(Stroke. 1996;27:544-549.)
© 1996 American Heart Association, Inc.
Articles |
From the University Department of Neurology, Utrecht, Netherlands.
Correspondence to Laurien L. Teunissen, MD, University Department of Neurology, Heidelberglaan 100, 3584 CX Utrecht, Netherlands.
| Abstract |
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|
|
|---|
Methods To identify studies we performed a Medline search from 1966 to 1994 and searched the reference lists of all relevant publications. Studies were included only if they fulfilled predefined methodological criteria. Case-control studies were included if the diagnosis of SAH was proved by CT, angiography, or autopsy in at least 70% of patients. Longitudinal studies were included if the criteria for SAH were based on a review of the medical records.
Results Nine longitudinal studies and 11 case-control studies were included. Significant risk factors were as follows: (1) smoking (relative risk [RR] for longitudinal studies, 1.9; 95% confidence interval [CI], 1.5 to 2.3; odds ratio [OR] for case-control studies, 3.5; 95% CI, 2.9 to 4.3); (2) hypertension (RR, 2.8; 95% CI, 2.1 to 3.6; OR, 2.9; 95% CI, 2.4 to 3.7) and (3) drinking 150 g or more of alcohol per week (RR, 4.7; 95% CI, 2.1 to 10.5; OR, 1.5; 95% CI, 1.1 to 1.9). Use of oral contraceptives, hormone replacement therapy, hypercholesterolemia, and physical activity were not significantly related to the risk of SAH.
Conclusions We conclude that smoking, hypertension, and alcohol abuse are important risk factors for SAH. Reduction of exposure to these risk factors might result in a decreased incidence of SAH.
Key Words: gender meta-analysis risk factors subarachnoid hemorrhage
| Introduction |
|---|
|
|
|---|
Many studies on risk factors for SAH suffer from small numbers of patients and loose diagnostic criteria; in the majority of longitudinal studies, the diagnosis of SAH is not verified at all. Lack of verification of the diagnosis SAH may result in inclusion of many patients with intracerebral hemorrhage, since intracerebral hemorrhage occurs twice as often as SAH,7 and distinction between these two types of hemorrhage without CT scanning is erroneous in approximately 20% of patients.8 Since SAH and intracerebral hemorrhage may have different risk factors, series with a substantial proportion of patients in whom the diagnosis is not confirmed by CT, angiography, or autopsy may provide inaccurate data.
We therefore conducted a systematic review of all studies on risk factors for SAH to identify robust risk factors for SAH. We emphasized the use of sufficiently precise criteria for the diagnosis of SAH.
| Methods |
|---|
|
|
|---|
We found data on the following risk factors: alcohol, smoking,
hypertension, hypercholesterolemia, physical
activity, oral contraceptives, and hormone replacement therapy. To
allow comparison of data from different studies, we recategorized some
of the risk factors. Alcohol consumption was recalculated in grams per
week. We divided alcohol use into three groups as follows: (1) no
alcohol consumption; (2) <150 g/wk; and (3)
150 g/wk. One average
drink contains 12 g of alcohol. No alcohol consumption was taken as
reference in the comparison with the other two categories. For smoking,
case and control subjects were divided into three groups: (1) never
smokers; 2) former smokers; and (3) current smokers. Since not all
studies distinguished between never smokers and former smokers, we
performed a separate analysis with a dichotomy into (1) current
smokers and (2) previous smokers or nonsmokers. For hypertension and
hypercholesterolemia, case and control subjects
were divided according to the criteria used in the separate studies.
Insufficient data on type or dosage were available to recategorize oral
contraceptives and hormone replacement therapy. Case and control
subjects were divided in three groups: (1) never, (2) former, and (3)
current users. Since not all studies distinguished between never users
and former users, we performed a separate analysis with a
dichotomy into (1) current users and (2) never and former users.
Regional Differences
Since the incidence of SAH in Finland is
higher than anywhere
else,9 risk factors for SAH might also be different in
Finland. We therefore performed a separate analysis after
exclusion of all three Finnish
studies.10 11 12 These Finnish
case-control studies addressed
smoking,10 11 12
hypertension,11 12 and alcohol12 as risk
factors.
