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13. sah in mexico

  1. 1. Aneurysmal Subarachnoid Hemorrhage in a Mexican Multicenter Registry of Cerebrovascular Disease: The RENAMEVASC Study ´ ´Jose L. Ruiz-Sandoval, MD,*† Carlos Cantu, MD, PhD,‡ Erwin Chiquete, MD, PhD,*† ´ ´ Carolina Leon-Jimenez, MD,x Antonio Arauz, MD, PhD,k Luis M. Murillo-Bonilla, MD, MSc,{ Jorge Villarreal-Careaga, MD,# ´ Fernando Barinagarrementerıa, MD,** and The RENAMEVASC Investigators Background: Information on risk factors and outcome of persons with aneurysmal subarachnoid hemorrhage (SAH) in Mexico is unknown. We sought to describe the clinical characteristics, risk factors, and outcome at discharge of Mexican pa- tients with aneurysmal SAH. Methods: A first-step surveillance system was con- ducted on consecutive cases confirmed by 4-vessel angiography from November 2002 to October 2004 in 25 tertiary referral centers. Age- and sex-matched control subjects were randomly selected by a 1:1 factor, for multivariate analysis on risk fac- tors. Results: We studied 231 patients (66% women; mean age 52 years, range 16-90 years). In 92%, the aneurysms were in the anterior circulation, and 15% had more than two aneurysms. After multivariate analysis, hypertension (odds ratio 2.46, 95% confidence interval 1.59-3.81) and diabetes mellitus (odds ratio 0.34, 95% confi- dence interval 0.17-0.68) were directly and inversely associated with aneurysmal SAH, respectively. Median hospital stay was 23 days (range 2-98 days). Invasive treatment was performed in 159 (69%) patients: aneurysm clipping in 126 (79%), en- dovascular coiling in 29 (18%), and aneurysm wrapping in 4 (2%). The in-hospital mortality was 20% (mostly due to neurologic causes), and 25% of patients were dis- charged with a modified Rankin score of 4 or 5. Conclusions: Hypertension is the main risk factor for aneurysmal SAH in hospitalized patients from Mexico. The fe- male:male ratio is 2:1. A relatively low in-hospital mortality and a high frequency of invasive interventions are observed. However, a high proportion of patients are dis- charged with important neurologic impairment. Key Words: Cerebral aneurysm— epidemiology—outcome—risk factors—subarachnoid hemorrhage. Ó 2009 by National Stroke Association From the *Department of Neurology and Neurosurgery, Hospital Received May 22, 2008; revision received September 1, 2008;Civil de Guadalajara ‘‘Fray Antonio Alcalde’’, †Department of Neuro- accepted September 11, 2008.sciences, Centro Universitario de Ciencias de la Salud, Universidad ´ Address correspondence to Jose L. Ruiz-Sandoval, MD, Servicio dede Guadalajara, ‡Department of Neurology, Instituto Nacional de ´ ´ Neurologıa y Neurocirugıa, Hospital Civil de Guadalajara ‘‘Fray An- ´ ´ ´Ciencias Medicas y Nutricion ‘‘Salvador Zubiran,’’ Mexico City, tonio Alcalde,’’ Hospital 278, Guadalajara, Jalisco, Mexico 44280. ´ ´xDepartment of Neurology, Hospital Regional Gomez Farıas, Zapo- E-mail: jorulej-1nj@prodigy.net.mx. ´ ´pan, kStroke Clinic, Instituto Nacional de Neurologıa y Neurocirugıa, 1052-3057/$—see front matterMexico City, {Department of Neurology, Instituto Panvascular de Oc- Ó 2009 by National Stroke Associationcidente, Guadalajara, #Department of Neurology, Hospital General doi:10.1016/j.jstrokecerebrovasdis.2008.09.019 ´ ´de Culiacan; and **Department of Neurology, Hospital Angeles Quer-´ ´etaro, Mexico.48 Journal of Stroke and Cerebrovascular Diseases, Vol. 18, No. 1 (January-February), 2009: pp 48-55
