Circumstances surrounding aneurysmal subarachnoid hemorrhage

doi:10.1016/0090-3019(89)90228-0

Surgical Neurology

Volume 32, Issue 4, October 1989, Pages 266-272

https://doi.org/10.1016/0090-3019(89)90228-0 Get rights and content

Abstract

The circumstances surrounding aneurysmal subarachnoid hemorrhage were investigated in a group of 500 consecutive patients admitted to a neurosurgical center. Subarachnoid hemorrhage occurred during stressful events in 42.8% of the patients, during nonstrenuous activities in 34.4%, and during rest or sleep in 11.8%. The activities or events preceding subarachnoid hemorrhage were not known in the remaining 11.0%. Men were more likely to have suffered their hemorrhage during stressful events than women (54.1% versus 36.6%; p < 0.00025). Only 30.1% of aneurysms arising from the internal carotid artery ruptured during stressful events compared with 48.1% of aneurysms at other locations (p < 0.005).

Physiological responses to the various activities and events are discussed as they may relate to mechanisms underlying aneurysmal subarachnoid hemorrhage. Two important factors in the precipitation of aneurysmal rupture are increased arterial blood pressure and decreased cerebrospinal fluid pressure around the aneurysm. These factors result in a high transmural pressure and concomitant wall stress. Physical exertion, activities involving the Valsalva maneuver, and emotional strain are associated with an increase in blood pressure and frequently preceded subarachnoid hemorrhage. Fluctuations in cerebrospinal fluid pressure around the aneurysm mainly occur during Valsalva's maneuver and postural changes.

References (60)

G Coccagna et al.
Arterial pressure changes during spontaneous sleep in man
Electroencephalogr Clin Neurophysiol
(1971)
SM de la Monte et al.
Risk factors for the development and rupture of intracranial berry aneurysms
Am J Med
(1985)
B Hillen et al.
A mathematical model of the flow in the circle of Willis
J Biomech
(1986)
WA Littler et al.
Direct arterial pressure, pulse rate and electrocardiogram during micturition and defecation in unrestricted man
Am Heart J
(1974)
WA Littler et al.
The variability of arterial pressure
Am Heart J
(1978)
E Lugaresi et al.
Snoring
Electroencephalogr Clin Neurophysiol
(1975)
L Symon
Subarachnoid haemorrhage from intracranial aneurysms and angiomas
HP Adams et al.
Pitfalls in the recognition of subarachnoid hemorrhage
JAMA
(1980)
RD Adams et al.
Principles of neurology
PO Astrand et al.
Textbook of work physiology: physiological bases of exercise

G Austin et al.

Pressure-volume-pulse rate factors in intracranial aneurysm enlargement: studies with a synthetic wall of elastic tissue and collagen

Neurol Res

(1987)

GM Austin et al.

Controlled pressure-volume factors in the enlargement of intracranial aneurysms

Neurosurgery

(1989)

AT Bevan et al.

Direct arterial pressure recording in unrestricted man

Clin Sci

(1969)

A Biemond

Brain diseases

C Borst et al.

Mechanisms of initial blood pressure response to postural change

Clin Sci

(1984)

KC Bradley

Cerebrospinal fluid pressure

J Neurol Neurosurg Psychiatry

(1970)

LR Caplan et al.

Stroke: a clinical approach

JP Castel et al.

Analyse des circonstances de la rupture d'un anévrysme intracranien

Neurochirurgie

(1986)

AM Coll et al.

Intraaneurysmal pressure differences in human saccular aneurysms

Surg Neurol

(1976)

CB Early et al.

Some fundamental applications of the law of La Place in neurosurgery

Surg Neurol

(1976)

I Feinberg et al.

