Stress in Patients With (Un)ruptured Intracranial Aneurysms vs Population-Based Controls.

BACKGROUND: Stress is associated with increased risk of stroke and might predispose to presence and rupture of intracranial aneurysms. OBJECTIVE: To study the association of recent and lifelong stress with unruptured intracranial aneurysm (UIA) and aneurysmal subarachnoid hemorrhage (ASAH). METHODS: In 227 UIA patients (mean age 61 ± 11 yr), 490 ASAH patients (59 ± 11 yr), and 775 controls (51 ± 15 yr) who were randomly retrieved from the general population, we assessed occurrence of major life events and perceived stress during the preceding 12 mo and the entire life. With multivariable logistic regression analysis, we calculated odds ratios (ORs) with 95% confidence intervals (95% CIs) for 4 categories of life events (financial-related, work-related, children-related, and death of family members) and for periods of perceived stress at home and at work (never vs sometimes, often, or always). We adjusted for sex, age, alcohol consumption, smoking, and hypertension. RESULTS: The 4 categories of life events and perceived stress at work had ORs ranging from 0.4 to 1.7, of which financial stress for UIA was statistically significant (95% CI: 1.1-2.5). ORs for chronic perceived stress at home in the previous year were 4.3 (95% CI: 1.8-10.3) for UIA and 2.5 (1.2-5.5) for ASAH, and for lifelong exposure 5.7 (2.2-14.5) for UIA and 3.0 (1.3-7.0) for ASAH. CONCLUSION: For some components of stress, there may be a relation with UIA and ASAH. The mechanisms underlying this relation should be unraveled; strategies to improve coping with stress may reduce the risk of rupture in patients with unruptured aneurysms.

Restrictions and satisfaction with participation in patients who are ADL-independent after an aneurysmal subarachnoid hemorrhage.

BACKGROUND: Most survivors of an aneurysmal subarachnoid hemorrhage (aSAH) are ADL-independent, but they often experience restrictions in (social) activities and, therefore, cannot regain their pre-morbid level of participation. OBJECTIVE: In this study, participation restrictions and participation satisfaction experienced after aSAH were assessed. Moreover, possible predictors of participation after aSAH were examined to identify goals for rehabilitation. METHOD: Participation restrictions experienced by a series of 67 patients visiting our SAH outpatient clinic were assessed as part of standard clinical care using the Participation Restrictions and Satisfaction sections of the Utrecht Scale for Evaluation of Rehabilitation Participation (USER-Participation) 6 months after aSAH. Cognitive impairments, cognitive and emotional complaints, and symptoms of depression and anxiety, assessed 10 weeks after aSAH, were examined as possible predictors of participation by means of linear regression analysis. RESULTS: Although patients were ADL-independent, 64% reported one or more participation restrictions and 60% were dissatisfied in one or more participation domains. Most commonly experienced restrictions concerned housekeeping, chores in and around the house, and physical exercise. Dissatisfaction was most often reported about outdoor activities, mobility, and work/housekeeping. The main predictors of participation restrictions as well as satisfaction with participation were cognitive complaints (subjective) (ß = -.30, p = .03 and ß = -.40, p = .002, respectively) and anxiety (ß = .32, p = .02 and ß = -.34, p = .007, respectively). CONCLUSIONS: Almost two-thirds of the ADL-independent patients experienced problems of participation 6 months after aSAH. Cognitive complaints (subjective) and anxiety symptoms showed the strongest association with participation restrictions and satisfaction. Cognitive rehabilitation and anxiety-reducing interventions may help to optimize rehabilitation and increase participation after aSAH.

Subjective hearing impairment after subarachnoid haemorrhage: Prevalence and risk factors.

