Prevalence Of Subarachnoid Hemorrhage Research Articles

Subarachnoid Hemorrhage in Mechanical Thrombectomy for Acute Ischemic Stroke: Analysis of the STRATIS Registry, Systematic Review, and Meta-Analysis.

Background: The indications for mechanical thrombectomy in acute ischemic stroke continue to broaden, leading neurointerventionalists to treat vessel occlusions at increasingly distal locations farther in time from stroke onset. Accessing these smaller vessels raises the concern of iatrogenic subarachnoid hemorrhage (SAH) owing to increasing complexity in device navigation and retrieval. This study aims to determine the prevalence of SAH following mechanical thrombectomy, associated predictors, and resulting functional outcomes using a multicenter registry and compare this with a systematic review and meta-analysis of the literature.Methods: Data from STRATIS (The Systematic Evaluation of Patients Treated with Neurothrombectomy Devices for Acute Ischemic Stroke) registry were analyzed dichotomized by the presence or absence of SAH after thrombectomy. Only patients with 24-h post-procedural neuroimaging were included (n = 841). Multivariable logistic regression was performed to identify significant predictors of SAH. A systematic review and random-effects meta-analysis was also conducted in accordance with the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analysis) protocol.Results: The prevalence of post-thrombectomy SAH was 5.23% in STRATIS with 15.9% (1.84% overall) experiencing neurological decline. Distal location of vessel occlusion (OR 3.41 [95% CI: 1.75–6.63], p < 0.001) and more than 3 device passes (OR 1.34 [95% CI: 1.09–1.64], p = 0.01) were associated with a higher probability of SAH in contrast to a reduction with administration of intravenous tissue plasminogen activator (tPA) (OR 0.48 [95% CI: 0.26–0.89], p = 0.02). There was a trend toward a higher discharge NIHSS (8.3 ± 8.7 vs. 5.3 ± 6.6, p = 0.07) with a significantly reduced proportion achieving functional independence at 90 days (modified Rankin Score 0–2: 32.5% vs. 57.8%, p = 0.002) in SAH patients. Pooled analysis of 10,126 patients from 6 randomized controlled trials and 64 observational studies demonstrated a prevalence of 5.85% [95% CI: 4.51–7.34%, I2: 85.2%]. Only location of vessel occlusion was significant for increased odds of SAH at distal sites (OR 2.89 [95% CI: 1.14, 7.35]).Conclusions: Iatrogenic SAH related to mechanical thrombectomy is more common with treatment of distally-situated occlusions and multiple device passes. While low in overall prevalence, its effect is not benign with fewer patients reaching post-procedural functional independence, particularly if symptomatic.

Abstract P696: Organic Sleep Disorders Are Linked With Stroke- A Nationwide Population Study