  2. 2. ANEURYSMAL SUBARACHNOID HEMORRHAGE IN MEXICAN HOSPITALS 49 Depending on the population and study design, it is es- nonneurologic clinics or services (e.g., internal medicine,timated that subarachnoid hemorrhage (SAH) accounts gastroenterology, and endocrinology facilities); (2) medicalfor less than 10% of the clinical forms of acute cerebrovas- students and their families; and (3) volunteers from out-cular disease.1,2 On the other hand, SAH as a result of rup- side the hospitals. The internal committee of ethics of everyture of intracranial aneurysms accounts for approximately participating center approved the study and the inclusion3% of all strokes2 and for 85% of all SAH cases.3 Its clinical of control subjects. Informed consent was obtained fromimpact is greater than it appears considering only the fre- the patient, control subject, or the patient’s legal proxy.quency of this condition as it affects otherwise healthy Mean arterial pressure (MAP) was calculated from theyoung adults. systolic blood pressure (SBP) and diastolic blood pressure Information regarding frequency, associated risk factors, (DBP) measurements at admittance to the emergency de-and outcome of persons with SAH in Mexico is unknown. partment as follows: MAP 5 DBP 1 0.412 (SBP – DBP).8,9 ´To address this issue, the Asociacion Mexicana de Enfer- This formula corrects for the spurious variation of MAPmedad Vascular Cerebral created the Registro Nacional in hypertensive persons; therefore, it is best suited for co-Mexicano de Enfermedad Vascular Cerebral (RENAME- horts with a high frequency of high blood pressure.8 Hy-VASC),4 which is a nationwide, nongovernmental, nonin- pertension and diabetes mellitus were defined asdustry-sponsored, multicentric register of consecutive established by standard guidelines.10,11 For the purposepatients with acute cerebrovascular disease hospitalized of the current report, smoking was defined as the con-in Mexico. The initial purpose of this national registry sumption (either past or current) of 5 or more cigaretteswas to conduct a first-step stroke surveillance system, for at least 2 days per week during 12 months or more,which implies the systematic registering of patients with and alcoholism as more than two alcoholic drinks peracute cerebrovascular disease admitted to a hospital or day (on average). Vasospasm was defined by means ofclinic-based facility and following up of the patients until a single angiography of 4 vessels during the diagnosticdischarge from hospital or death.5 The aim of this RENA- work-up, at any time of the hospital stay.MEVASC report on SAH was to describe the clinical and Parametric continuous variables are expressed as geo-demographic characteristics, risk factors, and outcome at metric means and SD, or minimum and maximum. Non-discharge of Mexican patients hospitalized for aneurysmal parametric continuous variables are expressed asSAH, with a nationwide representation. medians. As the median age of the study group was 51 years, we divided the cohort into people aged 49 years Methods or younger and 50 years or older to analyze the associa- tion of age with risk factors, clinical characteristics, and Patients outcome. To compare quantitative variables distributed This prospective hospital-based multicentric registry between two groups, Student t test and Mann-Whitneywas conducted from November 2002 to October 2004 in U test were performed in distributions of parametric25 tertiary referral centers from 14 Mexican states.4 Consec- and nonparametric variables, respectively. Chi-squareutive patients were registered if a suspected acute ischemic statistics (i.e., Pearson Chi-square or Fisher exact test, asor hemorrhagic stroke was confirmed by head computed corresponded) were used to compare nominal variablestomography scan or