BACKGROUND: Sensorineural hearing impairment is a key symptom in patients with superficial siderosis of the central nervous system, a disease caused by chronic or intermittent haemorrhage into the subarachnoid space. We investigated the prevalence and risk factors of subjective hearing impairment after SAH. METHODS: We systematically interviewed all SAH patients admitted between June 2011 and December 2014, who were able to visit the SAH outpatient clinic six to eight weeks after hospital discharge. We calculated the proportion of patients with subjective hearing impairment noticed after SAH onset, and adjusted risk ratios (aRR) with 95% confidence intervals (CI) for potential risk factors with Poisson regression. RESULTS: We included 277 patients. Subjective hearing impairment was reported by 54/277 (19%) patients (aneurysmal SAH: 42/212 [20%;95%CI:15-26%]; perimesencephalic haemorrhage 8/36 [22%;95%CI:12-38%], non-aneurysmal non-perimesencephalic SAH: 4/29 [14%;95%CI:6-31%]). Hearing impairment was associated with a poor clinical condition on admission (defined as PAASH score 4-5) (aRR3.00;95%CI:1.43-6.28), aneurysm rupture at the middle cerebral artery (aRR2.72;95%CI:1.38-5.39), and moderate/severe disability 3months after ictus (aRR2.25;95%CI:1.28-3.97), but not with large amounts of extravasated blood (highest vs. lowest tertile of Hijdra score) (aRR0.77;95%CI:0.33-1.81) or endovascular treatment (aRR1.19;95%CI:0.61-2.33). CONCLUSION: Subjective hearing impairment occurs in 1 of every 5 SAH patients. It is related to the clinical condition on admission, aneurysm rupture at the middle cerebral artery, and functional outcome, but not to the amount of subarachnoid blood or the method of aneurysm occlusion. Audiometric tests, auditory cognitive assessments, and follow-up studies are needed to determine the cause and prognosis of hearing impairment after SAH.

Sex-Related Differences in Outcome in Patients with Aneurysmal Subarachnoid Hemorrhage.

BACKGROUND: Several population-based studies found a higher case fatality after aneurysmal subarachnoid hemorrhage (ASAH) in women than in men. This may relate to differences in prognostic characteristics. We therefore assessed sex differences in prognosticators and outcome in ASAH patients. METHODS: From a prospectively collected ASAH database, we retrieved data on patients admitted from 1990 to 2010. We calculated prevalence ratios (PRs) with corresponding 95% confidence intervals (CIs) for prognosticators (clinical condition on admission, site and treatment of the aneurysm, and complications during the clinical course) and risk ratios (RRs) for in-hospital death and poor outcome (death or dependence) at 3 months. RRs were adjusted for possible confounding with Poisson regression analysis. RESULTS: Of the 1761 included patients, 1211 (68.8%) were women, who were 1.9 (95% CI: .5↔3.3) years older than men. PRs for women for the site of the aneurysm were 1.71 (95% CI: 1.38↔2.13) for the carotid artery, .68 (95% CI: .60↔.77) for the anterior communicating artery, 1.14 (95% CI: .92↔1.41) for the middle cerebral artery, and .85 (95% CI: .63↔1.13) for posterior circulation. PRs of other prognosticators were similar between sexes. The crude RR for in-hospital death for women was .91 (95% CI: .78↔1.05) and for poor outcome at 3 months was .95 (95% CI: .85↔1.06); both remained similar after adjustment. CONCLUSIONS: In this study, in-hospital death and poor outcome at 3 months did not differ between men and women. Women were slightly older than men and had different distributions of aneurysm sites, but not to an extent that it explained a sex difference in outcome.

Long-term risk of aneurysmal subarachnoid hemorrhage after a negative aneurysm screen.

