Review

Long-term outcomes of patients with aneurysmal

subarachnoid haemorrhage
Gabriel J E Rinkel, Ale Algra

More and more patients survive aneurysmal subarachnoid haemorrhage (aSAH), with case fatality decreasing by 17% Lancet Neurol 2011; 10: 349–56
in absolute terms over the past three decades and incidence remaining relatively stable at nine per 100 000 patient- See Editorial page 289
years. The mean age at which aSAH occurs is reasonably young at 55 years, and people of this age in the general Utrecht Stroke Center,
population have a good life expectancy. However, there are few data for life expectancy after aSAH, and the risks of Department of Neurology,
Rudolf Magnus Institute of
late recurrent aSAH and other vascular diseases are unclear. The course of associated long-term physical and cognitive
Neuroscience,
deficits after aSAH is not well established, leading to questions about potential outcomes to quality of life and working (Prof G J E Rinkel MD,
capacity, as well as best clinical practices. Prof A Algra MD) and the Julius
Center for Health Sciences and
Primary Care (A Algra),
Introduction the disorder was fixed by closure of the aneurysm (and
University Medical Center
Subarachnoid haemorrhage from a ruptured aneurysm is verification that there were no other unruptured Utrecht, Utrecht,
a subset of stroke that occurs at a relatively young age aneurysms). This notion has been overruled by evidence The Netherlands
compared with other stroke subtypes. The incidence is that aneurysms are not a one-off event, but rather a chronic Correspondence to:
around nine cases per 100 000 person-years, which has disease. The table summarises data from long-term follow- Prof Ale Algra, Julius Center for
Health Sciences and Primary
decreased little during the past four decades.1 However, the up studies on the occurrence of new aSAHs after
Care, STR 6.131, University
chance of a patient surviving an aneurysmal subarachnoid appropriate closure of the ruptured aneurysm that caused Medical Center Utrecht,
haemorrhage (aSAH) has increased by 17% over the past the initial event.10–15 Pooled mean follow-up was about PO Box 85500, 3584 CX Utrecht,
three decades and is around 65%.2–5 The reduction in 8 years after closure by means of surgical and endovascular The Netherlands
a.algra@umcutrecht.nl
fatality is remarkable because about 12% of patients who treatment. Pooled incidences after both procedures were
have a subarachnoid haemorrhage die immediately.6 Thus, about 190 cases per 100 000 patient-years, which is 15-times
a third of those who die from subarachnoid haemorrhage that reported in healthy individuals from Australia and
are not admitted to hospital and do not benefit from New Zealand who were matched for age and sex.16 Late
improved diagnostics and treatment methods. Most recurrent aSAHs might come from newly developed
patients who survive the initial weeks are functionally aneurysms, from remnants of incompletely closed
independent.3 As the mean age of occurrence is around aneurysms, or from reopening of closed ones (figure 1,
55 years, the question is whether patients who survive an table). In the case of aneurysms detected at different sites
aSAH have an equivalent life expectancy to that of healthy from those previously treated, the question is often
people of this age in the general population, which in the whether the aneurysm is new or was missed at the initial
Netherlands is around another 30 years.7 investigation. On CT angiography 2–19 years after clipping
Because aneurysms are not congenital as was previously of a ruptured aneurysm, 112 (18%) of 610 patients who
assumed but instead develop during life,8 patients who were screened had 151 aneurysms, of which 22 in
survive the initial weeks might be at risk of development 17 patients were already known at the time of the initial
of new aneurysms and new episodes of aSAH. aSAH.17,18 Of the 129 newly detected aneurysms, 105 (81%)
Furthermore, because hypertension and smoking are were located at a site remote from the clip site. Of 59 cases
major risk factors for aSAH,9 patients who survive the of these newly detected aneurysms for which the original
initial weeks might have a higher than normal risk of angiogram was available, 19 (32%) were truly de novo and
cardiovascular diseases. Equally, functional independence 40 (68%) were visible in retrospect. 13 (25%) of
is not the only important outcome: many patients who 53 aneurysms that were present at the time of the aSAH
are functionally independent have cognitive dysfunction (including 13 previously identified) had grown in size
in the initial phase after aSAH. Here, we review data for during follow-up. Thus, new aneurysms can develop and
life expectancy and the risk of new episodes of aSAH and existing aneurysms can enlarge in the years after aSAH.
other cardiovascular diseases for patients who survived Few data exist for risk factors of late recurrent aSAHs.
an aSAH. We also describe the long-term course of One study11 showed younger age (hazard ratio
residual physical and cognitive deficits, detail implications [HR] per 10 years decrease 1·7, 95% CI 1·1–2·5), verified
for quality of life and working capacity from an individual history of familial aSAH (3·8, 1·1–13·2), current
and societal perspective, and discuss the implications for smoking (4·8, 1·3–17·4), and presence of more than one
clinical practice and future research. aneurysm at the time of the initial aSAH (5·7, 2·3–14·5)
were risk factors on univariable analysis. Likewise, risk
Risk of late recurrent aSAH, death, and factors for aneurysm formation and enlargement
cardiovascular diseases included a family history of intracranial aneurysms (2·7,
Until the end of the 20th century, the prevailing perception 1·0–7·4), current smoking (3·2, 1·0–9·7), and presence
of outcomes of patients who survived an aSAH was that of more than one aneurysm (3·3, 1·2–8·9).18