Data Analysis
RR and OR estimates from individual studies
were combined with
the Mantel-Haenszel method into combined estimates. For
case-control studies, population-based studies were considered
separately and in combination with hospital-based studies.
| Results |
|---|
|
|
|---|
|
|
Analysis of Studies
Smoking
Smoking was
assessed in 2 longitudinal studies,11 14
4 population-based case-control
studies,10 23 24 25 26
and 3 hospital-based case-control
studies.12 27 28
The risk of SAH for current smoking was increased in both the
longitudinal studies (RR, 1.9; 95% CI, 1.5 to 2.3), and the
case-control studies (OR, 3.5; 95% CI, 2.9 to 4.3). Ever smoking
also elevated the risk of SAH in the case-control studies (OR, 3.2;
95% CI, 2.5 to 4.1).12 23 27
(Figure
).
|
Hypertension
Hypertension
was assessed in 3 longitudinal
studies,11 16 18 4 population-based
case-control
studies,22 24 25 26 and 3
hospital-based case-control
studies.12 27 28 Hypertension
significantly increased the
risk of SAH in the longitudinal studies (RR, 2.8; 95% CI, 2.1 to 3.6)
as well as the case-control studies (OR, 2.9; 95% CI, 2.4 to 3.7)
(Figure
).
Alcohol
Risk implications
of alcohol intake were assessed in 2
longitudinal studies,19 20 1 population-based
case-control study,23 and 2 hospital-based
case-control studies.12 29 In the longitudinal
studies
the RR of SAH for drinking <150 g/wk was 2.8 (95% CI, 1.3 to 6.3),
and that for drinking
150 g/wk was 4.7 (95% CI, 2.1 to 10.5). In the
case-control studies, the OR for drinking
150 g/wk was 1.5 (95%
CI, 1.1 to 1.9), and that for drinking <150 g/wk was 0.8 (95% CI, 0.6
to 1.0) (Figure
).
Oral Contraceptives
Use of oral contraceptives was assessed in 1 longitudinal
study17 and 5 case-control studies, all population
based.21 22 24 25 26
In the longitudinal study, based on only
eight cases, the risk for ever use of oral contraception was
inconclusive (RR, 5.4; 95% CI, 0.7 to 43.5). In the case-control
studies, the risks were not elevated for either current use (OR, 1.2;
95% CI, 0.8 to 1.9) or ever use (OR, 1.0; 95% CI, 0.8 to 1.3)
(Figure
).
Hormone Replacement Therapy
In the single longitudinal study that addressed hormone
replacement as a risk factor for SAH,15 the risk was not
altered for either current use (RR, 0.6; 95% CI, 0.2 to 1.5) or ever
use (RR, 1.0; 95% CI, 0.5 to 1.9). In one small population-based
case-control study, the risks for current use (OR, 0.5; 95% CI,
0.2 to 1.0) and ever use (OR, 0.5; 95% CI, 0.3 to 1.0) tended to be
lower.22 (Figure
).
Cholesterol
In 2 longitudinal studies16 18 and 1
hospital-based case-control study,28
hypercholesterolemia was studied as a possible
risk factor for SAH. Hypercholesterolemia did
not alter the risk of SAH in either the longitudinal studies (RR, 0.9;
95% CI, 0.4 to 1.9) or the case-control study (OR, 0.9; 95% CI,
0.5 to 1.7) (Figure
).
Physical Activity
In a longitudinal study with 37 patients,13 physical
activity was almost significant as a protective factor (RR for
activity, 0.5; 95% CI, 0.3 to 1.0), despite a small number of
cases.
Regional Differences
In separate analyses
after exclusion of the Finnish
studies, smoking and hypertension were still significant risk factors
for SAH, but the use of alcohol at
150 g/wk was no longer
significantly associated with SAH.
Sex Differences
In separate analyses, the risks for alcohol use, smoking,
hypertension, and hypercholesterolemia were not
different for men and women (Table 3
).
|
| Discussion |
|---|
|
|
|---|
150 g/wk was also a significant
although less constant risk factor. The use of smaller amounts of
alcohol seemed to have a protective effect in the case-control
studies, but this effect was not supported by the longitudinal studies.