OBJECTIVE: The objective was to assess the risk of aneurysmal subarachnoid hemorrhage (aSAH) in the initial 15 years after negative aneurysm screening in persons with one first-degree relative with aSAH. METHODS: From a cohort of first-degree relatives of patients with aSAH who underwent screening between 1995 and 1997 (n = 626), we included those with a negative screening (n = 601). We retrieved all causes of death and sent a questionnaire to screenees who were still alive. If aSAH was reported, we reviewed all medical data. We assessed the incidence of aSAH in this cohort with survival analysis and calculated an incidence ratio by dividing the observed incidence with the age- and sex-adjusted incidence in the general population. RESULTS: Of the 601 screenees, 3 had aSAH during 8,938 follow-up patient-years (mean 14.9 years). After 15 years, the cumulative incidence was 0.50% (95% confidence interval: 0.00%-1.06%) with an incidence rate of 33.6 per 100,000 person-years; the incidence rate ratio was 1.7 (95% confidence interval: 0.3-5.7). CONCLUSIONS: In the first 15 years after a negative screening, the risk of aSAH in persons with one first-degree relative with aSAH is not nil, but in the range of that in the general population, or even higher. Whether this finding justifies serial aneurysm screening in this population requires further study.

Patients with unruptured intracranial aneurysms at the waiting list for intervention: risk of rupture.

Unruptured intracranial aneurysms are usually not managed on an emergency basis, although for patients, uncertainty and waiting can be stressful. We assessed the incidence of aneurysms rupturing during the initial period of awareness of having an aneurysm. We studied all patients visiting our service with an unruptured intracranial aneurysm between January 2000 and March 2013. For the exposure time (time between diagnosis and discussion of treatment plan, together with time on waiting list for treatment), we calculated incidence of aneurysmal rupture with corresponding 95 % confidence intervals. We compared this incidence with expected incidence (based on size and site for each aneurysm). 398 patients were included; five had aneurysmal rupture during the exposure time. The observed incidence of aneurysmal rupture during exposure time was 47/1,000 patient-years (95 % confidence interval 15-111); the expected incidence was 0.7/1,000. Our data suggest that the risk of aneurysmal rupture early after detection of unruptured aneurysms is higher than expected based on aneurysm characteristics.

Circadian fluctuations in onset of perimesencephalic hemorrhage.

Aneurysmal subarachnoid hemorrhage (aSAH) occurs more often during working hours and in the evening, and thus at times of relatively high blood pressure, with an even distribution over the days of the week in most studies. Perimesencephalic hemorrhage (PMH) is a non-aneurysmal subset of subarachnoid hemorrhage (SAH) without known circadian fluctuation. We studied the time and day of onset in a large series of patients with PMH. For all 249 PMH patients included in our SAH-database we analyzed the time (categorized in 2- and 6-h intervals) and day of onset by calculating rate ratios (RRs) with corresponding 95 % confidence intervals (CIs) for time and day, with the afternoon and Saturday as reference. The risk of PMH was lower between 2-4 AM (RR 0.14; 95 % CI 0.03-0.63), 4-6 AM (RR 0.21; 95 % CI 0.06-0.75) and 6-8 AM (RR 0.07; 95 % CI 0.01-0.54). A tendency towards higher risks in the morning and afternoon was observed. Analyzing the time of onset in 6-h intervals also showed a lower risk (RR 0.35; 95 % CI 0.21-0.58) during night hours (12-6 AM). The risk of PMH was evenly distributed over the days of the week. PMH occurs less often during night hours. The pattern of PMH during the day shows similarities to that seen in aSAH, although the differences over the day are not statistically significant, as they are in aSAH. The occurrence of PMH is evenly distributed over the days of the week, as it is in aSAH.

Risk of rupture of an intracranial aneurysm based on patient characteristics: a case-control study.