www.thelancet.com/neurology Vol 10 April 2011 349

 Review

Publication Number of Mean age Women (%) Mean follow-up Number of Late recurrent aSAH Incidence per 100 000
year patients (years) (years) patient-years person-years (95% CI)
Original aneurysm Other or Total
confirmed unknown
After clipping
Tsutsumi et al10* 1998 220 56 53% 9·9 2178 NR NR 6 275 (101–600)
Wermer et al11 2005 752 50 67% 8·0 6016 4 14 18 299 (177–473)
CARAT study12† 2006 711 54 69% 3·7 2666 0 NR NR NR
ISAT13† 2009 1005 52‡ 63% 8·1 8177 3 4 7 86 (34–176)
Pooled§ ·· 1977 ·· ·· 8·3 16 371 ·· ·· 31 189 (129–269)
After coiling
CARAT study12† 2006 299 58 70% 3·0 904 1 NR NR NR
ISAT13† 2009 999 52‡ 63% 8·5 8447 10 7 17 201 (117–322)
Schaafsma et al14 2009 283 51 71% 6·3 1778 1 2 3 169 (35–493)
Choi et al15¶ 2010 87 NR NR 2·9 249 0 0 0 0 (0–1481)
Pooled§ ·· 1369 ·· ·· 7·7 10 474 ·· ·· 20 191 (117–295)

Data are n or %, unless otherwise stated. aSAH=aneurysmal subarachnoid haemorrhage. NR=not reported. CARAT=Cerebral Aneurysm Rerupture After Treatment. ISAT=International Subarachnoid Aneurysm
Trial. *All patients survived aSAH for more than 3 years. †Recurrent aSAHs more than 1 year after treatment of target aneurysm. ‡Median age. §The CARAT study was not included because of missing data for
total number of late recurrent aSAHs; pooled incidence was derived from summed late recurrent aSAHs and total patient-years. ¶All aneurysms from initial aSAH were designated as 100% obliterated
immediately after coiling.

Table: Incidence of late recurrent episodes of aSAH after successful treatment for a previous occurrence