Sleep variables as a function of age in man

Arch Gen Psychiatry

(1968)

GG Ferguson

Direct measurements of mean and pulsatile blood pressure at operation in human intracranial saccular aneurysms

J Neurosurg

(1972)

GG Ferguson

Physical factors in the initiation, growth, and rupture of human intracranial saccular aneurysms

J Neurosurg

(1972)

CM Fisher

Clinical syndromes in cerebral thrombosis, hypertensive hemorrhage and ruptured saccular aneurysms

Clin Neurosurg

(1975)

JL Fleiss

Statistical methods for rates and proportions

(1981)

E Freytag

Fatal rupture of intracranial aneurysms found in medicolegal autopsies

Arch Pathol

(1966)

R Heidrich

Die Subarachnoideale Blutung

M Hillbom et al.

Does alcohol intoxication precipitate aneurysmal subarachnoid hemorrhage?

J Neurol Neurosurg Psychiatry

(1981)

WE Hunt et al.

Surgical risk as related to time of intervention in the repair of intracranial aneurysms

J Neurosurg

(1968)

B Jennett et al.

An introduction to neurosurgery

Cited by (71)

Is physical activity a trigger factor for subarachnoid hemorrhage?
2022, Neurochirurgie
Citation Excerpt :
Subarachnoid hemorrhage (SAH) is a serious disease associated to a 43% of mortality [1] and a capability to go back to previous professional activity in only a third of survivors [2]. Defecation and sexual activity account for 5.3 to 14% of the circumstances in which SAH occurs [3–5]. Venous hypertension due to Valsalva maneuvers is a suggested mechanism for the sudden variation of pressure gradient between intrasaccular and cisternal space responsible for aneurysmal rupture [6,7].
Subarachnoid hemorrhage (SAH) is a serious pathology, associated with 43% mortality and significant disability. In the absence of relevant guidelines, some teams advocate that patients harboring an unruptured intracranial aneurysm (ICA) abstain from all sports activity, as a prophylactic precaution. The aim of the present study was to evaluate the impact of physical activity as a risk factor for SAH, through a review of the literature.
A systematic literature review was performed for the period 2000 to 2020 in accordance with the PRISMA guidelines. Prospective and retrospective articles reporting more than 50 patients whose physical activity was associated with onset of SAH were included. The main end-point was prevalence of SAH occurring after physical activity. For comparison purposes, the prevalences of other circumstances were calculated to establish a range of frequency.
Physical activity appeared to be quite rarely associated with onset of SAH, with a prevalence of 3%, compared to 30% at rest, 7.3% in association with defecation and 4.5% in association with sexual activity. Age under 60 years, male gender (M/F ratio 1.38) and smoking (67.1%) were associated with onset of SAH during physical activity.
Physical activity appears to be a rare trigger factor for SAH. These results are in contrast to the idea that physical activity should, as a precaution, be avoided in patients with unruptured ICA. There is at present no scientific evidence of an association with aneurysmal SAH.
L’hémorragie sous-arachnoïdienne (HSA) est une maladie grave responsable de 43 % de mortalité et d’un handicap important. Devant l’absence de recommandation, le principe de précaution a conduit certains soignants à déconseiller la pratique sportive chez les patients présentant un anévrisme intracrânien. L’objectif de ce travail était d’évaluer la responsabilité de l’activité physique comme circonstance de la survenue d’une HSA en se basant sur une revue de la littérature.
Une revue systématique de la littérature selon les critères PRISMA a été réalisée de 2000 à 2020. Des articles prospectifs ou rétrospectifs de plus de 50 patients dont l’activité physique était une circonstance d’hémorragie sous-arachnoïdienne ont été inclus. Le critère de jugement principal était la prévalence de l’HSA survenant après une activité physique. À des fins de comparaison, les prévalences des autres circonstances ont été calculées pour établir un rang de fréquence.
L’activité physique semble être une circonstance rare dans la survenue de l’HSA avec une prévalence de 3 % par rapport au repos (30 %), à la défécation (7,3 %) ou aux rapports sexuels (4,5 %). Les patients de moins de 60 ans (67 %), les hommes (ratio H/F de 1,38) et les fumeurs (67,1 %) semblaient plus susceptibles d’être victimes d’une HSA lors de la pratique d’une activité physique.
L’activité physique semble être une circonstance rare d’HSA. Ces résultats vont à l’encontre du principe de précaution chez les patients atteints d’un anévrisme intracrânien non rompu, car il n’existe actuellement aucune preuve scientifique d’association de l’activité physique avec l’HSA anévrismale.
Repeated Retching and Vomiting in the Pathophysiology of Isolated Spinal Aneurysms
2021, World Neurosurgery
Citation Excerpt :
Although our series is the first to attribute retching and vomiting to be involved in the formation and rupture of ISAs, data available in the literature support this hypothesis and clearly suggest that this phenomenon is more than a mere coincidence. Multiple studies have already demonstrated how hemodynamic changes increase the risk of SAH as seen in intense physical exertion,40,41 emotional stress,42 sexual activity,43,44 and physical maneuvers that increase intrathoracic pressure. Valsalva maneuver during defecation, micturition,45,46 and forceful sneezing47 have been attributed to causing SAH.
