title: Triggers of subarachnoid hemorrhage: role of physical exertion, smoking, and alcohol in the Australasian Cooperative Research on Subarachnoid Hemorrhage Study (ACROSS).
abstract: OBJECTIVE
  Unaccustomed strenuous physical exertion can trigger myocardial infarction, but little is known about the mechanisms precipitating subarachnoid hemorrhage (SAH).
  
  
  METHODS
  We identified all cases of first-ever SAH among the combined populations (2.8 million) of 4 urban centers in Australia and New Zealand. Information on the type, time, and intensity of exposures in the 26 hours before the onset of SAH was ascertained by structured interviews. We used the case-crossover technique to assess the risk of SAH associated with transient exposures of moderate to extreme physical exertion, heavy cigarette smoking, and binge alcohol consumption.
  
  
  RESULTS
  We registered 432 first-ever cases of SAH (62% women; mean age, 56.5 years). A definite time of onset of SAH was established for 393 patients (91%), and information on the levels of physical activity in the preceding 26 hours was obtained in 338 (78%). Of these patients, 19% engaged in moderate to extreme exertion (>or=5 metabolic equivalents) in the 2 hours before SAH, which was associated with a tripling in the risk of SAH (odds ratio [OR], 2.7; 95% CI, 1.6 to 4.6). There was no evidence of any association between heavy cigarette smoking or binge drinking and risk of SAH in the subsequent 2 hours (OR, 1.1; 95% CI, 0.4 to 3.7; and OR, 0.41; 95% CI, - infinity to 5.3). Habitual exercise did not appear to alter the risk of SAH associated with moderate to extreme exertion.
  
  
  CONCLUSIONS
  Moderate to extreme physical exertion tripled the risk of SAH, but there was no association between transient heavy smoking or binge drinking and risk of SAH. These data suggest that heavy physical activity may trigger SAH.
authors.affiliation: Clinical Trials Research Unit, University of Auckland, New Zealand. c.anderson@ctru.auckland.ad.nz
authors.forename: Craig
authors.initials: C
authors.lastname: Anderson
authors.forename: Cliona
authors.initials: C
authors.lastname: Ni Mhurchu
authors.forename: David
authors.initials: D
authors.lastname: Scott
authors.forename: Derrick
authors.initials: D
authors.lastname: Bennett
authors.forename: Konrad
authors.initials: K
authors.lastname: Jamrozik
authors.forename: Graeme
authors.initials: G
authors.lastname: Hankey
mesh_terms: D000328:Adult; D000368:Aged; D000428:Alcohol Drinking / Q000009:adverse effects* / Q000453:epidemiology; D001315:Australia / Q000453:epidemiology; D015897:Comorbidity; D018592:Cross-Over Studies; D005260:Female; D006801:Humans; D008297:Male; D008875:Middle Aged; D009520:New Zealand / Q000453:epidemiology; D016017:Odds Ratio; D005082:Physical Exertion; D012042:Registries / Q000706:statistics & numerical data; D018570:Risk Assessment; D012907:Smoking / Q000009:adverse effects* / Q000453:epidemiology; D013345:Subarachnoid Hemorrhage / Q000453:epidemiology / Q000209:etiology*; D014505:Urban Population / Q000706:statistics & numerical data