Patients who have an aSAH are young compared with
those who have other stroke subtypes, with a mean age of
about 55 years. After successful closure of the aneurysm
and survival with a good clinical outcome, these patients
might consider their life expectancy to be equal to that of
healthy people aged 55 years. However, hypertension and
cigarette smoking are important risk factors for aSAH,19
and hence long-term prognosis after aSAH could be
reduced. Three studies13,20,21 showed that mortality was
indeed increased after survival from aSAH compared with
healthy people of the same age and sex. A Finnish study
followed up 1537 patients for 7·5 years and reported that
the mortality was twice that of the general population.20 A
Dutch series21 of 752 patients noted the standardised
mortality ratio was 1·7 (95% CI 1·4–2·1) for all age groups
and 3·2 (0·8–13·1) for patients who were younger than
40 years. In the long-term follow-up of patients who
participated in the International Subarachnoid Aneurysm
Trial, the standardised mortality ratio of 1·57 (1·32–1·82)
was conditional on survival of the patients for at least
1 year.13 In a study of 11 374 Swedish patients who survived
for at least 3 months after an aSAH, the overall standardised
mortality ratio was 1·61 (1·52–1·70) and ranged between 2·1
and 2·6 for patients aged 50–65 years.22
For cardiovascular diseases other than aSAH, a study21
of 678 patients who were treated with surgical clipping
for aSAH and then discharged home or to a rehabilitation
facility reported 62 vascular events during a mean follow-
up of 8·1 years (10-year risk of 11·2%, 95% CI 7·0–14·4).
Vascular events included 27 ischaemic strokes, ten
intracranial haemorrhages, 16 myocardial infarctions,
and nine sudden deaths. The incidence of vascular events
was lower in patients who had aSAH than it was in
patients who had a transient ischaemic attack or minor
ischaemic stroke at entry (age and sex-adjusted HR 0·43,
95% CI 0·33–0·57; figure 2).21 In the aforementioned
study22 of Swedish survivors of aSAH, the overall
standardised mortality ratio for vascular death was 1·57
(95% CI 1·44–1·70) and ranged between 3·7 for patients
aged 50 years and 2·1 for patients aged 65 years.22 The
overall standardised incidence ratio for fatal or non-fatal
vascular diseases was 1·51 (1·45–1·56), and ranged
from 3·4 at age 50 years to 2·4 at age 65 years for women
and from 2·1 at age 50 years to 1·7 at age 65 years for
men, but was not significantly increased for patients
older than 85 years.
Residual deficits after aSAH
Although several population-based studies have described
case fatality rates of aSAH, only a few have also described
the proportion of patients who regain independence for
activities of daily life. Estimates of independence
(modified Rankin scale score of 0–3 dependent on the
study) varied between 36% and 55% at assessments
1–12 months after aSAH;3 however, there were too few
data to establish whether this proportion changed during
the preceding decades.
Clinical condition at admission is one of the most
important predictors of clinical outcome.23 Nevertheless,
one of five patients who is comatose at admission recovers
without important cognitive or physical deficits.24
Furthermore, patients who have no motor or verbal
responses at admission have a 5% chance of recovery to
independent functioning.23 Even patients who remain in
a coma during the first days to weeks after treatment of
the aneurysm can recover to independent functioning

350 www.thelancet.com/neurology Vol 10 April 2011

 Review

after weeks or months.25 If patients have not recovered

A B
during the clinical course and are discharged in poor
condition to a nursing home, one in three of such patients
improves and recovers to independent functioning within
the first 2 years of admission to the nursing home.26 One
of seven patients who are discharged to a nursing home
stay there for more than 2 years, and those who die usually
do so within the first year after admittance.26