magnetic resonance imaging. A stan- in bivariate analyses. To find independent risk factorsdardized, structured questionnaire was used to collect for aneurysmal SAH (as compared with control subjects)clinical and demographic data from the patient or primary a multivariate analysis was constructed by a binary logis-guardian and medical records by the local investigator. tic regression model. Independent variables were chosenOther data registered included in-hospital management if P was less than .1 in bivariate analyses, but relevantand outcome at discharge and at 3 months follow-up. nonsignificant variables remained in the model for adjust-The patient’s functional status was classified by the modi- ment. Subsequently a forward-stepwise method was per-fied Rankin scale.4 All data were sent to a reference center formed. Adjusted odds ratios with 95% confidencein hard version and electronically captured by two investi- intervals that resulted in final step of the model are pro-gators, after completion of the registering deadline. For the vided. The fitness of the model was evaluated by usingpurpose of this report, patients with SAH due to ruptured the Hosmer-Lemeshow goodness-of-fit test, which wasintracranial aneurysms confirmed by 4-vessel angio- considered as reliable if P was greater than .20. All Pgraphic techniques were included.6,7 To compare the fre- values reported are 2-sided and regarded as significantquency of putative risk factors between patients with when P was less than .05. Software (SPSS v 13.0) wasaneurysmal SAH and the general population, 231 age- used for all calculations.and sex-matched ambulatory persons without history ofSAH were included as control subjects. These people Resultswere registered explicitly for the purpose of this studyand consisted of persons without any known neurologic A total of 2000 patients with acute cerebrovascular dis-disease: (1) relatives of patients who attend to ease were included in the registry: 1092 ischemic stroke
  3. 3. 50 J.L. RUIZ-SANDOVAL ET AL.(either infarct or transient ischemic attack), 580 intracere- in patients 50 years or older than in younger persons;bral hemorrhage, 59 cerebral venous thrombosis, and 269 nonetheless, more seizures were reported in the latternontraumatic SAH. All patients included pertained to the group. Single aneurysms occurred in 85% cases (TableLatin American bioethnic group. In all, 38 patients were 4). In 92% patients the lesions were located at the anteriorexcluded because they had a cause of SAH other than circulation. There were no differences in vascular topog-ruptured aneurysms, or because they lacked angiogra- raphy according to age or sex (Table 4). Other anatomicphy. Therefore, after applying selection criteria, 231 pa- characteristics of the aneurysms, such as size, neck, andtients were analyzed. There were 153 (66%) women and dome, were not registered.78 (34%) men, with a mean age of 51.8 years (median 51 Duration of the hospital stay had a median of 23 daysyears, range 16-90). In all, 55 (24%) patients were younger (range 2-98 days) (Table 5). In all, 157 (68%) patients re-than 40 years and 49 (21%) were 65 years or older. Hyper- quired entering the intensive care department at anytension was more frequent among patients than control time of their hospitalization, whereas 74 (32%) patientssubjects, whereas few cases of diabetes mellitus were ob- were treated completely in general wards. The need forserved in the SAH group (Table 1). After multivariate mechanical ventilation occurred in 91 (39%) cases. Weanalysis controlled for potential confounders, hyperten- lacked information regarding the time to angiographysion