Rupture of spinal aneurysms is a rare cause of subarachnoid hemorrhage. These aneurysms are often associated with a variety of vascular malformations that increase blood flow in the spinal circulation or with disorders that compromise the vessel wall. However, spinal aneurysms may be isolated, not associated with any known predisposing condition. The objective of this study is to explore the possible mechanisms associated with the formation and rupture of isolated spinal aneurysms (ISAs).
We conducted a retrospective review of a series of consecutive patients admitted for a ruptured ISA. In all cases, spinal angiography confirmed the presence of a spinal aneurysm responsible for the bleeding. Particular attention was paid to medical history and symptoms before bleeding, for potential factors predisposing to their formation and rupture.
Between 2008 and 2020, ten cases of spinal aneurysms were seen at our institution including 4 cases of ISA. All patients with ISA were female, and in 3 cases the aneurysm involved the territory of the posterior spinal artery. In 3 of these 4 (75%) ISA cases, there was a strikingly similar history of retching and vomiting preceding the thunderclap headache. In 1 patient, the aneurysm was surgically resected; pathologic analysis revealed a fusiform dissecting aneurysm. All 4 patients had a favorable outcome.
We suggest that the straining during prolonged retching and vomiting plays a role in the formation and rupture of some ISAs, possibly because of pressure spikes, increased transmural arterial pressure, and increased wall shear stress during straining.
Clinical presentation of cerebral aneurysms
2013, European Journal of Radiology
Citation Excerpt :
Ruptured intracranial aneurysms (RIAs), on the other hand, are by far the most common cause of SAH (85%) [4] with half of patients being younger than 55 [5], and represent a neurological emergency with potentially devastating consequences. In recent study cohorts, case-fatality rates within the first months, although declined in the last decades, are still reported to be as high as 35–39% [3,6,7], and sudden death is reported to occur in about 10% [8]. We will describe the clinical spectrum of unruptured and ruptured intracranial aneurysms by discussing both typical and uncommon clinical features emerging from the literature review.
Presentation of a cerebral aneurysm can be incidental, discovered at imaging obtained for unrelated causes, can occur in the occasion of imaging obtained for symptoms possibly or likely related to the presence of an unruptured aneurysm, or can occur with signs and symptoms at the time of aneurismal rupture.
Most unruptured intracranial aneurysms are thought to be asymptomatic, or present with vague or non-specific symptoms like headache or dizziness. Isolated oculomotor nerve palsies, however, may typically indicate the presence of a posterior circulation aneurysm.
Ruptured intracranial aneurysms are by far the most common cause of non-traumatic subarachnoid hemorrhage and represent a neurological emergency with potentially devastating consequences. Subarachnoid hemorrhage may be easily suspected in the presence of sudden and severe headache, vomiting, meningism signs, and/or altered mental status. However, failure to recognize milder and more ambiguous clinical pictures may result in a delayed or missed diagnosis.
In this paper we will describe the clinical spectrum of unruptured and ruptured intracranial aneurysms by discussing both typical and uncommon clinical features emerging from the literature review. We will additionally provide the reader with descriptions of the underlying pathophysiologic mechanisms, and main diagnostic pitfalls.
Mechanobiology of the Arterial Wall
2013, Transport in Biological Media
Aneurysm rupture - Does the weather matter?
2013, World Neurosurgery
Circaseptan variation in case-fatality rate for patients with acute subarachnoid hemorrhage (Takashima Stroke Registry 1988-2003)
2010, Journal of Clinical Neuroscience
We explored the circaseptan variation in 28-day case-fatalities for patients with subarachnoid hemorrhage (SAH) across days of the week. Data were obtained from the Takashima Stroke Registry, which covers approximately 50 000 residents of central Japan. There were 169 first-ever SAH cases registered during the period 1988–2003 (68 in males, 101 in females). We divided the SAH cases into two groups according to the day on which the SAH occurred: “weekend” and “weekday”. The 28-day case-fatality rate and 95% confidence interval (CI) were calculated. Multiple logistic regression analysis was used to calculate the adjusted odds ratio (95% CI) for weekday fatalities by entering all relevant patient-level variables into the model. The 28-day case-fatality rate for SAH was higher on weekdays (51.7%) than on weekends (32.6%; odds ratio 2.19; 95% CI: 1.10–4.49). The differences in fatality rate persisted after adjustment for age, sex, severity, family history of stroke and patient history of hypertension, diabetes mellitus, dyslipidemia, drinking and smoking. We observed a circaseptan variation in fatalities from SAH, with higher fatality rates during weekdays in our study population.