Our analysis therefore does not support a J-shaped
association between the dose of alcohol and the risk of SAH, as was
found for the association between alcohol and hemorrhagic stroke in
general.30 The results regarding alcohol are of course
influenced by the stratification we used. This restratification
explains why data we extracted from studies differ in some instances
from those in the original publications. For example, a single study
found that alcohol was a risk factor only when >400
g/wk,29 but this finding was not included in our
analysis because our stratification precludes subdivision into
categories of
150 to 400 and >400 g/wk. Also, we did not consider
drinking patterns in our analysis. There is some evidence that
binge drinking might increase the risk of SAH, but these studies did
not meet the predefined criteria and were therefore not
included.31 32 Another explanation for the higher
risk of
alcohol consumption is confounding, since smoking and alcohol use are
often combined and hypertension can be caused by smoking and alcohol
use.33 Since the individual studies did not always provide
information on combinations of risk factors in one patient, it was not
possible to study the effect of confounding in this systematic
review. A remarkable result of this review is the lack of evidence that oral contraceptives and cholesterol are risk factors for SAH. In two studies oral contraceptives were a significant risk factor for SAH,17 26 but the remaining four studies did not support this finding.21 22 24 25 In one of these four studies oral contraceptives even had a significant protective effect.24 The variation between the studies might be explained by different dosages of estrogen, but none of the studies provided information about type of oral contraceptive or amount of estrogen. In the two studies in which oral contraceptives were found to be a risk factor, the periods of follow-up were from 1969 to 1977 and from 1968 to 1987; in these periods the majority of patients used oral contraceptives with high estrogen levels. In all but one of the remaining studies, follow-up included a more recent period during which oral contraceptives with lower estrogen levels were used. The notion that estrogen use is a dose-dependent risk factor for SAH is further supported by the finding that hormone replacement therapy had a protective albeit nonsignificant effect on the risk for SAH.
This review is based on a total of 20 studies. Many other studies were not included in our analysis because they did not meet our predefined criteria. These include, among others, two often-cited Finnish studies on alcohol use and SAH, because they used estimated data of the general population as control.31 32 The well-known Framingham Study did not analyze SAH and intracerebral hemorrhage separately.34 Moreover, we have excluded many case-control studies in which fewer than 70% of the diagnoses of SAH were confirmed by CT, angiography, or autopsy and longitudinal studies in which medical records were not reviewed and diagnosis of SAH was based only on ICD codes. Additionally, many studies were excluded because it was impossible to recalculate the data into RRs. (A list of studies that were considered for this systematic review but did not meet our predefined criteria can be obtained on request from the authors.) For future studies of risk factors for aneurysmal SAH, we recommend CT scanning in as large a proportion of patients as possible and exclusion of patients with perimesencephalic hemorrhage. This benign subset of SAH is characterized by mild symptoms at onset, a typical pattern of hemorrhage on CT, absence of an aneurysm, an uneventful clinical course, and an excellent outcome.35 36 37 The risk factors for this nonaneurysmal type of SAH might be quite different from those for aneurysmal SAH. In the analysis we recommend reporting the RR of each risk factor separately in addition to the results of multivariate analysis. We divided the case-control studies into population-based and hospital-based studies, since hospital-based studies may contain a selected sample of the population with different risk factors. However, the analysis of population-based studies alone did not show important differences compared with the analysis of population-based and hospital-based studies together. The diagnostic criteria in the longitudinal studies were less strict than in the case-control studies. When longitudinal and case-control studies were compared, smoking and hypertension emerged as risk factors in every analysis, but for smoking the observed risk was higher in the case-control studies than in the longitudinal studies. Only two longitudinal studies considered alcohol as a risk factor, and in these studies alcohol was a stronger risk factor than in the case-control studies. Therefore, differences between longitudinal and case-control studies exist only in magnitude and not in the direction of the effect. An explanation for the different results obtained from longitudinal and case-control studies is that in longitudinal studies exposure status may be determined many years before the onset of the SAH, whereas in case-control studies exposures occur closer in time to stroke onset. The difference between longitudinal and case-control studies might also be explained by chance, since only two longitudinal studies considered smoking as a risk factor.
