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Year : 2000  |  Volume : 48  |  Issue : 2  |  Page : 191-2

Ordinary daily activities commonly precede the onset of subarachnoid haemorrhage.

How to cite this article:
Kaul S, Wozniak M, Sloan M, Price T R. Ordinary daily activities commonly precede the onset of subarachnoid haemorrhage. Neurol India 2000;48:191

How to cite this URL:
Kaul S, Wozniak M, Sloan M, Price T R. Ordinary daily activities commonly precede the onset of subarachnoid haemorrhage. Neurol India [serial online] 2000 [cited 2022 May 25];48:191. Available from: https://www.neurologyindia.com/text.asp?2000/48/2/191/1542

No consensus exists on the nature of events just preceding the onset of spontaneous subarachnoid haemorrhage (SAH). While some consider stress, intense physical activity, or sexual intercourse important,[1],[2],[3] others do not agree.[4] Further difficulty arises as there is no uniform definition of stress.[5] The purpose of this study was to get an insight into the nature of events just preceding onset of SAH. The issue has assumed greater importance with the advent of modern neuroimaging when incidental aneurysms are being detected with increasing frequency and the patients may ask for advice to prevent aneurysmal rupture.
The events at the onset of spontaneous subarachnoid haemorrhage (SAH) admitted at the University of Maryland Medical Center between January 1, 1992 and December 31, 1994, were entered prospectively into the Maryland Stroke Data Bank. The events were divided into 1) Sleep; 2) Rest; 3) Activity; and 4) Unknown. The event was presumed to have occurred during sleep if it was noticed by relatives while the patient was sleeping or if the patient woke up with the symptoms. Rest was defined as a condition, sitting or lying down, in which the patient was not involved in any physical work and was not under any mental stress. Activity was defined as any form of obvious physical or mental activity. The preceding event was unknown if the patient was unconscious/unable to give details or no relative was available. The categorization of patients was made based on patient's own description or the information obtained from the patient's attendant(s). As the information was collected immediately following admission into hospital, the possibility of recall bias was minimized. The patient group consisted of 70 males and 137 females. The mean age was 52 years (range 18-85). In 28 (13.5%) patients, the ictus occurred during a resting but awake state. In 24 (11.5%) patients, the haemorrhage occurred during sleep or the patient woke up with symptoms. Some kind of physical or mental activity was found to precede the ictus in 83 (40%) of patients. In 72 (34.7%) patients, the nature of preceding activity was unknown [Table I]. Interestingly, the majority of patients developed SAH during some kind of routine or ordinary daily activity. Previous studies have classified various activities on the basis of stress.[2],[3],[4],[5] However, stress being a subjective experience, we have described what the patient was actually doing at the time of ictus, while attempting to list the events in order of increasing physical and mental demands that the particular activity would make on the patient. Most of the patients were simply walking or standing at the time of ictus. None of the 11 patients who developed the ictus at work had an occupation involving heavy manual work.It is clear that in only 5 (2.4%) patients was the activity physically strenuous, like lifting a boat anchor, doing heavy labour, carrying heavy luggage and cutting grass. Similarly, in only 5 (2.4%) one could assume any degree of mental stress like giving a presentation or visiting a funeral. Contrary to an earlier study[2] where sexual activity was linked to 11% of cases, we found it only in 3 (1.4%) patients. Only 11.5% of patients developed the ictus during sleep. Others have found similar results.[3],[4] In a study on circadian rhythmicity and stroke, it has been reported that the majority of patients with SAH reported onset times between 1000 and 1200 hours.[6] Considering the fact that 1/3rd of a person's life is spent in sleep, SAH seems to be uncommon during sleep. Compared to the other series[1],[4] where the unknown category constituted 11% - 27% of patients, the percentage of unknown cases was somewhat higher in our study. This is possibly because University of Maryland Medical Center, being a tertiary care center, attracts more sick patients, many of whom are unconscious and unable to give details.
In summary, the events preceding subarachnoid hemorrhage are mostly related to ordinary daily activities. In a significant number, the onset occurs during rest or sleep. The exact event preceding the ictus is unknown in about a third of patients.


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1.Caplan LR: Subarachnoid hemorrhage. In: Stroke: A clinical approach, Second Edition, Caplan LR, editor. MA: Butterworth-Heineman, Boston. 1993; 391.   Back to cited text no. 1    
2.Ferro JM, Pinto AN: Sexual activity is a common precipitant of subarachnoid hemorrhage. Cerebrovas Dis 1994; 4: 375.   Back to cited text no. 2    
3.Toole JF, Robinson MK, Mercuri M: Primary subarachnoid hemorrhage. In: Vinken PH, Bruyn GW, Klawans HL (Edt. ): Handbook of Clinical Neurology. Vol 55, Vascular Disease, Part III. Amsterdam: Elsivier, 1989; 12.   Back to cited text no. 3    
4.Matsuda M,Ohashi M, Shiino A et al: Circumstances precipitating aneurysmal subarachnoid hemorrhage. Cerebrovas Dis 1993; 3: 285-288.   Back to cited text no. 4    
5.Schievink WI, Karemaker JM, Hageman LM et al: Circumstances surrounding aneurysmal subarachnoid hemorrhage. Surg Neurol 1989; 32: 266-272.   Back to cited text no. 5    
6.Sloan MA, Price TR, Foulkes MA et al: Circadian rhythmicity of stroke onset; Intracerebral and subarachnoid hemorrhage. Stroke 1992; 23: 1420-1426.   Back to cited text no. 6    


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