View all citing articles on Scopus

View full text

Circumstances surrounding aneurysmal subarachnoid hemorrhage

Abstract

Electroencephalogr Clin Neurophysiol

Am J Med

J Biomech

Am Heart J

Am Heart J

Electroencephalogr Clin Neurophysiol

Pitfalls in the recognition of subarachnoid hemorrhage

JAMA

Principles of neurology

Textbook of work physiology: physiological bases of exercise

Pressure-volume-pulse rate factors in intracranial aneurysm enlargement: studies with a synthetic wall of elastic tissue and collagen

Neurol Res

Controlled pressure-volume factors in the enlargement of intracranial aneurysms

Neurosurgery

Direct arterial pressure recording in unrestricted man

Clin Sci

Brain diseases

Mechanisms of initial blood pressure response to postural change

Clin Sci

Cerebrospinal fluid pressure

J Neurol Neurosurg Psychiatry

Stroke: a clinical approach

Analyse des circonstances de la rupture d'un anévrysme intracranien

Neurochirurgie

Intraaneurysmal pressure differences in human saccular aneurysms

Surg Neurol

Some fundamental applications of the law of La Place in neurosurgery

Surg Neurol

Sleep variables as a function of age in man

Arch Gen Psychiatry

Direct measurements of mean and pulsatile blood pressure at operation in human intracranial saccular aneurysms

J Neurosurg

Physical factors in the initiation, growth, and rupture of human intracranial saccular aneurysms

J Neurosurg

Clinical syndromes in cerebral thrombosis, hypertensive hemorrhage and ruptured saccular aneurysms

Clin Neurosurg

Statistical methods for rates and proportions

Fatal rupture of intracranial aneurysms found in medicolegal autopsies

Arch Pathol

Die Subarachnoideale Blutung

Does alcohol intoxication precipitate aneurysmal subarachnoid hemorrhage?

J Neurol Neurosurg Psychiatry

Surgical risk as related to time of intervention in the repair of intracranial aneurysms

J Neurosurg

An introduction to neurosurgery