remained a significant risk and diabetes an inversely or time to surgery or endovascular intervention after hos-associated factor for aneurysmal SAH. Table 2 shows the pital arrival. Invasive treatment of the aneurysms wasdistribution of risk factors among patients, stratified by performed in 159 (69%) patients by using the followingsex and age. Alcohol consumption and smoking were techniques: clipping of ruptured aneurysm in 126 (79%more common in men than in women. Hypertension of those surgically treated), endovascular coiling in 29and diabetes mellitus were more frequent in patients 50 (18%, all of them performed in a single center), and aneu-years or older than in younger persons. rysm wrapping in 4 (2%) patients. The type of manage- The onset of the clinical manifestations was registered ment (any invasive intervention v only medicalin 184 cases; of these, 69 (37.5%) occurred during the first treatment) did not differ with age (P 5 .31, for persons12 hours of the day (at awakening in 8%, n 5 19) and in aged $ 50 v younger individuals), sex (P 5 .45, for men115 (62.5%) during the afternoon or night. No monthly v women), or aneurysm topography (P 5 .20, for anterioror seasonal patterns in hospitalization for aneurysmal v posterior circulation); however, aneurysm wrappingSAH were identified. The hemorrhage was preceded by was performed only for aneurysms of the anterior circula-a physical effort in 29 (12%) cases and by emotional stress tion (P , .001). Hydrocephalus was observed in 22%in 11 (5%) (without differences according to age or sex). cases; of them, 72% received a shunting procedure. Pneu-Table 3 shows the clinical manifestations and laboratory monia was the most frequent systemic complication (87/work-up at hospital arrival. The main features were head- 231, 38%), followed by urinary tract infections (47/231,ache, vomiting, and impaired consciousness. More men 20%), cardiac arrhythmia (17/231, 7%), and lower-limbthan women presented to hospital with a Glasgow deep-vein thrombosis (4/231, 2%). In all, 46 (20%) pa-Coma Scale score greater than 13 (80% v 59%, respec- tients died in the hospital; 25 (54%) with a neurologictively; P 5 .002). Impaired consciousness at event onset cause, 13 (28%) with a systemic nonneurologic complica-and higher blood pressure measures were more frequent tion, and 8 (17%) with both groups of causes. At Table 1. Case-control analysis on risk factors for aneurysmal subarachnoid hemorrhage: Bivariate analysis and a multivariate logistic regression model Group Variable Patients (n 5 231) Control subjects (n 5 231) P value* Multivariate OR (95% CI)y Age, y, mean (range) 51.6 (16-90) 51.6 (16-90) .99 NS Female, n (%) 156 (66) 156 (66) .99 NS Hypertension, n (%) 96 (42) 67 (29) .005 2.46 (1.59-3.81) Diabetes mellitus, n (%) 16 (7) 35 (15) .005 0.34 (0.17-0.68) Alcoholism, n (%) 30 (13) 35 (15) .50 NS Current smoker, n (%) 68 (29) 61 (26) .47 NS Former smoker, n (%) 15 (6) 12 (5) .55 NS Abbreviations: CI, confidence interval; NS, not significant; OR, odds ratio. *P value for differences between patient and control groups; Student t test or Fisher exact test, as appropriate. yHosmer-Lemeshow goodness-of-fit test: Chi-square 5 0.48, 2 df, P 5 .98. The rest of the variables that resulted with P $ .1 in bivariateanalysis remained in the multivariate model for adjustment; however, their multivariate ORs are not shown to avoid confusion.