BACKGROUND AND PURPOSE: Knowledge about risk factors contributes to understanding the pathophysiological mechanisms that cause intracranial aneurysm rupture and helps to develop possible treatment strategies. We aimed to study lifestyle and personal characteristics as risk factors for the rupture of intracranial aneurysms. METHODS: We performed a case-control study with 250 patients with an aneurysmal subarachnoid hemorrhage and 206 patients with an unruptured intracranial aneurysm. All patients with an aneurysmal subarachnoid hemorrhage and patients with a unruptured intracranial aneurysm were asked to fill in a structured questionnaire about their lifestyle and medical history. For patients with an unruptured intracranial aneurysm, we also collected data on the indication for imaging. With logistic regression analysis, we identified independent risk factors for aneurysmal rupture. RESULTS: Reasons for imaging in patients with an unruptured intracranial aneurysm were atherosclerotic disease (23%), positive family history (18%), headache (8%), preventive screening (3%), and other (46%). Factors that increased risk for aneurysmal rupture were smoking (odds ratio, 1.9; 95% confidence interval, 1.2-3.0) and migraine (2.4; 1.1-5.1); hypercholesterolemia decreased this risk (0.4; 0.2-1.0), whereas a history of hypertension did not independently influence the risk. CONCLUSIONS: Smoking, migraine and, inversely, hypercholesterolemia are independent risk factors for aneurysmal rupture. Data from the questionnaire are insufficient to conclude whether hypercholesterolemia or its treatment with statins exerts a risk-reducing effect. The pathophysiological mechanisms through which smoking and migraine increase the risk of aneurysmal rupture should be investigated in further studies. Although a history of hypertension does not increase risk of rupture, a sudden rise in blood pressure might still trigger aneurysmal rupture.

Independent risk factors for intracranial aneurysms and their joint effect: a case-control study.

BACKGROUND AND PURPOSE: Three percent of the population has an unruptured intracranial aneurysm (UIA). We aimed to identify independent risk factors from lifestyle and medical history for the presence of UIAs and to investigate the combined effect of well-established risk factors. METHODS: We studied 206 patients with an UIA who never had a subarachnoid hemorrhage and 574 controls who were randomly retrieved from general practitioner files. All participants filled in a questionnaire on potential risk factors for UIAs. With logistic regression analysis, we identified independent risk factors for UIA and assessed their combined effect. RESULTS: Independent risk factors were current smoking (odds ratio [OR], 3.0; 95% confidence interval [CI], 2.0-4.5), hypertension (OR, 2.9; 95% CI, 1.9-4.6), family history of stroke other than subarachnoid hemorrhage (OR, 1.6; 95% CI, 1.0-2.5), hypercholesterolemia (OR, 0.5; 95% CI, 0.3-0.9), and regular physical exercise (OR, 0.6; 95% CI, 0.3-0.9). The joint risk of smoking and hypertension was higher (OR, 8.3; 95% CI, 4.5-15.2) than the sum of the risks independently. CONCLUSIONS: Current smoking, hypertension, and family history of stroke increase the risk of UIA, with smoking and hypertension having an additive effect, whereas hypercholesterolemia and regular physical exercise decrease this risk. A healthy lifestyle probably reduces the risk of UIA and thereby possibly also that of aneurysmal subarachnoid hemorrhage. Whether smoking and hypertension increase the risk of aneurysmal subarachnoid hemorrhage only through an increased risk of aneurysm formation or also through an increased risk of rupture remains to be established.

Lifetime risks for aneurysmal subarachnoid haemorrhage: multivariable risk stratification.

OBJECTIVE: The overall incidence of aneurysmal subarachnoid haemorrhage (aSAH) in western populations is around 9 per 100 000 person-years, which confers to a lifetime risk of around half per cent. Risk factors for aSAH are usually expressed as relative risks and suggest that absolute risks vary considerably according to risk factor profiles, but such estimates are lacking. We aimed to estimate incidence and lifetime risks of aSAH according to risk factor profiles. METHODS: We used data from 250 patients admitted with aSAH and 574 sex-matched and age-matched controls, who were randomly retrieved from general practitioners files. We determined independent prognostic factors with multivariable logistic regression analyses and assessed discriminatory performance using the area under the receiver operating characteristic curve. Based on the prognostic model we predicted incidences and lifetime risks of aSAH for different risk factor profiles. RESULTS: The four strongest independent predictors for aSAH, namely current smoking (OR 6.0; 95% CI 4.1 to 8.6), a positive family history for aSAH (4.0; 95% CI 2.3 to 7.0), hypertension (2.4; 95% CI 1.5 to 3.8) and hypercholesterolaemia (0.2; 95% CI 0.1 to 0.4), were used in the final prediction model. This model had an area under the receiver operating characteristic curve of 0.73 (95% CI 0.69 to 0.76). Depending on sex, age and the four predictors, the incidence of aSAH ranged from 0.4/100 000 to 298/100 000 person-years and lifetime risk between 0.02% and 7.2%. CONCLUSIONS: The incidence and lifetime risk of aSAH in the general population varies widely according to risk factor profiles. Whether persons with high risks benefit from screening should be assessed in cost-effectiveness studies.