Objective: Primary aim of this study is to identify prevalence of organic sleep disorders (OSDs) [REM sleep behaviour disorder (REMSBD), hypersomnia, parasomonia, insomnia, circadian rhythm] and compare prevalence of stroke [acute ischemic stroke (AIS), transient ischemic attack (TIA), intracerebral hemorrhage (ICeH), subarachnoid hemorrhage (SAH)] amongst OSDs. Secondary aim of the study is to evaluate the association between OSDs and stroke subtypes. Methods: A retrospective study was performed using National Inpatient Sample [2016-2017] for adult hospitalizations. We extracted a cohort of diagnoses of OSDs amongst which diagnoses of stroke were identified using ICD 10 code. Weighted analysis using chi-square test and mix-effects multivariable survey logistic regression was performed to evaluate the prevalence and odds of stroke amongst OSDs. Results: Out of 58,259,589 US hospitalizations, 2715 (0.00005%), 4120 (0.01%), 3420 (0.01%), 1,301,209 (2.23%) and 24870 (0.04%) had REMSBD, parasomnia, circadian rhythm, insomnia, and hypersomnia, respectively. Prevalence of AIS was higher in REMSBD [3.1 vs 2.1% p&lt;.0004], hypersomnia [2.7 vs 2.1% p&lt;.0001], parasomnia [2.6 vs 2.1% p=.0714], and circadian rhythm [2.8 vs 2.1% p=.0102]. Prevalence of TIA was higher in REMSBD [1.3 vs 0.6% p&lt;.0001], parasomnia [1.3 vs 0.6% p&lt;.0001] and hypersomnia [0.7 vs 0.5% p=.0188]. Prevalence of ICeH was higher in hypersomnia [0.5 vs 0.4% p=.0043], parasomnia [0.5 vs 0.4% p=.3239], and circadian rhythm [1.3 vs 0.4% p=.0188]. Prevalence of SAH was higher in circadian rhythm [0.6 vs 0.1% p&lt;.0001]. In analysis, patients with parasomnia had higher odds of TIA [aOR 2.8; 95%CI 1.02-7.5] and a weak association with ICeH [1.9 (0.5-7.9)]. Circadian rhythm OSD had 214% [3.1 (1.6-6.1)] and 310% [4.1 (1.5-11.0)] higher risk of ICeH and SAH, respectively and a weak association with AIS [1.3 (0.8-2.1)]. Hypersomnia had a weak association with AIS [1.2 (1.0-1.4)], TIA [1.1 (0.8-1.6)] and ICeH [1.4 (0.9-2.0)]. REMSBD had a weak association with AIS [3.6 (0.8-15.4)]. Conclusion: Our study shows organic sleep disorders (OSDs) are associated with strokes. Even Though the extent of association varies in each OSDs, early identification and prompt management of OSDs may mitigate the risk of stroke.

Impact of ICD-9 to ICD-10 Coding Transition on Prevalence Trends in Neurology.

To determine the effect of International Classification of Diseases, Ninth Revision, Clinical Modification (ICD-9-CM) to International Classification of Diseases, 10th Revision, Clinical Modification (ICD-10-CM) coding transition on the point prevalence and longitudinal trends of 16 neurologic diagnoses. We used 2014-2017 data from the National Inpatient Sample to identify hospitalizations with one of 16 common neurologic diagnoses. We used published ICD-9-CM codes to identify hospitalizations from January 1, 2014, to September 30, 2015, and used the Agency for Healthcare Research and Quality's MapIt tool to convert them to equivalent ICD-10-CM codes for October 1, 2015-December 31, 2017. We compared the prevalence of each diagnosis before vs after the ICD coding transition using logistic regression and used interrupted time series regression to model the longitudinal change in disease prevalence across time. The average monthly prevalence of subarachnoid hemorrhage was stable before the coding transition (average monthly increase of 4.32 admissions, 99.7% confidence interval [CI]: -8.38 to 17.01) but increased after the coding transition (average monthly increase of 24.32 admissions, 99.7% CI: 15.71-32.93). Otherwise, there were no significant differences in the longitudinal rate of change in disease prevalence over time between ICD-9-CM and ICD-10-CM. Six of 16 neurologic diagnoses (37.5%) experienced significant changes in cross-sectional prevalence during the coding transition, most notably for status epilepticus (odds ratio 0.30, 99.7% CI: 0.26-0.34). The transition from ICD-9-CM to ICD-10-CM coding affects prevalence estimates for status epilepticus and other neurologic disorders, a potential source of bias for future longitudinal neurologic studies. Studies should limit to 1 coding system or use interrupted time series models to adjust for changes in coding patterns until new neurology-specific ICD-9 to ICD-10 conversion maps can be developed.

Subarachnoid Hemorrhage in Hospitalized Renal Transplant Recipients with Autosomal Dominant Polycystic Kidney Disease: A Nationwide Analysis.