  4. 4. ANEURYSMAL SUBARACHNOID HEMORRHAGE IN MEXICAN HOSPITALS 51 Table 2. Risk factors for aneurysmal subarachnoid hemorrhage stratified by sex and age Sex Age, y Variable Total Male Female P value* #49 $50 P valuey Age, y, mean (range) 51.6 (16-90) 49.1 (16-90) 52.8 (17-90) .89 38.1 (16-49) 63.0 (50-90) ,.001 Hypertension, n (%) 96 (42) 29 (37) 67 (44) .33 26 (24) 70 (56) ,.001 Diabetes mellitus, n (%) 16 (7) 6 (8) 10 (6) .74 2 (2) 14 (11) .005 Alcoholism, n (%) 30 (13) 21 (27) 9 (6) ,.001 13 (12) 17 (14) .76 Current smoker, n (%) 68 (29) 30 (38) 38 (25) .03 35 (33) 33 (26) .27 Former smoker, n (%) 43 (19) 19 (24) 24 (16) .11 18 (17) 25 (20) .56 *P value for differences between men and women; Student t test or Fisher exact test, as appropriate. yP value for differences between persons 49 years old or younger and 50 years of age or older; Student t test or Fisher exact test, as appropriate.discharge, 25 (11%) had severe disabilities with depen- SAH among forms of stroke has been reported to bedence on others for activities of daily living, 33 (14%) around 15%.13-15with partial dependence and walking impairment, 43 We found that the main risk factor for aneurysmal SAH(19%) with disabilities but able to walk without assis- was hypertension, whereas diabetes mellitus was in-tance, 30 (13%) with mild disabilities, 30 (13%) with min- versely related with this condition; which is consistentimal impairment, and 23 (10%) completely asymptomatic with previous studies.16 According to other reports,17-20(Table 5). Table 6 shows the analyses on in-hospital mor- we found that the female:male ratio is 2:1. A high numbertality according to different clinical scales. Of note, the of persons younger than 40 years was observed, contrast-presence of radiographic findings typical of cerebral vaso- ing with the respective frequency reported for other coun-spasm was not associated with in-hospital mortality. tries, including those with a very high incidence of SAH.17,21 This phenomenon could be due at least in part Discussion to the high proportion of young Mexican inhabitants. Cerebrovascular disease is the fourth cause of death in Other possible explanations could be that congenital vas-the general population of Mexico, accounting for more cular abnormalities and other conditions associated withthan 27,000 (5.5% of total) deaths by 2006.12 In previous the aneurysm formation or rupture has a high representa-hospital series from Mexico, the proportion of cases of tion in our young population, or that the young have Table 3. Clinical manifestations and laboratory analysis at hospital arrival, stratified by sex and age Sex Age, y Variable Total Male Female P value* #49 $50 P valuey Headache, n (%) 209 (90) 67 (89) 142 (94) .21 99 (94) 110 (91) .34 Vomiting, n (%) 152 (66) 48 (61) 104 (68) .33 72 (68) 80 (64) .53 Probable seizures, n (%) 49 (21) 17 (22) 32 (21) .87 31 (29) 18 (14) .006 Impaired consciousness at 130 (56) 32 (41) 98 (64) .001 50 (47) 80 (64) .01 event onset, n (%) Systolic blood pressure, mm 142 (28) 137 (21) 145 (30) .09 134 (24) 149 (29) .01 Hg, mean (SD)z Mean arterial pressure, mm 110 (18) 107 (15) 111 (20) .10 105 (17) 113 (19) .004 Hg, mean (SD)z Pulse pressure, mm Hg, mean 55 (21) 51 (16) 57 (22) .07 50 (16) 60 (23) .002 (SD)z Glucose, mg/dL, mean (SD) 136 (63) 136 (68) 136 (60) .98 130 (58) 142 (67) .17 International normalized ratio, 1.11 (0.17) 1.10 (0.15) 1.13 (0.18) .54 1.13 (0.17) 1.09 (0.17) .40 mean (SD) Hematocrit, %, mean (SD) 40 (6) 43 (7) 39 (5) ,.001 40 (7) 41 (6) .28 Platelets, 310-4, mean (SD) 24.6 (8.4) 22.3 (7.6) 25.8 (8.6) .003 25.0 (9.4) 24.2 (7.4) .45 *P value for differences between men and women; Fisher exact test or Student t test, as appropriate. yP value for differences between persons 49 years old or younger and 50 years of age or older; Fisher exact test or Student t test, as appropriate. zData available on 224 persons.