Quality of life, anxiety, and depression in patients with an unruptured intracranial aneurysm with or without aneurysm occlusion.

BACKGROUND: Awareness of having an unruptured intracranial aneurysm can affect quality of life and provoke feelings of anxiety and depression, even in treated patients, because of fear of recurrence of aneurysms. OBJECTIVE: To assess quality of life and feelings of anxiety and depression in patients with an unruptured aneurysm with or without aneurysm occlusion. METHODS: We sent postal questionnaires (Medical Outcomes Study Short Form-36, EuroQol-5D, Hospital Anxiety and Depression Scale) to 229 patients with an unruptured aneurysm and no history of subarachnoid hemorrhage identified from our database. Group mean scores and corresponding 95% confidence intervals (CIs) were compared between the no intervention group and the intervention group and with a reference population using the Student t test and χ(2) test. RESULTS: In total, 173 questionnaires (76%) were returned. There were no statistically significant differences in quality of life and anxiety and depression levels between patients with and those without aneurysm occlusion. Patients in the no intervention group compared with the reference population had a significantly reduced quality of life in the physical function (-10.7; 95% CI, -16.2 to -5.1), role physical (-15.8; 95% CI, -25.5 to -6.0), role emotional (-9.9; 95% CI, -18.7 to -1.1), vitality (-7.2; 95% CI, -12.1 to -2.4), and general health (-11.6; 95% CI, -16.2 to -6.9) domains. Results were comparable in the intervention group except for the role emotional domain, which was not statistically significantly reduced. CONCLUSION: Patients with an unruptured aneurysm have a reduced quality of life compared with the reference population, mainly in physical domains, but without an apparent effect on mood or anxiety. The extent of reduction in quality of life is similar in patients with and without aneurysm occlusion.

Trigger factors for rupture of intracranial aneurysms in relation to patient and aneurysm characteristics.

Female gender, age above 60 years, and an aneurysm larger than 5 mm or location on the posterior circulation are associated with a higher rupture risk of intracranial aneurysms. We hypothesized that this association is explained by a higher susceptibility to (one of) the eight trigger factors that were recently identified. We included 250 patients with aneurysmal subarachnoid hemorrhage. We calculated relative risks (RR) with 95% confidence intervals (95% CI) of aneurysmal rupture for trigger factors according to sex, age, site, and size of the aneurysms by means of the case-crossover design. None of the triggers except for physical exercise differed according to patient and aneurysm characteristics. In the hour after exposure to physical exercise: (1) patients over the age of 60 have a six-times-higher risk of rupture (RR 13; 95% CI 6.3-26) than those of 60 years of age and under (RR 2.3; 1.3-4.1); (2) aneurysms at the internal carotid artery have a higher risk than those at other locations (RR 17; 7.8-37), but this was only statistically significant when compared to anterior communicating artery aneurysms (RR 3.2; 1.6-6.1); (3) aneurysms 5 mm or smaller had a higher risk of rupture (RR 9.5; 4.6-19) than larger aneurysms (RR 2.4; 1.3-4.3); and (4) women and men had similar risks. A higher susceptibility to exercise might explain part of the higher risk of rupture in older patients. Why women and patients with aneurysms larger than 5 mm or posterior circulation aneurysms have a higher risk of rupture remains to be settled.

Trigger factors and their attributable risk for rupture of intracranial aneurysms: a case-crossover study.

