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

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Abstract

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.

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Data availability

Anonymised datasets and statistical code are available upon reasonable request to the corresponding authors.

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Funding

This study was partially funded by Friends of A, a charitable organization.

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Authors and Affiliations

  1. National Neurosurgical Centre, Beaumont Hospital, Dublin, 9 D09 V2N0, Ireland

    Jack Henry, Michael Amoo, Mohamed O. Dablouk, Paula Corr, Deirdre Nolan, Deirdre Coffey & Mohsen Javadpour

  2. Department of Academic Neurology, Trinity College Dublin, Dublin, Ireland

    Michael Amoo & Mohsen Javadpour

  3. Royal College of Surgeons in Ireland, Dublin, Ireland

    Mohsen Javadpour

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  1. Jack Henry
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Contributions

Concept and design: JH, MA, and MJ. Data collection: MOD, PC, DN, and DC. Statistical analysis: JH. Interpretation of data: JH, MA, and MJ. Writing: JH, MA, and MJ. Review and revision of manuscript: JH, MA, MOD, PC, DN, DC, and MJ. All authors reviewed the manuscript prior to final submission.

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Correspondence to Jack Henry or Mohsen Javadpour.

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This study was approved by the local institutional review board (CA248) and performed in accordance with the ethical standards laid down in the 1964 Declaration of Helsinki and its later amendments. All participants provided informed consent to all treatment.

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Henry, J., Amoo, M., Dablouk, M.O. et al. Risk factor synergism in aneurysmal subarachnoid hemorrhage: a cross-sectional study. Acta Neurochir 165, 3665–3676 (2023). https://doi.org/10.1007/s00701-023-05852-8

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