  5. 5. 52 J.L. RUIZ-SANDOVAL ET AL. Table 4. Number and vascular topography of the intracranial aneurysms as assessed by angiographic studies Sex Age, y Variable Total Male Female #49 $50 No. of aneurysms* 1, n (%) 197 (85) 67 (86) 130 (85) 91 (86) 106 (85) .1, n (%) 34 (15) 11 (14) 23 (15) 15 (14) 19 (15) Anterior circulation (n 5 213, 92%)y Posterior communicating artery, n (%) 64 (28) 20 (26) 44 (29) 28 (26) 36 (29) Anterior communicating artery, n (%) 61 (26) 22 (28) 39 (26) 25 (24) 36 (29) Middle cerebral artery, n (%) 46 (20) 16 (21) 30 (20) 23 (22) 23 (18) Internal carotid artery (supraclinoid), 27 (12) 8 (10) 19 (12) 16 (15) 11 (9) n (%) Internal carotid artery (opthalmic), n 15 (6) 4 (5) 11 (7) 7 (6) 8 (6) (%) Posterior circulation (n 5 18, 8%)z Posterior cerebral artery, n (%) 5 (2) 0 (0) 5 (3) 2 (2) 3 (2) Basilar artery, n (%) 7 (3) 4 (5) 3 (2) 1 (1) 6 (5) Vertebral artery, n (%) 6 (3) 4 (5) 2 (1) 4 (4) 2 (2) *P 5 .99, for comparison in frequency of number of aneurysms between men and women; and P 5 .85, for comparison between persons 49years old or younger and 50 years of age or older; Fisher exact test. yP 5 .93, for comparison in homogeneity of aneurysmal localization of the anterior circulation between men and women; and P 5 .57, forcomparison between persons 49 years old or younger and 50 years of age or older; Pearson Chi square. zP 5 .06, for comparison in homogeneity of aneurysmal localization of the posterior circulation between men and women; and P 5 .15, forcomparison between persons 49 years old or younger and 50 years of age or older; Pearson Chi square.a low prehospital mortality and reach the hospital more to the patient and possibly a high chance of being surgi-frequently than do older persons. cally treated.24 The rate of microsurgical intervention or endovascular We observed a lower mortality than that previously re-therapy was higher in our study, as compared with other ported.19,23-27 Our explanation to this finding is that RE-reports.19,22,23 Indeed, this is possibly due to the fact that NAMEVASC is a hospital-based study on persons whoour cohort corresponds to patients hospitalized in urban reached medical assistance in urban teaching hospitals,teaching hospitals, where the patients are treated almost and who had a diagnosis based on 4-vessel angiography.entirely with microsurgical clipping.24 In the United Many patients with the extreme medical conditions afterStates, higher rates of any invasive procedure in the urban SAH could be lost in the prehospital part of their diseasesetting were observed, when compared with rural facili- evolution, due to a wrong diagnosis or death. Also, someties.23 In Mexico most of the invasive procedures are patients who arrived at our centers may not have beenperformed in governmental teaching hospitals or in correctly diagnosed as having SAH, or may not havepublic-insurance settings, which implies a minimal cost been documented by angiography and thus, were not Table 5. Events during hospitalization and clinical outcome at discharge stratified by sex and age Sex Age, y Variable Total Male Female P value* #49 $50 P valuey Days of hospitalization, median 23 (2-98) 24 (3-92) 23 (2-98) .81 19 (2-98) 28 (2-82) .24 (minimum and maximum) In-hospital systemic complications, n 107 (46) 34 (44) 73 (48) .55 43 (41) 64 (51) .11 (%) Modified Rankin score at discharge .77 .03 0-2, n (%) 83 (36) 29 (37) 54 (35) 46 (43) 37 (30) 3-6, n (%) 148 (64) 49 (63) 99 (65) 60 (57) 88 (70) *P value for differences between men and women; Mann-Whitney U test or Fisher exact test as appropriate. yP value for differences between persons 49 years old or younger and 50 years of age or older; Mann-Whitney U test or Fisher exact test, asappropriate.