BACKGROUND AND PURPOSE: Little is known about activities that trigger rupture of an intracranial aneurysm. Knowledge on what triggers aneurysmal rupture increases insight into the pathophysiology and facilitates development of prevention strategies. We therefore aimed to identify and quantify trigger factors for aneurysmal rupture and to gain insight into the pathophysiology. METHODS: During a 3-year period, 250 patients with aneurysmal subarachnoid hemorrhage completed a structured questionnaire regarding exposure to 30 potential trigger factors in the period soon before subarachnoid hemorrhage (hazard period) and for usual frequency and intensity of exposure. We assessed relative risks (RR) of rupture after exposure to triggers with the case-crossover design comparing exposure in the hazard period with the usual frequency of exposure. Additionally, we calculated population-attributable risks. RESULTS: Eight triggers increased the risk for subarachnoid hemorrhage: coffee consumption (RR, 1.7; 95% CI, 1.2-2.4), cola consumption (RR, 3.4; 95% CI,1.5-7.9), anger (RR, 6.3; 95% CI, 4.6-25), startling (RR, 23.3; 95% CI, 4.2-128), straining for defecation (RR, 7.3; 95% CI, 2.9-19), sexual intercourse (RR, 11.2; 95% CI, 5.3-24), nose blowing (RR, 2.4; 95% CI, 1.3-4.5), and vigorous physical exercise (RR, 2.4; 95% CI, 1.2-4.2). The highest population-attributable risks were found for coffee consumption (10.6%) and vigorous physical exercise (7.9%). CONCLUSIONS: We identified and quantified 8 trigger factors for aneurysmal rupture. All triggers induce a sudden and short increase in blood pressure, which seems a possible common cause for aneurysmal rupture. Some triggers are modifiable, and further studies should assess whether reduction of exposure to these factors or measures preventing sudden increase in blood pressure decrease the risk of rupture in patients known to have an intracranial aneurysm.

Functional outcome and quality of life 5 and 12.5 years after aneurysmal subarachnoid haemorrhage.

Patients who recover from aneurysmal subarachnoid haemorrhage (SAH) often remain disabled or have persisting symptoms with a reduced quality of life (QoL). We assessed functional outcome and QoL 5 and 12.5 years after SAH. In a consecutive series of 64 patients with mean age at SAH of 51 years, initial outcome assessments had been performed at 4 and 18 months after SAH. At the initial and current outcome assessments, functional outcome was measured with the modified Rankin Scale (mRS) and QoL with the SF-36 and a visual analogue scale (VAS). We studied the change in outcome measurements over time. We used the non-parametric Wilcoxon test to compare differences in mRS grades and calculated differences with corresponding 95% confidence intervals in the domain scores of the SF-36 and the VAS. After 5 years, seven patients had died and five patients had missing data. Compared with the 4-month follow-up, the mRS had improved in 29 of the 52 patients, remained similar in 19 patients. The overall QoL (SF-36 domains and VAS score) was better. At 12.5 years an additional six patients had died. Compared to the 4-month study, 25 of the 46 remaining patients had improved mRS, 12 had remained the same and in nine patients the mRS had worsened. Between the 5 and the 12.5 years follow-up, the improvement in mRS had decreased but patients reported overall a better QoL. Among long-time survivors, QoL may improve more than a decade after SAH.

Long-term outcome of patients discharged to a nursing home after aneurysmal subarachnoid hemorrhage.

OBJECTIVE: To study long-term outcome in patients with aneurysmal subarachnoid hemorrhage (SAH) who are relatively young. DESIGN: Retrospective cohort study. SETTING: Nursing homes. PARTICIPANTS: Patients with SAH (N=92) admitted to our hospital from 1996 to 2006 who were discharged to a nursing home. INTERVENTIONS: Not applicable. MAIN OUTCOME MEASURES: Death, discharge from nursing home, and functional status at end of follow-up. RESULTS: Of the 92 patients included, 45 had died after a median of 1.1 years (range, 0.0-8.5 y), 35 were discharged to home or a sheltered housing or rehabilitation center after a median of 0.6 years (range, 0.1-9.6 y), and 12 remained in a nursing home after a median of 4.8 years (range, 2.2-12.0 y). Forty-four (43%) had survived longer than 5 years, and 29 (31%) had regained functional independence within the initial 2 years after admission to the nursing home. Early discharge tended to occur more often in patients admitted from 2001 to 2006 than in those admitted from 1996 to 2001 (hazard ratio=1.8; 95% confidence interval, 0.9-3.7) and in those with an aneurysm not in the anterior communicating artery (hazard ratio=1.9; 95% confidence interval, 0.9-3.9). CONCLUSIONS: The prognosis for patients with SAH after admission to a nursing home is not gloomy. The type of rehabilitation that offers best chances to these patients needs to be investigated.