Background: This study aimed to evaluate the hospitalization rates for subarachnoid hemorrhage (SAH) among renal transplant patients with adult polycystic kidney disease (ADPKD) and its outcomes, when compared to non-ADPKD renal transplant patients. Methods: The 2005–2014 National Inpatient Sample databases were used to identify all hospitalized renal transplant patients. The inpatient prevalence of SAH as a discharge diagnosis between ADPKD and non-ADPKD renal transplant patients was compared. Among SAH patients, the in-hospital mortality, use of aneurysm clipping, hospital length of stay, total hospitalization cost and charges between ADPKD and non-ADPKD patients were compared, adjusting for potential confounders. Results: The inpatient prevalence of SAH in ADPKD was 3.8/1000 admissions, compared to 0.9/1000 admissions in non-ADPKD patients (p < 0.01). Of 833 renal transplant patients with a diagnosis of SAH, 30 had ADPKD. Five (17%) ADPKD renal patients with SAH died in hospitals compared to 188 (23.4%) non-ADPKD renal patients (p = 0.70). In adjusted analysis, there was no statistically significant difference in mortality, use of aneurysm clipping, hospital length of stay, or total hospitalization costs and charges between ADPKD and non-ADPKD patients with SAH. Conclusion: Renal transplant patients with ADPKD had a 4-fold higher inpatient prevalence of SAH than those without ADPKD. Further studies are needed to compare the incidence of overall admissions in ADPKD and non-ADPKD patients. When renal transplant patients developed SAH, inpatient mortality rates were high regardless of ADPKD status. The outcomes, as well as resource utilization, were comparable between the two groups.

Surgical Treatment of Intracranial Aneurysms in Elderly

Introduction: Twenty years ago, elderly patients who had a diagnosis of intracerebral aneurysms were considered to have a poor prognosis and, thus, were excluded of any kind of treatment. With the rapid aging of the population, there was a consistent increase on the prevalence of subarachnoid hemorrhage and, consequently, all of its complications. Delayed neurological deterioration from cerebral arterial vasospasm is a major cause of morbidity and mortality. Thus, specific treatment strategy for intracranial aneurysms in the elderly has been developed. Materials and Methods: Analysis of medical records, office charts, and imaging studies of all elderly patients who underwent surgical treatment of intracerebral aneurysms, and review of literature. Data related to these patients, like gender, aneurysm location, rupture, and comorbidities, were recorded. Results: Between June 1996 and November 2009, among 152 patients with 209 ruptured and unruptured intracranial aneurysms treated surgically, 23 patients were 65 years of age or older. Discussion: Withholding aneurysm surgery merely because of the patient’s age is not necessarily the most appropriate decision. Early surgery, in order to avoid re-rupture, vasospasm and infection, still is the better decision, independently of the treatment modality - open surgery or endovascular.

Internet search volumes in brain aneurysms and subarachnoid hemorrhage: Is there evidence of seasonality?

ObjectiveResults of previous studies examining seasonal variation in the incidence of aneurysmal subarachnoid hemorrhage (SAH) are conflicting. The aim of this brief report is to investigate whether there is a seasonal effect in online search queries for SAH that may reflect an association between meteorological factors and aneurysm rupture. Patients and methodsWe used the Google Trends data service to analyze the volume of internet queries for SAH on Google’s search engine from January 1, 2004 to November 2016. We used comprehensive search terms and collected data from: USA, Canada, and countries known for their high prevalence of SAH (Finland, and Japan), as well as worldwide search volume. Potential seasonal variations in the data were assessed by comparative non-parametric tests and curve-fit regression model. ResultsOur analyses revealed that USA had the highest median value in cumulative search scores (115 vs. 86, 46, 46 for Finland, Canada and Japan, respectively). The term “brain aneurysm” was the commonly used search term among countries, followed by “cerebral aneurysm”. There was no evidence of seasonality in any of the countries studied on both univariate tests and regression time-adjusted analysis. ConclusionsThere are no seasonal variations in internet search query volume for SAH. Further studies are needed to explore whether online search volumes correlate with the actual incidence of SAH.

Cost-effectiveness Analysis of Follow-up Strategies for Thunderclap Headache Patients With Negative Noncontrast CT.