  6. 6. ANEURYSMAL SUBARACHNOID HEMORRHAGE IN MEXICAN HOSPITALS 53 Table 6. In-hospital mortality according to clinical and brain imaging characteristics at hospital arrival Sex Age, y In-hospital death Variable Total Male Female P value* #49 $50 P valuey Present Absent P valuez Hunt-Hess scalex .09 .04 .001 Grade I-II, n (%) 133 (66) 51 (74) 82 (62) 72 (73) 61 (59) 14 (40) 119 (71) Grade III-V, n (%) 69 (34) 51 (38) 18 (26) 26 (27) 43 (41) 21 (60) 48 (29) Fisher scale// .86 .34 ,.001 Grade I-II, n (%) 52 (26) 17 (25) 35 (26) 28 (29) 24 (23) 0 (0) 52 (31) Grade III-IV, n (%) 149 (74) 52 (75) 97 (74) 68 (71) 81 (77) 34 (100) 115 (69) Glasgow Coma Scale{ .007 .01 ,.001 Points 13-15, n (%) 149 (67) 61 (80) 88 (59) 78 (76) 71 (59) 17 (39) 132 (73) Points 9-12, n (%) 43 (19) 9 (12) 34 (23) 12 (11) 31 (25) 14 (33) 29 (16) Points 3-8, n (%) 32 (14) 6 (8) 26 (18) 13 (13) 19 (16) 12 (28) 20 (11) Cerebral vasospasm# .36 .67 .99 Present, n (%) 88 (44) 26 (39) 62 (47) 41 (43) 47 (46) 15 (44) 73 (45) Absent, n (%) 110 (56) 40 (61) 70 (53) 55 (57) 55 (54) 19 (56) 91 (55) *P value for differences between men and women; Pearson Chi square or Fisher exact test, as appropriate. yP value for differences between persons 49 years old or younger and 50 years of age or older; Pearson Chi square or Fisher exact test, asappropriate. zP value for differences between fatal and nonfatal cases; Pearson Chi square or Fisher exact test, as appropriate. x Data available on 202 persons. // Data available on 201 persons. { Data available on 224 persons. # Data available on 198 persons.registered. It is well known that many patients die before compared with non-Hispanic whites,1,30,31 population-they reach medical attention or diagnosis, and a consider- based studies on stroke incidence have shown that theable proportion of patients are missed during an emer- proportion of aneurysmal SAH among subtypes ofgency department visit, mainly due to a wrong cerebrovascular disease is less than 10%, which includesdiagnostic impression.28 populations with Mexican ancestry.30,31 A long-term As expected,7 the global neurologic impairment and follow-up was not possible for all patients of our registry,SAH grade at hospital arrival were associated with in- and only 35% persons of our sample were followed up forhospital mortality, and notably, the vasospasm did not ex- 3 months or more (data not shown). A population-basedplain any effect on short-term outcome. However, our study on incidence, conditioning factors, and long-termdefinition of vasospasm was limited, based on a single an- outcome of persons with aneurysmal SAH in Mexico isgiography performed at any time during hospitalization, urgently needed. This issue will be certainly solved bywhich is not a standard procedure to define this very dy- the US National Institutes of Health–sponsored Brainnamic phenomenon. Therefore, the consequences and Attack Surveillance in Durango City (BASID) Study. Themagnitude of clinically significant vasospasm could not RENAMEVASC prospective study is the first attempt inbe described with precision. This problem represents describing the general characteristics of aneurysmala limitation of our study. Nevertheless, vasospasm is SAH in Mexico with a nonsponsored and completelynot the only factor associated with neurologic worsening voluntary multicentric organization. Person-orientedafter SAH and its contribution on outcome may be small, data were registered with clinical and radiologic informa-as could be inferred from clinical trials aimed to prevent tion on aneurysmal topography and short-term outcome,or reverse vasospasm to change the fate of SAH.29 information that could be hardly provided in prospective Indeed, our study has other limitations. This is a hospi- nonsponsored studies.tal-based registry with a rather small