In a separate analysis after exclusion of the three Finnish
studies, alcohol intake of
150 g/wk was no longer a risk factor for
SAH. Although there might be loss of information caused by
stratification with this small number of studies, these data suggest
that alcohol abuse is more important a risk factor for SAH in Finland
than in other countries.
Our analysis of studies in which the diagnosis of SAH was verified in the majority of patients indicates that smoking, hypertension, and to a lesser extent alcohol abuse are significant risk factors for SAH. The decline in incidence of stroke in general, brought about by the reduction in these cardiovascular risk factors,38 39 has not been found for SAH: both a community study as well as a recent compilation disproved a decline in incidence of SAH over the last 30 years.9 40 The apparent lack of reduction in the incidence of SAH despite the reduction of its risk factors can be at least partly explained by the low incidence of SAH. The SAH incidence studies of the last few decades have been based on so few patients that even substantial reductions in incidence may not have been detected. Given an SAH incidence of 6/100 000 person-years,9 a prevalence of hypertension approximating 10%, and an RR of hypertension of 3, the incidence of SAH in patients without hypertension is 5/100 000 person-years and that of patients with hypertension 15/100 000 person-years. This means that hypertension should be effectively treated in 100 000 hypertensive patients to prevent 10 cases of SAH per year. The absence of a decline in SAH incidence might also be related to the presence of nonmodifiable risk factors, such as a familial, probably genetic factor,41 and a sex-related factor. SAH is more common in women, although smoking, hypertension, and alcohol use are more common in men, and the influence of the risk factors is equal in men and women. Since the genetic and sex-related risk factors are thus far unknown, the only method at present to decrease the incidence of SAH is the reduction of the major cardiovascular risk factors.
| Selected Abbreviations and Acronyms |
|---|
|
| Acknowledgments |
|---|
Received October 2, 1995; revision received November 27, 1995; accepted November 27, 1995.
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Y.B.W.E.M. Roos, G. Pals, P.M. Struycken, G.J.E. Rinkel, M. Limburg, J.C. Pronk, J.S.P. van den Berg, J.A.F.M. Luijten, P.L. Pearson, M. Vermeulen, et al. Genome-Wide Linkage in a Large Dutch Consanguineous Family Maps a Locus for Intracranial Aneurysms to Chromosome 2p13 Stroke, October 1, 2004; 35(10): 2276 - 2281. [Abstract] [Full Text] [PDF] |
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B. Stegmayr, M. Eriksson, and K. Asplund Declining Mortality From Subarachnoid Hemorrhage: Changes in Incidence and Case Fatality From 1985 Through 2000 Stroke, September 1, 2004; 35(9): 2059 - 2063. [Abstract] [Full Text] [PDF] |
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T. Mannami, H. Iso, S. Baba, S. Sasaki, K. Okada, M. Konishi, S. Tsugane, and for the Japan Public Health Center-Based Prospecti Cigarette Smoking and Risk of Stroke and its Subtypes Among Middle-Aged Japanese Men and Women: The JPHC Study Cohort I Stroke, June 1, 2004; 35(6): 1248 - 1253. [Abstract] [Full Text] [PDF] |
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Y.M. Ruigrok, G.J.E. Rinkel, A. Algra, T.W.M. Raaymakers, and J. van Gijn Characteristics of intracranial aneurysms in patients with familial subarachnoid hemorrhage Neurology, March 23, 2004; 62(6): 891 - 894. [Abstract] [Full Text] [PDF] |
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C. S. Anderson, V. Feigin, D. Bennett, R.-B. Lin, G. Hankey, K. Jamrozik, and for the Australasian Cooperative Research on Subar Active and Passive Smoking and the Risk of Subarachnoid Hemorrhage: An International Population-Based Case-Control Study Stroke, March 1, 2004; 35(3): 633 - 637. [Abstract] [Full Text] [PDF] |
