were obese, and 4% drank excessively. Younger patients, whites, and men were more likely to smoke, and younger whites were more likely to drink excessively. Women and nonwhites were more likely to be obese. Those living in hospital, nursing home, or residential care and nonwhites were more likely to give up smoking, but there were no other associations between lifestyle change and the sociodemographic characteristics of patients. Different behavioral risk factors were associated with specific sociodemographic groups within the stroke population. After stroke, high-risk groups should continue to be targeted to prevent stroke recurrence. However, the relationship between sociodemographic characteristics and lifestyle change remains unclear; more research is needed into the process of change to find out how best to intervene to improve secondary prevention.

Risk Factors for Subarachnoid Hemorrhage

Article

Oct 2001

Cigarette smoking has been demonstrated to increase the risk of subarachnoid hemorrhage (SAH). Whether cessation of smoking decreases this risk remains unclear. We performed a case-control study to examine the effect of smoking and other known risk factors for cerebrovascular disease on the risk of SAH. We reviewed the medical records of all patients with a diagnosis of SAH (n = 323) admitted to Johns Hopkins Hospital between January 1990 and June 1997. Controls matched for age, sex, and ethnicity (n = 969) were selected from a nationally representative sample of the Third National Health and Nutrition Examination Survey. We determined the independent association between smoking (current and previous) and various cerebrovascular risk factors and SAH by use of multivariate logistic regression analysis. A separate analysis was performed to determine associated risk factors for aneurysmal SAH. Of 323 patients admitted with SAH (mean age, 52.7+/-14 yr; 93 were men), 173 (54%) were hypertensive, 149 (46%) were currently smoking, and 125 (39%) were previous smokers. In the multivariate analysis, both previous smoking (odds ratio [OR], 4.5; 95% confidence interval [CI], 3.1-6.5) and current smoking (OR, 5.2; 95% CI, 3.6-7.5) were significantly associated with SAH. Hypertension was also significantly associated with SAH (OR, 2.4; 95% CI, 1.8-3.1). The risk factors for 290 patients with aneurysmal SAH were similar and included hypertension (OR, 2.4; 95% CI, 1.8-3.2), previous smoking (OR, 4.1; 95% CI, 2.7-6.0), and current smoking (OR, 5.4; 95% CI, 3.7-7.8). Hypertension and cigarette smoking increase the risk for development of SAH, as found in previous studies. However, the increased risk persists even after cessation of cigarette smoking, which suggests the importance of early abstinence from smoking.

Cessation of Smoking After First-Ever Stroke A Follow-Up Study

Article

Oct 2002
STROKE

Cessation of smoking is widely recommended in patients with stroke to reduce the risk of myocardial infarction and recurrent stroke, but little is known regarding how patients modify their smoking habits after a stroke. We used data from a prospective follow-up study to assess modification of smoking habits and to identify predictors of persistent smoking after first-ever stroke. All patients admitted to the only neurology department of Funen County (465 000 inhabitants) with first-ever stroke from August 1, 1999, to January 31, 2001, were prospectively identified. A comprehensive structured interview was completed both during hospitalization and at 6-month follow-up. The interview comprised questions on education, occupation, marital status, lifestyle, concomitant diseases, and functional disability. We estimated the relative risk of persistent smoking at follow-up using unconditional logistic regression. We identified 734 patients with a first-ever stroke in the study period. One hundred three patients (14%) died in the 6-month period after their admission. A total of 511 patients (81%) who participated in the interview both on admission and at follow-up were included in the present study. Among 198 patients (38.7%) who were current smokers on admission, 43 patients (21.7%) gave up smoking within 6 months of suffering a stroke. Sex, functional status, and sociodemographic characteristics were independently associated with persistent smoking. Our results suggest that more efficient antismoking counseling is required to reduce the proportion of persistent smokers after stroke. This counseling should take into account the increased risk of persistent smoking in men, patients with no disability, blue-collar workers, and patients living alone.

Passive smoking and heart disease: epidemiology , physiology, and biochemistry Passive smoking as well as active smoking increases the risk of acute stroke

1-12156

Sa Glantz
Ww Parmley
R Bonita
J Duncan
T Truelsen
Rt Jackson
Beaglehole

Glantz SA, Parmley WW. Passive smoking and heart disease: epidemiology, physiology, and biochemistry. Circulation. 1991;83:1–12. 5. Bonita R, Duncan J, Truelsen T, Jackson RT, Beaglehole R. Passive smoking as well as active smoking increases the risk of acute stroke. Tobacco Control. 1999;8:156 –160.

The Fitness of Australians. Australian Government Publishing Service

Jan 1992

Australia Commonwealth

Commonwealth of Australia. The Fitness of Australians. Australian Government Publishing Service; 1992.

Cessation of smoking after first-ever stroke: a follow-up study Anderson et al Smoking and Subarachnoid Hemorrhage 637 by on May 25

2263-2269

S Bak
Sh Sindrup
T Alslev
O Kristensen
K Christensen
Gaist

Bak S, Sindrup SH, Alslev T, Kristensen O, Christensen K, Gaist D. Cessation of smoking after first-ever stroke: a follow-up study. Stroke. 2002;33:2263–2269. Anderson et al Smoking and Subarachnoid Hemorrhage 637 by on May 25, 2011 stroke.ahajournals.org Downloaded from

The Fitness of Australians

Australia Commonwealth Of

Active and Passive Smoking and the Risk of Subarachnoid Hemorrhage An International Population-Based Case-Control Study

Abstract

No full-text available

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