1. Background
Stroke is one of the most expensive and important causes of disability-adjusted life year (DALYs) (1). Approximately 5% of strokes are caused by subarachnoid hemorrhage (SAH) following the rupture of an aneurysm that primarily occurs at an early age and is associated with a poor prognosis (2).
Compared to other cerebral hemorrhages, SAH occurs at an early age, as well as in the sixth decade of life (3). Gender and country of residence have a significant effect on the incidence of SAH. In women, the risk is 1.6 times higher than in men (4). The results of a systematic review illustrated that compared to other parts of the world, the incidence of SAH in Japan (22.7%) and Finland (19.7 %) was higher, but lower in Central and South America (5).
According to the literature, risk factors for SAH are as follows: smoking, gender, advanced age, diabetes, obesity, inactivity, high cholesterol, high sodium diet, alcohol consumption, atrial fibrillation, familial history, and use of OCP medication (6-8). Another significant risk factor is hypertension, which is the most common and preventable cause of stroke (8).
The results of mortality and permanent disability due to SAH are relatively high. The results of a large retrospective study in Norway, conducted from 1984 to 2007, showed that the 30-day mortality rate in patients with SAH was 36% (6). While the Aneurysmal SAH mortality rate is 50% and less than 60% of survivors returning to functional independence (6, 9).
2. Objectives
Given that the frequency and risk factors for SAH may vary in patients from different world regions, as well as those with and without an aneurysm, this study was conducted with the aim of determining the risk factors and outcome of SAH in patients with and without an aneurysm.
3. Methods
The present study is a cross-sectional (descriptive-analytical) study that was performed on hospitalized SAH patients at Farshchian Hospital in Hamadan from 2015 to 2016. By using the Medical Records Department of the hospital, data on the hospitalized SAH patients were retrieved from medical records and entered the researcher-made checklist. The checklist included demographic information such as age and gender as well as clinical patient information like the history of hypertension, diabetes, hyperlipidemia, smoking, and disease outcome. Patients with ischemic stroke, hemorrhage in other parts of the brain and those with incomplete records were excluded. Descriptive statistics, including relative frequency, percentage, mean and standard deviation, were used to describe the study population. A chi-square test was used to compare the outcome of patients with and without an aneurysm. Data was analyzed using SPSS software, version 21. The significance threshold was set at less than 0.05.
4. Results
Overall, 69 patient records were investigated in this study. Among them 17 (24.63%) were aneurysm. 46.38% of patients were 60 years of age or older. There was a significant difference between the age of aneurysmal and non-aneurysmal in SAH patients; specifically, the proportion of aneurysmal SAH patients above 60 years of age was 11.76% compared to 57.69% in non-aneurysmal SAH patients (P = 0.003). Also, 40 (57.97%) of the patients were male. A portion of the patient population had a history of risk factors for the disease, including 59.4% with hypertension, 17.4% with diabetes, and 29% were smokers. However, as noted in Table 1, there was no significant correlation between these risk factors and aneurysm status of patients (P > 0.05).
Table 1.Demographic and Clinical Characteristics of SAH Patients with and Without Aneurysma
| Variable | Aneurysmal SAH (N = 17) | Non-Aneurysmal SAH (N = 52) | Total (N = 69) | P Value |
|---|---|---|---|---|
| Age group | 0.003 | |||
| 20 - 29 | 0 | 2 (3.85) | 2 (2.9) | |
| 30 - 39 | 1 (5.88) | 5 (9.62) | 6 (8.7) | |
| 40 - 49 | 6 (35.29) | 5 (9.62) | 11 (15.94) | |
| 50 - 59 | 8 (47.06) | 10 (19.23) | 18 (26.09) | |
| ≥ 60 | 2 (11.76) | 30 (57.69) | 32 (46.38) | |
| Gender | 0.52 | |||
| Male | 11 (64.71) | 29 (55.77) | 40 (57.97) | |
| Female | 6 (35.29) | 23 (44.23) | 29 (42.03) | |
| History of hypertension | 0.42 | |||
| Yes | 12 (70.59) | 29 (55.77) | 41 (59.42) | |
| No | 5 (29.41) | 23 (44.23) | 28 (40.58) | |
| History of diabetes | 0.97 | |||
| Yes | 3 (17.65) | 9 (17.31) | 12 (17.4) | |
| No | 14 (82.35) | 43 (82.69) | 57 (82.61) | |
| History of Hyperlepidemia | 0.87 | |||
| Yes | 1 (8.33) | 4 (7.02) | 5 (7.25) | |
| No | 11 (91.67) | 53 (92.98) | 64 (92.75) | |
| Smoking status | 0.51 | |||
| Yes | 6 (65.29) | 14 (26.92) | 20 (29.00) | |
| No | 11 (64.71) | 38 (73.08) | 49 (71.00) |
aValues are expressed as No. (%).
The outcomes of SAH in hospitalized patients are shown in Table 2. As indicated, the proportion of death, persistent defect, hydrocephaly and re-bleeding in the patients was 36.23%, 43.48%, 26.09%, and 17.39%, respectively. The different outcomes between SAH patients with and without aneurysm were not statistically significant (P > 0.05).