Cognitive dysfunction
Functional independence is not the only factor that
contributes to quality of life after a stroke. Many patients
who are able to take care of themselves cannot resume
their previous work, have difficulties in their relationships,
and have mood disturbances and an impaired quality of
C D
life. Cognitive dysfunction is an important cause of this
disability after aSAH.27,28 A review28 of 61 empirical studies
examining cognitive and functional outcome in patients
who survived aSAH reported high proportions of
impairment in the domains memory (up to 60%),
executive function (up to 75%), and language (up to 75%).
Self-reported cognitive complaints are even more
prevalent than are measured cognitive dysfunction. In a
series29 of 111 patients from the University Medical Center
Utrecht, 105 (95%) reported at least one cognitive or
emotional complaint that hampered day-to-day
functioning 3 months after aSAH. The most frequently
reported cognitive complaints were mental slowness,
short-term memory problems, and attention deficits.
These cognitive complaints were associated with memory E F
deficits, disability, and depressive symptoms. Although
cognitive dysfunction improves with time, especially in
the first year,28,30,31 half of patients in a population-based
study reported ongoing difficulties with memory 1 year
after aSAH and one in seven reported ongoing difficulties
with speech.32
The causes of these cognitive deficits are not completely
understood. The method of treatment of the aneurysm
seems to be implicated; for example, in the International
Subarachnoid Aneurysm Trial, patients who were treated Figure 1: Recurrence of aneurysms
by coiling had fewer neuropsychological deficits than did (A and B) Catheter angiograms of a woman who had an aSAH at age 38 years. (A) Occlusion of the ruptured
aneurysm at the top of the basilar artery after coiling. (B) Repeated catheter angiography after 6 months shows
patients who had been treated by clipping.33 In patients partial recanalisation of the aneurysm. (C–F) CT and catheter angiograms of a man initially treated for a carotid artery
who survived an aSAH, reduced mesiotemporal volumes, aneurysm at age 43 years. The aneurysm was detected because the patient had an ischaemic stroke at that time in
ischaemic lesions in the territory of the aneurysm- the right middle cerebral artery territory. The aneurysm was clipped, but after 9 years the patient had an aSAH from a
bearing artery and in the territory of remote arteries, and recurrence of the aneurysm at the clip site. The aneurysm was occluded endovascularly with coils, but the patient did
not recover from the aSAH and died 5 days after the haemorrhage. (C) Aneurysm detected after the stroke. (D) CT
global brain atrophy have been noted on MRI and have scan confirming the aSAH 9 years after aneurysm clipping with artifacts from the clip (green arrow), subarachnoid
been related to cognitive deficits.34–37 These brain lesions blood (red arrows), intraparenchymal extension (blue arrow), and intraventricular extension (white arrow).
might be caused by the initial effect of the aSAH, by (E) Previously placed clip (green arrow) and the recurred aneurysm with a small nipple (red arrow) that presumably
complications such as secondary ischaemia, or by the was the site of rupture. (F) Aneurysm after occlusion with coils. aSAH=aneurysmal subarachnoid haemorrhage.
treatment of the aneurysm.
improve in the first 2 years following the aSAH.28 Whether
Mood disturbances mood disturbances are so serious that they lead to suicide
Mood disturbances are common after aSAH. Increased has not been investigated systematically. Sleep disturbances
rates of symptoms of anxiety and depression are noted in are noted in a third of patients 1–3 years after aSAH.41
up to half of patients in the second year after an aSAH,28,38,39 These disturbances are related to fatigue,41 but because
and a post-traumatic stress disorder is reported in up to fatigue occurs in two-thirds of patients,42 other unknown
one in three patients.38,40 These mood changes do not factors probably have a role in fatigue after aSAH.

