A. Algra

Incidence of Subarachnoid Haemorrhage: A systematic review with emphasis on region, age, gender and time trends

Background and aim: To update our 1996 review on the incidence of subarachnoid haemorrhage (SAH) and assess the relation of incidence with region, age, gender and time period. Methods: We searched for studies on the incidence of SAH published until October 2005. The overall incidences with corresponding 95% confidence intervals were calculated. We determined the relationship between the incidence of SAH and determinants by means of univariate Poisson regression. Results: We included 51 studies (33 new), describing 58 study populations in 21 countries, observing 45 821 896 person-years. Incidences per 100 000 person-years were 22.7 (95% CI 21.9 to 23.5) in Japan, 19.7 (18.1 to 21.3) in Finland, 4.2 (3.1 to 5.7) in South and Central America, and 9.1 (8.8 to 9.5) in the other regions. With age category 45–55 years as the reference, incidence ratios increased from 0.10 (0.08 to 0.14) for age groups younger than 25 years to 1.61 (1.24 to 2.07) for age groups older than 85 years. The incidence in women was 1.24 (1.09 to 1.42) times higher than in men; this gender difference started at age 55 years and increased thereafter. Between 1950 and 2005, the incidence decreased by 0.6% (1.3% decrease to 0.1% increase) per year. Conclusions: The overall incidence of SAH is approximately 9 per 100 000 person-years. Rates are higher in Japan and Finland and increase with age. The preponderance of women starts only in the sixth decade. The decline in incidence of SAH over the past 45 years is relatively moderate compared with that for stroke in general.

Glucose levels and outcome after subarachnoid hemorrhage

Abstract– In a cohort of 337 patients with subarachnoid hemorrhage (SAH), we investigated the relationship between blood glucose levels, baseline characteristics, and outcome by means of Student’s t-test and multivariate logistic regression. The mean glucose levels on admission and from day 1 to 10 were significantly higher in patients with poor condition on admission and in patients with poor outcome. In a multivariate analysis, glucose level on admission was not an independent predictor of outcome. Hyperglycemia may be a link in the association between poor condition on admission and poor outcome.

Female risk factors for subarachnoid hemorrhage: A systematic review

Objective: To systematically review the literature on female risk factors and risk of SAH. Methods: We searched Medline and EMBASE for articles published between January 1985 and July 2011. For all studies fulfilling the predefined criteria, we obtained risk ratios (RRs) or odds ratios (ORs) with 95% confidence intervals (CIs) for female risk factors. We pooled crude and adjusted ORs (aORs) with a general variance-based random-effects method. We evaluated methodologic quality with the Newcastle-Ottawa Scale. Results: We included 16 studies; 8 had good quality. Twelve studies had a case-control design, 3 studies had a longitudinal design, and 1 study had a case-crossover design. Overall aORs were 1.31 (95% CI 1.05–1.64; 5 studies, 2 with good quality [GQ]) for current use of combined oral contraceptives (COC), 0.90 (95% CI 0.74–1.09; 7 studies, 4 GQ) for ever COC use, 0.86 (95% CI 0.69–1.08; 6 studies, 3 GQ) for current use of hormone replacement therapy (HRT), 0.74 (95% CI 0.54–1.00; 3 studies, 1 GQ) for ever use of HRT, and 1.29 (95% CI 1.03–1.61; 5 studies, 2 GQ) for postmenopausal women. Data on parity and age at menarche were heterogeneous. Risk of subarachnoid hemorrhage (SAH) was not increased during pregnancy, labor, or puerperium (RR 0.40, 95% CI 0.20–0.90; 1 GQ study). Conclusions: Female hormone levels might influence risk of SAH, but the pathophysiology of this effect and its influence on the difference in incidence of SAH between the sexes remains unclear. Further studies are needed to identify modifiable risk factors of SAH in women older than age 50.

High mean fasting glucose levels independently predict poor outcome and delayed cerebral ischaemia after aneurysmal subarachnoid haemorrhage