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R. L. Macdonald Advances in Vascular Surgery Stroke, February 1, 2004; 35(2): 375 - 380. [Full Text] [PDF] |
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D. Gaist, L. Pedersen, S. Cnattingius, and H. T. Sorensen Parity and Risk of Subarachnoid Hemorrhage in Women: A Nested Case-Control Study Based on National Swedish Registries Stroke, January 1, 2004; 35(1): 28 - 32. [Abstract] [Full Text] [PDF] |
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D. Krex, H. Rohl, I. R. Konig, A. Ziegler, H. K. Schackert, and G. Schackert Tissue Inhibitor of Metalloproteinases-1, -2, and -3 Polymorphisms in a White Population With Intracranial Aneurysms Stroke, December 1, 2003; 34(12): 2817 - 2821. [Abstract] [Full Text] [PDF] |
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S. Yamada, A. Koizumi, H. Iso, Y. Wada, Y. Watanabe, C. Date, A. Yamamoto, S. Kikuchi, Y. Inaba, H. Toyoshima, et al. Risk Factors for Fatal Subarachnoid Hemorrhage: The Japan Collaborative Cohort Study Stroke, December 1, 2003; 34(12): 2781 - 2787. [Abstract] [Full Text] [PDF] |
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S. Juvela Prehemorrhage Risk Factors for Fatal Intracranial Aneurysm Rupture Stroke, August 1, 2003; 34(8): 1852 - 1857. [Abstract] [Full Text] [PDF] |
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C. Anderson, C. Ni Mhurchu, D. Scott, D. Bennett, K. Jamrozik, and G. Hankey Triggers of Subarachnoid Hemorrhage: Role of Physical Exertion, Smoking, and Alcohol in the Australasian Cooperative Research on Subarachnoid Hemorrhage Study (ACROSS) Stroke, July 1, 2003; 34(7): 1771 - 1776. [Abstract] [Full Text] [PDF] |
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T. Vogel, R. Verreault, J.-F. Turcotte, M. Kiesmann, and M. Berthel Review Article. Intracerebral Aneurysms: A Review With Special Attention to Geriatric Aspects J. Gerontol. A Biol. Sci. Med. Sci., June 1, 2003; 58(6): M520 - 524. [Abstract] [Full Text] [PDF] |
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T. Kurth, C. S. Kase, K. Berger, E. S. Schaeffner, J. E. Buring, and J. M. Gaziano Smoking and the Risk of Hemorrhagic Stroke in Men Stroke, May 1, 2003; 34(5): 1151 - 1155. [Abstract] [Full Text] [PDF] |
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K. Okamoto, R. Horisawa, T. Kawamura, A. Asai, M. Ogino, T. Takagi, and Y. Ohno Family History and Risk of Subarachnoid Hemorrhage: A Case-Control Study in Nagoya, Japan Stroke, February 1, 2003; 34(2): 422 - 426. [Abstract] [Full Text] [PDF] |
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H. Ohkuma, H. Tabata, S. Suzuki, and M. S. Islam Risk Factors for Aneurysmal Subarachnoid Hemorrhage in Aomori, Japan Stroke, January 1, 2003; 34(1): 96 - 100. [Abstract] [Full Text] [PDF] |
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W T Longstreth Jr Coffee and subarachnoid haemorrhage J. Neurol. Neurosurg. Psychiatry, August 1, 2002; 73(2): 112 - 112. [Full Text] |
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J Isaksen, A Egge, K Waterloo, B Romner, and T Ingebrigtsen Risk factors for aneurysmal subarachnoid haemorrhage: the Tromso study J. Neurol. Neurosurg. Psychiatry, August 1, 2002; 73(2): 185 - 187. [Abstract] [Full Text] [PDF] |
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B. M. Kissela, L. Sauerbeck, D. Woo, J. Khoury, J. Carrozzella, A. Pancioli, E. Jauch, C. J. Moomaw, R. Shukla, J. Gebel, et al. Subarachnoid Hemorrhage: A Preventable Disease With a Heritable Component Stroke, May 1, 2002; 33(5): 1321 - 1326. [Abstract] [Full Text] [PDF] |