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 Review
0·6
Cumulative incidence of vascular events 0·5
0·4
0·3
0·2
0·1
0 at which they occur and the poor outcomes they lead to.
0 5
Number at risk
Subarachnoid
haemorrhage
Transient ischaemic
attack or minor stroke
Figure 2: Age and sex-adjusted cumulative incidence of vascular events after
aneurysmal subarachnoid haemorrhage and transient ischaemic attack or
minor ischaemic stroke
Reproduced from Wermer and colleagues with permission of the BMJ
publishing group.21
Deficits of smell and hearing
An often-neglected deficit after aSAH is anosmia. Loss of
smell has an important effect on eating and drinking,
quality of life, social functioning, sex, and psychological
wellbeing.43,44 Overall, anosmia occurs in about 25–33%
of patients after aSAH, and is rated by patients to have
substantial effect on their wellbeing.45 The risk of anosmia
is twice as high in patients with anterior communicating
artery aneurysms as it is in patients with aneurysms at
other sites,45 and 2–10-times as high after clipping than it
is after coiling of the aneurysm. Recovery from anosmia
occurs more often after coiling than it does after
clipping.45,46 Aneurysm treatment, however, is not the
only cause of anosmia after aSAH. Olfactory dysfunction
can occur in the first few days after aSAH before
treatment of the aneurysm47 and also occurs in one in
16 patients with perimesencephalic non-aneurysmal
haemorrhage,48 suggesting that the presence of blood in
the vicinity of the olfactory nerves also has a role in the
development of anosmia. Hearing loss is one of the key
features in superficial siderosis of the CNS,49 but has
rarely been reported after aSAH from a ruptured
aneurysm. In most of the reported cases, patients’
hearing loss was temporary.50
Quality of life
All residual deficits negatively affect quality of life, life
satisfaction, social participation, and return to work.
2–4 years after aSAH, only a third of patients who were
working at the time of aSAH resumed work entirely,
another third worked fewer hours or had a less responsible
position.28,51 The inability to resume work is a major cause
of dissatisfaction with life.51 7% of patients suggested that
they were divorced because of problems related to aSAH.52
352
The aforementioned residual deficits and complaints
Subarachnoid haemorrhage
Transient ischaemic attack or minor stroke
explain why patients as a group have a reduced quality of
life.28 However, in the long term, quality of life improves.
Findings from one study53 showed that 5 years after aSAH,
overall quality of life was better than it was after 4 months
and quality of life continued to improve between 5 and
12·5 years after aSAH, despite a decrease in functional
outcome in this time.
Effect on society
Although aSAHs account for only 5% of strokes, their
effect on society is substantial because of the young age
10 15
Follow-up (years) In the last decades of the 20th century, the proportion of
466 226 60 years of potential life lost from subarachnoid
haemorrhage was similar to that of ischaemic stroke
1768 1200 254
and intracerebral haemorrhage.54 In the first years of the
21st century, the mean hospital charge in the USA for
aSAH was more than US$65 000 per patient.55 The total
cost to society of aSAH also includes out-of-hospital
costs in addition to direct hospital-related costs. These
out-of-hospital costs include rehabilitation, primary
care, and community health and social services. About a
quarter of patients with aSAH follow an inpatient or
outpatient rehabilitation programme, with a mean
duration of 5 months for inpatient courses and 7 months
for outpatient courses.52 Finally, costs not related to
health care can also be added, including informal care
and productivity losses arising from morbidity and
premature death. The burden for partners of patients
with aSAH is striking. As long as 18 months after the
aSAH, caregiving partners have a substantial reduction
in the quality of life domains of sleep and rest, emotional
behaviour, and recreation and pastimes; moreover, half
of partners who had a job before their spouse’s aSAH
worked less or not at all after the event.56 A study from
the UK57 calculated that the total economic burden
(including informal care and calculated with the human
capital method to estimate production losses) of aSAH
in the UK was £510 million per year.
Clinical implications
Multidisciplinary outpatient clinics
Although most patients who recover from aSAH are well
informed about their event and about the type of
treatment they received, a third with non-treated
additional aneurysms are not aware of having one or
more unsecured aneurysms.58 Moreover, most patients
interviewed about the information that they were given
expressed a need for more and improved information.59
The same study59 also reported that in most instances the
information about the aSAH was given to the patient in
the absence of their spouse or other relatives.
The various physical and cognitive deficits, mood
problems, long-term risks, and need for more information
intuitively call for a multidisciplinary outpatient clinic
dedicated to patients with aSAH and their proxies. We
www.thelancet.com/neurology Vol 10 April 2011