Background: Hyperglycaemia has been related to poor outcome and delayed cerebral ischaemia (DCI) after aneurysmal subarachnoid haemorrhage (aSAH). Objective: This study aimed to assess whether in patients with aSAH, levels of mean fasting glucose within the first week predict poor outcome and DCI better than single admission glucose levels alone. Methods: Data on non-diabetic patients admitted within 48 h after aSAH with at least two fasting glucose assessments in the first week were retrieved from a prospective database (n = 265). The association of admission glucose or mean fasting glucose, dichotomised at the median levels, with outcome was assessed using logistic regression, and for DCI using Cox regression. To explore whether the association between glucose levels and outcome was mediated by DCI, we adjusted for DCI. Results: The crude and multivariable adjusted odds ratios and 95% confidence intervals for poor outcome were 1.9 (1.1 to 3.2) and 1.6 (0.9 to 2.7) for high admission glucose and 3.5 (2.0 to 6.1) and 2.5 (1.4 to 4.6) for high mean fasting glucose. The crude and adjusted hazard ratios for DCI were 1.7 (1.1 to 2.5) and 1.4 (0.9 to 2.1) for high admission glucose and 2.0 (1.3 to 3.0) and 1.7 (1.1 to 2.7) for high mean fasting glucose. After adjusting for DCI, the odds ratios on poor outcome for high mean fasting glucose decreased only marginally. Conclusions: Compared with high admission glucose, high mean fasting glucose, representing impaired glucose metabolism, is a better and independent predictor of poor outcome and DCI. DCI is not the key determinant in the relationship between high fasting glucose and poor outcome.

Female- and Male-Specific Risk Factors for Stroke : A Systematic Review and Meta-analysis

Importance The incidence of stroke is higher in men than in women. The influence of sex-specific risk factors on stroke incidence and mortality is largely unknown. Objective To conduct a systematic review and meta-analysis of female- and male-specific risk factors for stroke. Data Sources PubMed, EMBASE, and the bibliographies of articles were searched for studies published between January 1, 1985, and January 26, 2015, reporting on the association between female- and male-specific characteristics and stroke. Study Selection Observational studies reporting associations between sex-specific risk factors and stroke were selected. Data Extraction and Synthesis Two authors performed data extraction independently. Estimates were pooled with a generic variance-based, random-effects method. We followed the Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) recommendations. In addition, our study adhered to the Meta-analysis of Observational Studies in Epidemiology (MOOSE) guidelines. Main Outcomes and Measures Ischemic stroke, hemorrhagic stroke, any stroke, and stroke mortality. Results This systematic review and meta-analysis included 78 studies (70 longitudinal and 8 case-control) comprising 10 187 540 persons. In women, the pooled relative risks of ischemic stroke were 1.80 (95% CI, 1.49-2.18) after any hypertensive disorder in pregnancy (HDP) (gestational hypertension [GH], preeclampsia, or eclampsia) and 1.81 (95% CI, 1.44-2.27) after GH vs no HDP. The pooled relative risks of hemorrhagic stroke were 2.24 (95% CI, 1.19-4.21) in women with menopause at the age of at least 55 years vs 50 to 54 years and 5.08 (95% CI, 1.80-14.34) after GH vs no GH. The pooled relative risks of any stroke were 1.42 (95% CI, 1.34-1.50) after oophorectomy vs no oophorectomy, 0.88 (95% CI, 0.85-0.90) after hysterectomy vs no hysterectomy, 1.63 (95% CI, 1.52-1.75) after any vs no HDP, 1.54 (95% CI, 1.39-1.70) after preeclampsia or eclampsia, 1.51 (95% CI, 1.27-1.80) after GH vs no HDP, 1.62 (95% CI, 1.46-1.79) after preterm delivery, and 1.86 (95% CI, 1.15-3.02) after stillbirth vs no pregnancy complications. The pooled relative risk of stroke mortality was 1.57 (95% CI, 1.04-2.39) after GH vs no GH. In men, the pooled relative risks of ischemic stroke were 1.19 (95% CI, 1.05-1.34) after androgen deprivation therapy (ADT) vs no ADT and 1.21 (95% CI, 1.00-1.46) after orchiectomy vs no orchiectomy. The pooled relative risks of any stroke were 1.21 (95% CI, 1.06-1.37) for ADT vs no ADT and 1.35 (95% CI, 1.18-1.53) for erectile dysfunction vs no dysfunction. Conclusions and Relevance Female-specific characteristics increasing stroke risk include HDP for ischemic stroke, late menopause and gestational hypertension for hemorrhagic stroke, and oophorectomy, HDP, preterm delivery, and stillbirth for any stroke. Hysterectomy is possibly protective against any stroke. Male-specific characteristics increasing stroke risk include medical androgen deprivation therapy for ischemic and any stroke and erectile dysfunction for any stroke. Consideration of sex-specific risk factors can improve individualized stroke risk assessment.

Hypotension in anaesthetized patients during aneurysm clipping: not as bad as expected?