Accurate diagnosis of acute subarachnoid hemorrhage (SAH) is critical in thunderclap headache patients due to high morbidity and mortality associated with missed aneurysmal bleeds. The objective of this study was to determine the utility of computed tomography angiography (CTA) in managing patients with acute, severe headaches and negative noncontrast CT and assess the cost-effectiveness of three different screening strategies-no follow up, CTA, and lumbar puncture (LP). A modeling-based economic evaluation was performed with a time horizon of 1 year for thunderclap headache patients in the emergency department with negative noncontrast CT for SAH. Sensitivity analyses were performed to determine the effect of sensitivity of CT and the prevalence of SAH on cost-effectiveness. Lumbar puncture follow-up has the lowest cost and the highest utility in the mathematical model. The Monte Carlo simulation shows noncontrast CT with LP follow-up to be the most cost-effective strategy in 85.3% of all cases even at a $1 million/quality-adjusted life-years willingness-to-pay. Sensitivity analyses demonstrate that LP follow-up should be performed, except for when CT sensitivity exceeds 99.2% and the SAH prevalence is below 3.2%, where no follow-up may be considered. Although CTA is frequently used for evaluation of thunderclap headache patients, its utility is not clearly defined. LP follow-up is shown to be the most cost-effective strategy for evaluation of thunderclap headache patients in most clinical settings.

Paradoxical Increase in Mortality and Rupture of Intracranial Aneurysms in Microsomal Prostaglandin E2 Synthase Type 1-Deficient Mice: Attenuation by Aspirin.

Inflammation plays an important role in formation and rupture of intracranial aneurysms. Expression of microsomal prostaglandin E2 (PGE2) synthase type 1 (mPGES-1) is increased in the wall of intracranial aneurysms in humans. PGE2, a by-product of mPGES-1, is associated with inflammation and cerebrovascular dysfunction. To test the hypothesis that deletion of mPGES-1 decreases the formation and rupture of intracranial aneurysms in a murine model. Intracranial aneurysms were induced in wild-type and mPGES-1 knockout (mPGES-1 KO) mice by using a combination of deoxycorticosterone acetate-salt-induced hypertension and intracranial injection of elastase in the basal cistern. Prevalence of aneurysms, subarachnoid hemorrhage, and mortality were assessed. We also tested the effects of administration of aspirin (6 mg/kg/d) by gavage and PGE2 (1 mg/kg/d) by subcutaneous infusion. Systolic blood pressure and prevalence of aneurysm were similar in wild-type and mPGES-1 KO mice. However, mortality and the prevalence of subarachnoid hemorrhage were markedly increased in mPGES-1 KO mice (P < .05). Bone marrow reconstitution studies suggest that mPGES-1 derived from leukocytes does not appear to increase rupture of intracranial aneurysms. Aspirin, but not PGE2, attenuated the increased mortality in mPGES-1 KO mice (P < .05). Vascular mPGES-1 plays a protective role in blood vessels and attenuates rupture of cerebral aneurysms. In contrast to effects on abdominal aneurysms, mPGES-1 deficiency is associated with an increase in rupture of cerebral aneurysms and mortality, which are attenuated by low-dose aspirin.

Angiotensin 1-7 reduces mortality and rupture of intracranial aneurysms in mice.

Angiotensin II (Ang II) stimulates vascular inflammation, oxidative stress, and formation and rupture of intracranial aneurysms in mice. Because Ang 1-7 acts on Mas receptors and generally counteracts deleterious effects of Ang II, we tested the hypothesis that Ang 1-7 attenuates formation and rupture of intracranial aneurysms. Intracranial aneurysms were induced in wild-type and Mas receptor-deficient mice using a combination of Ang II-induced hypertension and intracranial injection of elastase in the basal cistern. Mice received elastase+Ang II alone or a combination of elastase+Ang II+Ang 1-7. Aneurysm formation, prevalence of subarachnoid hemorrhage, mortality, and expression of molecules involved in vascular injury were assessed. Systolic blood pressure was similar in mice receiving elastase+Ang II (mean±SE, 148±5 mm Hg) or elastase+Ang II+Ang 1-7 (144±5 mm Hg). Aneurysm formation was also similar in mice receiving elastase+Ang II (89%) or elastase+Ang II+Ang 1-7 (84%). However, mice that received elastase+Ang II+Ang 1-7 had reduced mortality (from 64% to 36%; P<0.05) and prevalence of subarachnoid hemorrhage (from 75% to 48%; P<0.05). In cerebral arteries, expression of the inflammatory markers, Nox2 and catalase increased similarly in elastase+Ang II or elastase+Ang II+Ang 1-7 groups. Ang 1-7 increased the expression of cyclooxygenase-2 and decreased the expression of matrix metalloproteinase-9 induced by elastase+Ang II (P<0.05). In Mas receptor-deficient mice, systolic blood pressure, mortality, and prevalence of subarachnoid hemorrhage were similar (P>0.05) in groups treated with elastase+Ang II or elastase+Ang II+Ang 1-7. The expression of Mas receptor was detected by immunohistochemistry in samples of human intracranial arteries and aneurysms. In conclusion, without attenuating Ang II-induced hypertension, Ang 1-7 decreased mortality and rupture of intracranial aneurysms in mice through a Mas receptor-dependent pathway.