run such a clinic, in which patients are seen 6 weeks after
discharge by a neuropschychological assistant, a
dedicated stroke nurse, and a rehabilitation physician.
The neuropschychological assistant undertakes a brief
neuropsychological screening and assesses the presence
of symptoms of depression and anxiety. The stroke nurse
interviews patients about restrictions that they encounter
in day-to-day life and provides information about
management of risk factors, in particular smoking and
hypertension, familial aSAH, long-term prognosis, and
restrictions on car driving. Cessation of smoking is
pivotal for aSAH survivors even though the effectiveness
of smoking cessation in this particular subset of patients
has not been formally studied. Data from the setting of
primary prevention, however, broadly support smoking
cessation and are in our view not only applicable to
patients who have had a transient ischaemic attack or
ischaemic stroke, but also to patients who have had an
aSAH.60,61 In case of existing unsecured aneurysms, the
stroke nurse checks whether the treatment plan for these
aneurysms is known by the patient. The rehabilitation
doctor assesses physical restrictions and develops a
rehabilitation programme if needed that is tailored to an
individual patient’s needs on the basis of all information
received. We have not formally assessed the effects of
this clinic on patients’ quality of life or life satisfaction,
but most patients expressed satisfaction with the service
provided in a questionnaire that they are sent a couple of
months after their visit (unpublished data).
Follow-up screening
Patients who have successfully been treated for an aSAH
have an increased risk of further episodes (table 1); however,
because overall risks outweighed benefits in a formal
decision analysis,62 follow-up screening for new aneurysms
is in general not recommended. Screening saved costs and
increased quality-adjusted life-years at acceptable costs in
patients with a high risk of both aneurysm formation and
rupture. Screening increased quality-adjusted life-years at
acceptable costs in patients with fear of a recurrence.62 For
daily practice, repeated screening 3–5 years after aSAH is
recommended for patients who had a first episode at a
young age (roughly aged younger than 35–40 years),
especially if the patient is female or has more than one
aneurysm,63 and for patients who have a positive family
history for aSAH or autosomal dominant polycystic kidney
disease.64,65 In our practice, we do not mandate repeated
screening, but rather leave the decision to return 3–5 years
later with the patient and strongly encourage them to have
a consultation before the screening to carefully assess the
risks and benefits of screening.66–69
Whether follow-up imaging for additional unruptured
aneurysms that are untreated is beneficial, and if so at
what frequency, is unknown. In a study70 of follow-up to
1 year, enlargement occurred in less than 5% of patients
and enlargement to a size that necessitated intervention
was very rare. At 10-year follow-up, one in four aneurysms
www.thelancet.com/neurology Vol 10 April 2011
Review
had enlarged, but the enlargement was more than 3 mm
in only 4%.18 There is no evidence that follow-up by
screening and treatment of enlarging aneurysms prevents
new episodes of aSAH. Assessment of such a strategy is
hampered by the fact that aneurysm growth and thereby
propensity for rupture is not constant over time.71 Despite
this absence of evidence, at our centre we do follow-up
imaging in patients with untreated aneurysms if they are
in a good condition after the aSAH and have a life
expectancy of around 15 years or more.
Future directions
Secondary prevention of cardiovascular diseases after
clinically manifest atherosclerotic disease is broadly
accepted and has, apart from recommendations to adapt
lifestyle, three key principles: blood pressure reduction,
lipid lowering, and antithrombotic treatment. As
previously mentioned, patients have an increased risk of
vascular disease after aSAH; however there are no data
for effectiveness of secondary prevention. Such data are
needed before secondary prevention can be implemented,
because the risk of cardiovascular ischaemic diseases
might not be increased to the extent that prevention of
these events by administration of antiplatelets outweighs
the risk of haemorrhagic complications. Furthermore,
antiplatelet drugs could be detrimental in new episodes
of aSAH. The costs of secondary prevention and its
efficiency in terms of compliance needs to be assessed.
At the University Medical Center Utrecht, a review of
patients’ charts showed that 49 of 100 patients used
blood-pressure-lowering drugs after aSAH, 20 used
lipid-lowering drugs, and 17 used antiplatelet drugs at
the first follow-up visit after discharge (unpublished
data). Hence, there is much room for optimisation of
secondary preventive treatment, which might be achieved
with a polypill containing blood-pressure-lowering
drugs, statins, and aspirin to achieve optimum
compliance.72 Compared with no use of these drugs, a
potential relative risk reduction of vascular events by a
polypill strategy of around 80% was calculated to be
possible.72 4 years after aSAH, the risk of fatal or non-