sample size on pa- In conclusion, hypertension is the main risk factor fortients admitted to referral centers with neurosurgical aneurysmal SAH in Mexico; however, other contributingdepartments, which may favor hospitalization of patients risk factors could not be completely excluded with thesuitable for a surgical intervention, with the correspond- methodology of this study.6,15 The female:male ratio ofing high recording of the hemorrhagic forms of cerebro- hospitalized patients with aneurysmal SAH is 2:1, andvascular disease (i.e., intracerebral hemorrhage and a considerably high proportion of patients are young.SAH).13-15 Although it has been recognized that hemor- Most aneurysms are solitary and located at the anteriorrhagic stroke is more frequent among Hispanics, when circulation. We observed a high rate of invasive therapy,
  7. 7. 54 J.L. RUIZ-SANDOVAL ET AL.owing to the characteristics of our study design and the 3. van Gijn J, Kerr RS, Rinkel GJE. Subarachnoid hemor-Mexican health care system. A low in-hospital mortality rhage. Lancet 2007;369:306-318.was observed, possibly due to a low registering of fatal ´ 4. Arauz A, Cantu C, Ruiz-Sandoval JL, et al. Short-term prognosis of transient ischemic attacks: Mexican multi-cases that occurred before aneurysm documentation. center stroke registry [in Spanish]. Rev Invest Clin 2006;However, a high proportion of patients are discharged 58:530-539.with important neurologic impairment. 5. Bonita R, Mendis S, Truelsen T, et al. The global stroke ini- tiative. Lancet Neurol 2004;3:391-393. The RENAMEVASC Investigators: Steering Committee 6. Matsuda M, Watanabe K, Saito A, et al. Circumstances, ´ ´ C. Cantu-Brito, A. Arauz-Gongora, J. L. Ruiz-Sandoval, J. activities, and events precipitating aneurysmal subarach-Villarreal-Careaga, L. Murillo-Bonilla, R. Rangel-Guerra, noid hemorrhage. J Stroke Cerebrovasc Dis 2007;16:25-29. 7. Kazumata K, Kamiyama H, Ishikawa T. Reference tableF. Barinagarrementeria predicting the outcome of subarachnoid hemorrhage in Coordinating Office the elderly, stratified by age. J Stroke Cerebrovasc Dis ´ C. Cantu-Brito, L. Murillo-Bonilla 2006;15:14-17. Participants 8. Meaney E, Alva F, Moguel R, et al. Formula and nomo- The following centers and investigators participated in the gram for the sphygmomanometric calculation of the ´RENAMEVASC study: C. Cantu-Brito (Instituto Nacional de mean arterial pressure. Heart 2000;84:64. 9. Chiquete E, Ruiz-Sandoval MC, Alvarez-Palazuelos LE,Ciencias Me ´ dicas y Nutricion Salvador Zubiran, Ciudad de ´ ´ et al. Hypertensive intracerebral hemorrhage in theMe ´ xico); A. Arauz-Gongora, L. Murillo-Bonilla, and L. ´ very elderly. Cerebrovasc Dis 2007;24:196-201. ´Hoyos (Instituto Nacional de Neurologıa y Neurocirugıa, ´ 10. Chobanian AV, Bakris GL, Black HR, et al. The seventh re-Ciudad de Me ´ xico); J. L. Ruiz-Sandoval and E. Chiquete port of the joint national committee on prevention, detec-(Hospital Civil de Guadalajara, Jalisco); J. Villarreal-Careaga tion, evaluation, and treatment of high blood pressure: ´and F. Guzman-Reyes (Hospital General de Culiacan, ´ The JNC 7 report. JAMA 2003;289:2560-2572. 11. American Diabetes Association. Diagnosis and classifica-Sinaloa); F. Barinagarrementeria (Hospital Angeles de Quer- tion of diabetes mellitus. Diabetes Care 2006;28:S37-S42.´ ´ ´ ´etaro, Queretaro); J. A. Fernandez (Hospital Juarez, Ciudad ´ 12. Statistics on general mortality. Secretarıa de Salud, ´de Mexico); B. Torres (Hospital General de Leon, Guana- ´ ´ Mexico, 2006. Available from: URL:http://www.salud. ´ ´juato); C. Leon-Jimenez (Hospital Regional ISSSTE, Zapopan, gob.mx/. Accessed April 2, 2008. ´Jalisco); I. Rodrıguez-Leyva (Hospital General de San Luis 13. Chiquete E, Ruiz-Sandoval JL. 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