Can Computed Tomography Angiography of the Brain Replace Lumbar Puncture in the Evaluation of Acute‐onset Headache After a Negative Noncontrast Cranial Computed Tomography Scan?

The primary goal of evaluation for acute-onset headache is to exclude aneurysmal subarachnoid hemorrhage (SAH). Noncontrast cranial computed tomography (CT), followed by lumbar puncture (LP) if the CT is negative, is the current standard of care. Computed tomography angiography (CTA) of the brain has become more available and more sensitive for the detection of cerebral aneurysms. This study addresses the role of CT/CTA versus CT/LP in the diagnostic workup of acute-onset headache. This article reviews the recent literature for the prevalence of SAH in emergency department (ED) headache patients, the sensitivity of CT for diagnosing acute SAH, and the sensitivity and specificity of CTA for cerebral aneurysms. An equivalence study comparing CT/LP and CT/CTA would require 3,000 + subjects. As an alternative, the authors constructed a mathematical probability model to determine the posttest probability of excluding aneurysmal or arterial venous malformation (AVM) SAH with a CT/CTA strategy. SAH prevalence in ED headache patients was conservatively estimated at 15%. Representative studies reported CT sensitivity for SAH to be 91% (95% confidence interval [CI] = 82% to 97%) and sensitivity of CTA for aneurysm to be 97.9% (95% CI = 88.9% to 99.9%). Based on these data, the posttest probability of excluding aneurysmal SAH after a negative CT/CTA was 99.43% (95% CI = 98.86% to 99.81%). CT followed by CTA can exclude SAH with a greater than 99% posttest probability. In ED patients complaining of acute-onset headache without significant SAH risk factors, CT/CTA may offer a less invasive and more specific diagnostic paradigm. If one chooses to offer LP after CT/CTA, informed consent for LP should put the pretest risk of a missed aneurysmal SAH at less than 1%.

Association of genetic variants with hemorrhagic stroke in Japanese individuals

Although genetic epidemiological studies have implicated several genetic variants as risk factors for hemorrhagic stroke, the genetic determinants of this condition remain largely unknown. We examined an association of genetic variants with intracerebral or subarachnoid hemorrhage among Japanese individuals. The study population comprised 4,304 unrelated Japanese individuals, including 377 subjects with intracerebral hemorrhage, 205 subjects with subarachnoid hemorrhage, and 3,722 controls. The 150 polymorphisms examined in the present study were selected by genome-wide association studies of ischemic stroke and myocardial infarction with the use of the GeneChip Human Mapping 500K Array Set. The chi-square test, multivariable logistic regression analysis with adjustment for covariates, as well as a stepwise forward selection procedure revealed that the C->T polymorphism (rs1324694) of ERLIN1, the C->T polymorphism (rs12679196) of TRAPPC9, and the G->T polymorphism (rs16936752) of WNK2 were significantly (P<0.05) associated with the prevalence of intracerebral hemorrhage, and that the A->G polymorphism (rs3111754) of ITM2C and the A->G polymorphism (rs10986769) of MAPKAP1 were significantly associated with the prevalence of subarachnoid hemorrhage. Genotypes for ERLIN1, TRAPPC9, and WNK2 may prove informative for assessment of the genetic risk for intracerebral hemorrhage, and those for ITM2C and MAPKAP1 may be beneficial in assessment of the genetic risk for subarachnoid hemorrhage in Japanese individuals.

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