Anosmia after perimesencephalic nonaneurysmal hemorrhage.

BACKGROUND AND PURPOSE: Anosmia frequently occurs after aneurysmal subarachnoid hemorrhage not only after clipping, but also after endovascular coiling. Thus, at least in part, anosmia is caused by the hemorrhage itself and not only by surgical treatment. However, it is unknown whether anosmia is related to rupture of the aneurysm with sudden increase in intracranial pressure or to the presence of blood in the basal cisterns. Therefore, we studied the prevalence of anosmia in patients with nonaneurysmal perimesencephalic hemorrhage. METHODS: We included all patients admitted to our hospital with perimesencephalic hemorrhage between 1983 and 2005. Patients were interviewed with a structured questionnaire. We calculated the proportion of patients with anosmia with corresponding 95% CIs. RESULTS: Nine of 148 patients (6.1%; 95% CI, 2.8% to 11%) had noticed anosmia shortly after the perimesencephalic hemorrhage. In 2, the anosmia had disappeared after 8 to12 weeks; in the other 7, it still persisted after a mean period of follow-up of 9 years. CONCLUSIONS: Anosmia occurs in one of every 16 patients with perimesencephalic hemorrhage, which is lower than previously reported rates after coiling in patients with subarachnoid hemorrhage but higher than rates after coiling for unruptured aneurysms. These data suggest that blood in the vicinity of the olfactory nerves plays a role in the development of anosmia.

Anosmia after aneurysmal subarachnoid hemorrhage.

OBJECTIVE: Anosmia has an important impact on well-being but is often neglected by physicians. In patients with subarachnoid hemorrhage (SAH), anosmia has mainly been reported after surgery for aneurysms of the anterior communicating artery. We studied the prevalence, predisposing factors (aneurysm site and type of treatment), impact, and prognosis of anosmia in patients with SAH. METHODS: Of the patients with SAH who resumed independent living, we included all patients treated by coiling between 1997 and 2003 and a sample of patients treated by clipping between 1985 and 2001. Patients underwent structured interviews regarding the presence and duration of anosmia. The impact of anosmia was scored using a visual analog scale ranging from 0 (no influence) to 100 (the worst thing that ever happened to them). Risk factors for anosmia were assessed by logistic regression analysis. RESULTS: Overall, 89 of the 315 interviewed patients (28%; 95% confidence interval [CI], 23-34%) reported anosmia after SAH (mean follow-up period, 7.4 yr), including 10 (15%) of the 67 coiled patients and 79 (32%) of the 248 clipped patients. The median visual analog scale impact score was 53 (range, 0-100). In 20 of the 89 patients (23%; 95% CI, 15-33), the symptoms had improved over time. Risk factors for anosmia were treatment by clipping (odds ratio [OR], 2.7; 95% CI, 1.3-5.7) and anterior communicating artery aneurysms (OR, 2.0; 95% CI, 1.2-3.3). CONCLUSION: Anosmia after SAH has a high prevalence, considerable impact, and poor prognosis. Its occurrence after coiling suggests not only damage to the olfactory nerve by clipping but also that the SAH itself plays a role in its pathogenesis.

Life expectancy after perimesencephalic subarachnoid hemorrhage.