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H. Ohkuma, S. Fujita, and S. Suzuki Incidence of Aneurysmal Subarachnoid Hemorrhage in Shimokita, Japan, From 1989 to 1998 Stroke, January 1, 2002; 33(1): 195 - 199. [Abstract] [Full Text] [PDF] |
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K. Okamoto, R. Horisawa, T. Kawamura, A. Asai, M. Ogino, T. Takagi, and Y. Ohno Menstrual and Reproductive Factors for Subarachnoid Hemorrhage Risk in Women: A Case-Control Study in Nagoya, Japan Stroke, December 1, 2001; 32(12): 2841 - 2844. [Abstract] [Full Text] [PDF] |
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B. Zhang, S. Dhillon, I. Geary, W. M. Howell, F. Iannotti, I. N.M. Day, and S. Ye Polymorphisms in Matrix Metalloproteinase-1, -3, -9, and -12 Genes in Relation to Subarachnoid Hemorrhage Stroke, September 1, 2001; 32(9): 2198 - 2202. [Abstract] [Full Text] [PDF] |
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T. Inagawa Trends in Incidence and Case Fatality Rates of Aneurysmal Subarachnoid Hemorrhage in Izumo City, Japan, Between 1980-1989 and 1990-1998 Stroke, July 1, 2001; 32(7): 1499 - 1507. [Abstract] [Full Text] [PDF] |
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Y. M. Ruigrok, E. Buskens, and G. J. E. Rinkel Attributable Risk of Common and Rare Determinants of Subarachnoid Hemorrhage Stroke, May 1, 2001; 32(5): 1173 - 1175. [Abstract] [Full Text] [PDF] |
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C. N. Mhurchu, C. Anderson, K. Jamrozik, G. Hankey, D. Dunbabin, W.T. Longstreth Jr, and L. M. Nelson Hormonal Factors and Risk of Aneurysmal Subarachnoid Hemorrhage : An International Population-Based, Case-Control Study Editorial Comment : The Gender Gap in Aneurysmal Subarachnoid Hemorrhage Stroke, March 1, 2001; 32(3): 606 - 612. [Abstract] [Full Text] [PDF] |
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P Sharma and M J Brown Neurovascular lessons from a pair of identical twins with cerebral aneurysms Postgrad. Med. J., March 1, 2001; 77(905): 197 - 198. [Abstract] [Full Text] |
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J. van Gijn and G. J. E. Rinkel Subarachnoid haemorrhage: diagnosis, causes and management Brain, February 1, 2001; 124(2): 249 - 278. [Abstract] [Full Text] [PDF] |
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C. G. Sobey Potassium Channel Function in Vascular Disease Arterioscler Thromb Vasc Biol, January 1, 2001; 21(1): 28 - 38. [Abstract] [Full Text] [PDF] |
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J. B. Bederson, I. A. Awad, D. O. Wiebers, D. Piepgras, E. C. Haley Jr, T. Brott, G. Hademenos, D. Chyatte, R. Rosenwasser, and C. Caroselli Recommendations for the Management of Patients With Unruptured Intracranial Aneurysms : A Statement for Healthcare Professionals From the Stroke Council of the American Heart Association Stroke, November 1, 2000; 31(11): 2742 - 2750. [Full Text] [PDF] |
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J. B. Bederson, I. A. Awad, D. O. Wiebers, D. Piepgras, E. C. Haley Jr, T. Brott, G. Hademenos, D. Chyatte, R. Rosenwasser, and C. Caroselli Recommendations for the Management of Patients With Unruptured Intracranial Aneurysms : A Statement for Healthcare Professionals From the Stroke Council of the American Heart Association Circulation, October 31, 2000; 102(18): 2300 - 2308. [Full Text] [PDF] |
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Anonymous Epidemiology of Aneurysmal Subarachnoid Hemorrhage in Australia and New Zealand : Incidence and Case Fatality From the Australasian Cooperative Research on Subarachnoid Hemorrhage Study (ACROSS) Stroke, August 1, 2000; 31(8): 1843 - 1850. [Abstract] [Full Text] [PDF] |