Table 2.Complications in SAH Patients with and Without Aneurysma
| Outcome | Aneurysmal SAH | Non-Aneurysmal SAH | Total | P Value |
|---|---|---|---|---|
| Death | 7 (41.18) | 18 (34.62) | 25 (36.23) | 0.62 |
| Stable impairment | 5 (29.41) | 25 (48.08) | 30 (43.48) | 0.18 |
| Hydrocephaly | 2 (11.76) | 16 (30.77) | 18 (26.09) | 0.12 |
| Re-bleeding | 1 (5.88) | 11 (21.15) | 12 (17.39) | 0.15 |
aValues are expressed as No. (%).
Of the 17 patients with aneurysm, the mean and standard deviation of aneurysm length and width were 7.71 ± 10.40 and 5.33 ± 7.60 mm, respectively. As indicated in Table 3, the most common hemorrhage sites in aneurysmal SAH patients were ACOM (38.10%) and MCA (28.57%).
Table 3.Frequency of Aneurysm Location in Patients with SAHa
| Location | Values |
|---|---|
| Left ACA | 2 (9.52) |
| Place of plugging right MCA | 1 (4.76) |
| ACOM | 4 (19.05) |
| Place of detachment ACOM left MCA | 3 (14.29) |
| Nut A3 | 1 (4.76) |
| Ophthalmic left carotid artery | 1 (4.76) |
| The location of the arteries top besila apcom | 2 (9.52) |
| Proximal MCA | 1 (4.76) |
| Interiors ACOM | 1 (4.76) |
| Place of plugging LCA (ACA an MCA) | 1 (4.76) |
| Bifurcation site right MCA | 1 (4.76) |
| Carotid sinus | 1 (4.76) |
| Proximal branch of fufani left MCA | 2 (9.52) |
aValues are expressed as No. (%).
5. Discussion
The results of this study showed that the majority of SAH patients had over 60 years old and among them, non-aneurysmal SAH patients had a higher proportion of advanced age. Hypertension and smoking were two common preventable risk factors in aneurysmal and non-aneurysmal SAH patients. The disease led to death in approximately one-third of patients, and of the rest, nearly half had persistent complications.
In this study, the ratio of male patients was higher. In a study conducted by Eden et al. (10), the occurrence of SAH was higher in men than women. Whereas, in the study by Korja et al. (11) there was a significant relationship between female patients and the incidence of SAH. It is important to note that the incidence of SAH is more common in men; however, the greater life expectancy of women, coupled with the fact that the prevalence of stroke increases with age, results in higher frequency of stroke in women compared with men (12). Perhaps another reason for the high prevalence of this disease in women can be attributed to the effect of hormones and oral contraceptives in women (8).
In the present study, a significant percentage of patients had a history of hypertension, diabetes and smoking. In the study by Korja et al. (11), there was a significant relationship between patient history of smoking and systolic blood pressure with the incidence of SAH. In the review study conducted by Fejin et al. (13), the odds ratio of the incidence of SAH was 2.9 in smokers and 2.6 in hypertensive patients; in addition, the authors noted that smoking and hypertension were risk factors that had a significant relationship with the incidence of SAH. However, there was no significant relationship between diabetes and hypercholesterolemia with SAH. Conversely, in a study conducted by Lindbohm et al. (14), high cholesterol in men was a risk factor for SAH. In their study, Duran et al. (15), also noted that 50% of patients had a history of hypertension and 7.5% were smokers. Although in the present study, the proportion of patients who smoked and had hypertension was higher than the findings of Duran et al. (15).
In the present study on the outcomes of SAH in hospitalized patients, 36.2% of patients died and 43.5% had stable complication. The results of the study by Duran et al. (15) showed that in patients with SAH low systolic blood pressure at the time of admission was associated with a poor prognosis (15).
In some studies, they have reported a significant correlation between the size of aneurysms that are 7 mm or more and the incidence of SAH (11). A high aneurysm size is also associated with an acute physiological condition (10). In the present study, the average length and width of the aneurysm observed was over 7 mm, but the outcome of the disease and physiological status of the patients were not included in the study variables or goals. A study conducted by Park et al. (16), investigated the site of aneurysms in 384 patients with SAH. In their study, they noted that the most common site of aneurysm occurrence was MCA (51.9%), followed by ICA (23.6%) and ACOM (20.6%). The sample size of the present study was smaller than that of Park et al. (16). In regards to the site of hemorrhage, the results of our study were not consistent with the above findings, which may be due to the anatomical differences of cerebral vessels in different races.
The primary limitation of this study was the sample size. The secondary limitation concerns possible inaccuracies and incomplete documentation in patient medical records.
5.1. Conclusions
The results of this study showed that SAH was more common in men and in the sixth decade of life regardless of gender. In addition, the majority of patients had a history of underlying diseases. We found that approximately one-third of patients died and nearly half of were left with long-term difficulties. Hypertension and smoking were two common modifiable risk factors in aneurysmal and non-aneurysmal SAH patients. Unlike non-aneurysmal SAH patients, aneurysmal SAH was more common in younger patients.