fatal myocardial infarction or ischaemic stroke is 5%.22
With a presumed risk reduction of 40% (and usual type I
and II errors) about 3000 patients would be needed to
assess the effectiveness of secondary prevention after
aSAH, which implies that a multinational study would
be needed.
Risk factors for aneurysm formation and rupture in
patients with previous aSAH and the optimum strategy
for management of fear of a recurrence are unclear.
Identification of subgroups of patients with such risk
factors would enable targeted screening.62 Interpretation
of pooled analyses of individual patients’ data from
studies on risk of rupture of unruptured aneurysms
might enable this selection. Furthermore, investigation
of anatomical risk factors73,74 and the pathological nature
of the vessel wall is warranted.
353
 Review
Panel: Numbers to remember
• Incidence of aneurysmal subarachnoid haemorrhage (aSAH) has remained stable over
the past four decades at nine per 100 000 patient-years, but case fatality has
decreased by 17% in absolute terms during the previous three decades and is presently
around 35%
• Risk of a new aSAH in survivors is 15-times higher than it is in the general population;
absolute risk is 3% in the first 10 years after an event
• Risk of death in aSAH survivors is around 25% within 10 years; the standardised
mortality ratio is 1·5
• Two-thirds of aSAH survivors regain functional independence, but half have cognitive
impairments, half are dissatisfied with life, and only a third resume the same work as
before the event
• The proportion of years of potential life lost from aSAH is similar to that from
ischaemic stroke and intracerebral haemorrhage
In patients who regained independent living after
aSAH, a passive coping style is an important determinant
of life satisfaction and for cognitive domains of health-
related quality of life.42,51 Training programmes for more
efficient coping styles need to be developed and assessed.
Treatment of cognitive impairment after aSAH could
be approached in a similar way to that for patients in the
early stages of Alzheimer’s disease. An uncontrolled
pilot study of 20 Chinese patients with cognitive
impairment 9 months after aSAH suggested
improvement of cognitive abilities after a 12-week course
of rivastigmine 1·5 mg twice per day.75 Efficacy, safety,
and effectiveness of such treatments need to be assessed
in randomised clinical trials. A preliminary study of
statins in the weeks after experimental subarachnoid
haemorrhage showed improved cognition tests in rats,76
but whether these data can be extrapolated to patients is
very uncertain. A large phase 3 trial of statins for the
treatment of aSAH is underway in the UK (NCT00731627),
but whether this trial will answer the question about
cognitive function after subarachnoid haemorrhage is
unknown because cognitive function is not listed as one
of the secondary outcomes.
Conclusions
Previous studies13,20,21 have shown that life expectancy is
reduced for patients who survived aSAH. These patients
have a higher risk of aSAH in their remaining life than
do the general population (panel), but because the
absolute risk is still low, screening for new aneurysms is
in general not cost effective after aSAH. Furthermore,
the risk of cardiovascular diseases apart from aSAH is
higher in patients who have had aSAH than it is in the
general population. Consequently, life expectancy is
shortened after aSAH survival. The various physical and
cognitive deficits, mood problems, long-term risks, and
general need for more information call for a multidisci-
plinary outpatient clinic dedicated to aSAH patients and
their families. Cessation of smoking is pivotal for aSAH
survivors even though the effectiveness of smoking
354
Search strategy and selection criteria
References for this Review were retrieved from a
prospectively built database of references collected between
Jan 1, 2000, and Jan 19, 2011, by unrestricted PubMed
searches with the terms “subarachnoid hemorrhage”,
“aneurysm”, “arteriovenous malformation”,
“perimesencephalic”, “subarachnoid haemorrhage”, OR
“aneurysm*”. References were also identified by searching
the PubMed database with the terms “hearing loss” or
“deafness”; “blindness” or “loss of vision”; or “costs”, in
combination with “subarachnoid hemorrhage”, “aneurysm”,
“subarachnoid haemorrhage” OR “aneurysm”. Only papers or
abstracts published in English, French, German, Dutch, or
Italian were eligible. Papers about extracranial aneurysms
were excluded.
cessation in this subset of patients has not been formally
studied. The effectiveness of secondary prevention with
antithrombotics, statins, and antihypertensive drugs is
not known.
Contributors
GJER and AA had the idea for the Review, wrote separate sections, and
did corresponding searches of the published work. Both authors
commented on consecutive versions of the manuscript.
Conflicts of interest
We declare that we have no conflicts of interest.
Acknowledgments
We thank M J H Wermer for critical review of a draft of this Review.
References
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2 Koffijberg H, Buskens E, Granath F, et al. Subarachnoid
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