BACKGROUND AND PURPOSE: Patients with a perimesencephalic nonaneurysmal subarachnoid hemorrhage are not at risk for rebleeding in the initial years after the hemorrhage. Nevertheless, uncertainty remains on the long-term prognosis after perimesencephalic hemorrhage, and former patients are often considered high-risk cases for health insurance or are denied life insurance. We performed a very long-term follow-up study of a large consecutive series of such patients and compared mortality in this cohort with that in the general population. METHODS: All patients with a perimesencephalic hemorrhage (defined by pattern of hemorrhage on computed tomography within 72 hours after onset and absence of aneurysm) admitted between 1983 and 2005 to our service were followed-up by telephone. For patients who had died, we retrieved age and cause of death. We compared the age- and sex-specific mortality of this cohort with that of the general population by means of standardized mortality ratios with corresponding 95% confidence intervals. RESULTS: The cohort consisted of 160 patients, with a total number of patient-years of 1213. No new episodes of subarachnoid hemorrhage had occurred. During follow-up 11 patients had died; the expected number of deaths based on mortality rates in the general population (adjusted for age and gender) was 18.1. The standardized mortality ratio was 0.61 (95% confidence interval, 0.34 to 1.1). CONCLUSIONS: Patients with perimesencephalic hemorrhage have a normal life expectancy and are not at risk for rebleeding. No restrictions should be imposed on these patients by physicians or health or life insurance companies.

Feasibility of follow-up through e-mail in patients discharged after subarachnoid hemorrhage.

BACKGROUND: Long-term follow-up in patients with a subarachnoid hemorrhage (SAH) can be important in patients care and for clinical research, but outpatients' visits or telephone interviews are time consuming. METHODS: We studied the feasibility of follow up through e-mail in a prospectively collected series of patients with aneurysmal SAH. RESULTS: Of the 97 patients who were discharged 58 (60%; 95% CI 49-70%) had e-mail, and all 58 provided their e-mail address. At 1 year 37 patients (64%; 95% CI 50-76%) responded to the first questionnaire sent by e-mail, 6 did so after an e-mail reminder. Fifteen responded after a telephone call, of which 12 had a new e-mail address. CONCLUSIONS: E-mail follow-up after SAH is feasible and for patients acceptable, but the proportion of patients with no or with changing e-mail address is considerable. The validity of the responses via e-mail has to be assessed in further studies.

Incidence of recurrent subarachnoid hemorrhage after clipping for ruptured intracranial aneurysms.

BACKGROUND AND PURPOSE: Because intracranial aneurysms develop during life, patients with subarachnoid hemorrhage (SAH) and successfully occluded aneurysms are at risk for a recurrence. We studied the incidence of and risk factors for recurrent SAH in patients who regained independence after SAH and in whom all aneurysms were occluded by means of clipping. METHODS: From a cohort of patients with SAH admitted between 1985 and 2001, we included those patients who were discharged home or to a rehabilitation facility. We interviewed these patients about new episodes of SAH. We retrieved all medical records and radiographs in case of reported recurrences. If patients had died, we retrieved the cause of death. We analyzed the incidence of and risk factors for recurrent SAH by Kaplan-Meier curves and Cox regression analysis. RESULTS: Of 752 patients with 6016 follow-up years (mean follow up 8.0 years), 18 had a recurrence. In the first 10 years after the initial SAH, the cumulative incidence of recurrent SAH was 3.2% (95% confidence interval [CI], 1.5% to 4.9%) and the incidence rate 286 of 100,000 patient-years (95% CI, 160 to 472 per 100,000). Risk factors were smoking (hazard ratio [HR], 6.5; 95% CI, 1.7 to 24.0), age (HR, 0.5 per 10 years; 95% CI, 0.3 to 0.8) and multiple aneurysms at the time of the initial SAH (HR, 5.5; 95% CI, 2.2 to 14.1). CONCLUSIONS: After SAH, the incidence of a recurrence within the first 10 years is 22 (12 to 38) times higher than expected in populations with comparable age and sex. Whether this increased risk justifies screening for recurrent aneurysms in patients with a history of SAH requires further study.