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Y. Mira, J. Aznar, A. Estelles, A. Vaya, P. Villa, and F. Ferrando State-of-the-Art Review : Congenital and Acquired Thrombotic Risk Factors in Women Using Oral Contraceptives: Clinical Aspects Clinical and Applied Thrombosis/Hemostasis, July 1, 2000; 6(3): 162 - 168. [Abstract] [PDF] |
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J. M. Wardlaw and P. M. White The detection and management of unruptured intracranial aneurysms Brain, February 1, 2000; 123(2): 205 - 221. [Abstract] [Full Text] [PDF] |
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D. Gaist, M. Væth, I. Tsiropoulos, K. Christensen, E. Corder, J. Olsen, and H. T. Sørensen Risk of subarachnoid haemorrhage in first degree relatives of patients with subarachnoid haemorrhage: follow up study based on national registries in Denmark BMJ, January 15, 2000; 320(7228): 141 - 145. [Abstract] [Full Text] |
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J. M. Leppala, J. Virtamo, R. Fogelholm, D. Albanes, and O. P. Heinonen Different Risk Factors for Different Stroke Subtypes : Association of Blood Pressure, Cholesterol, and Antioxidants Stroke, December 1, 1999; 30(12): 2535 - 2540. [Abstract] [Full Text] [PDF] |
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T. W. M. Raaymakers Aneurysms in relatives of patients with subarachnoid hemorrhage: Frequency and risk factors Neurology, September 1, 1999; 53(5): 982 - 982. [Abstract] [Full Text] |
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J. S. P. van den Berg, G. Pals, F. Arwert, R. C. M. Hennekam, K. W. Albrecht, A. Westerveld, and M. Limburg Type III Collagen Deficiency in Saccular Intracranial Aneurysms : Defect in Gene Regulation? Stroke, August 1, 1999; 30(8): 1628 - 1631. [Abstract] [Full Text] [PDF] |
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K. R. Evenson, W. D. Rosamond, J. Cai, J. F. Toole, R. G. Hutchinson, E. Shahar, and A. R. Folsom Physical Activity and Ischemic Stroke Risk : The Atherosclerosis Risk in Communities Study Stroke, July 1, 1999; 30(7): 1333 - 1339. [Abstract] [Full Text] [PDF] |
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T. Uehara, M. Tabuchi, and E. Mori High frequency of unruptured intracranial aneurysms in female patients with ischaemic heart disease J. Neurol. Neurosurg. Psychiatry, April 1, 1998; 64(4): 536 - 538. [Abstract] [Full Text] [PDF] |
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G. J. E. Rinkel, M. Djibuti, A. Algra, and J. van Gijn Prevalence and Risk of Rupture of Intracranial Aneurysms : A Systematic Review Stroke, January 1, 1998; 29(1): 251 - 256. [Abstract] [Full Text] [PDF] |
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T. Ostbye, A. R. Levy, and N. E. Mayo Hospitalization and Case-Fatality Rates for Subarachnoid Hemorrhage in Canada From 1982 Through 1991 : The Canadian Collaborative Study Group of Stroke Hospitalizations Stroke, April 1, 1997; 28(4): 793 - 798. [Abstract] [Full Text] |
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C. G. Sobey, D. D. Heistad, F. M. Faraci, and D. R. Harder Effect of Subarachnoid Hemorrhage on Cerebral Vasodilatation in Response to Activation of ATP-Sensitive K+ Channels in Chronically Hypertensive Rats Stroke, February 1, 1997; 28(2): 392 - 397. [Abstract] [Full Text] |
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G. J.E. Rinkel, N. E.M. Prins, and A. Algra Outcome of Aneurysmal Subarachnoid Hemorrhage in Patients on Anticoagulant Treatment Stroke, January 1, 1997; 28(1): 6 - 9. [Abstract] [Full Text] |
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F.H.H. Linn, G.J.E. Rinkel, A. Algra, and J. van Gijn Incidence of Subarachnoid Hemorrhage : Role of Region, Year, and Rate of Computed Tomography: A Meta-Analysis Stroke, April 1, 1996; 27(4): 625 - 629. [Abstract] [Full Text] |
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