Background: Patients with aneurysmal subarachnoid haemorrhage (SAH) often have disturbed autoregulation of cerebral blood flow. A reduction in systemic blood pressure during surgery may therefore lead to delayed cerebral ischaemia (DCI). To assess the incidence and severity of intra‐operative hypotension, we performed a retrospective cohort study in 164 patients with recent SAH and surgical clipping of the aneurysm.

The Effects of Secondary Cardiovascular Prevention on Cancer Risk in Patients With Manifest Vascular Disease

Cardiovascular disease and cancer share important risk factors and pathophysiology, including smoking, obesity, physical inactivity, insulin resistance, and inflammation. As the survival of acute ischemic events has increased notably, the number of patients in the chronic phase of vascular disease

Relation between adiposity and vascular events, malignancy, and mortality in patients with stable cerebrovascular disease

Background:Abdominal adiposity is associated with various risk factors including hypertension, and is therefore particularly relevant in patients with stable cerebrovascular disease (CeVD). A U-shaped relation between body mass index (BMI, kg m−2) and cardiovascular events is often described. Whether this U-shape persists for abdominal adiposity, and consequently which reference values should guide clinical practice, is unclear. We described the relation between multiple adiposity measurements and risk of vascular events, vascular mortality, malignancy and all-cause mortality in patients with clinically stable CeVD.Methods:During a median follow-up time of 6.8 years, 1767 patients were prospectively followed. Relations were assessed using multivariable adjusted Cox proportional hazards models. Adiposity was assessed with BMI, waist circumference (stratified by gender) and the contribution of visceral fat to total abdominal fat (VAT%) measured using ultrasound. Relations were nonlinear if the χ2-statistic of the nonlinear term was significant (P-value<0.05). Nadirs were reported for nonlinear and hazard ratios (HRs) for linear relations.Results:The relations between BMI and outcomes were nonlinear with nadirs ranging between 27.1 (95% confidence interval (CI) 21.9–29.3) kg m2 for vascular mortality and 28.1 (95% CI, 19.0–38.2)) kg m−2 for malignancy. The relation between waist circumference and all-cause mortality was nonlinear with a nadir of 84.0 (95% CI, 18.7–134.8) cm for females and 94.8 (95% CI, 80.3–100.1) cm for males. No nonlinearity was detected for VAT%. A 1-s.d. (9.8%) increase in VAT% was related to both vascular (HR, 1.23, 95% CI 1.00–1.51) and all-cause mortality (HR, 1.22, 95% CI 1.05–1.42).Conclusions:In patients with CeVD, a BMI around 27–28 kg m−2 relates to the lowest risk of vascular events, vascular mortality, malignancy and all-cause mortality. However, increasing abdominal adiposity confers a higher risk of all-cause mortality. Thus, whereas traditional BMI cutoffs may be re-evaluated in this population, striving for low abdominal obesity should remain a goal.

Clot length predicts recanalisation but not outcome after basilar artery occlusion

Introduction The aim of our study was to evaluate the effect of clot length on both recanalisation and outcome in acute basilar artery occlusion (BAO). Patients and methods One hundred forty-nine patients with an acute basilar artery occlusion from the Basilar Artery International Cooperation Study (BASICS) were included. Clot length was assessed on computed tomographic angiography. Thrombus length was divided in tertiles and was related to recanalisation and outcome at 1 month, with Poisson regression. Modified Rankin scale scores of 4 or 5, or death were considered poor outcomes. Additionally, clot length was analysed as a continuous variable. Results Forty-nine patients (33%) had a short (4–11 mm), 50 (34%) an intermediate (12–22 mm), and 50 (34%) a long clot (≥23 mm). Multivariable analyses showed a significantly lower probability of recanalisation but no statistically significant difference in poor outcome for patients with a long clot compared with patients with a short clot (RR 0.64, 95% CI: 0.42–0.98 and RR 1.10, 95% CI: 0.88–1.37, respectively). No statistically significant differences were found for patients with an intermediate clot length compared with patients with a short clot length (RR 0.97, 95% CI: 0.75–1.25 and RR 1.11, 95% CI: 0.88–1.40, respectively). Analyses of clot length as a continuous variable showed a 10% reduction in chance of recanalisation and a 2% increase in risk of poor outcome with every centimeter increase in clot length (RR 0.90, 95% CI: 0.78–1.04 and RR 1.02, 95% CI: 0.98–1.05, respectively). Conclusions Clot length predicted recanalisation but not outcome at 1 month in patients with a BAO. We found 2% more poor outcome and 10% less recanalisation with every centimeter increase in clot length.