title: Stable incidence but declining case-fatality rates of subarachnoid hemorrhage in a population.
abstract: OBJECTIVE
  To characterize temporal trends in subarachnoid hemorrhage (SAH) incidence and outcomes over 5 time periods in a large population-based stroke study in the United States.
  
  
  METHODS
  All SAHs among residents of the Greater Cincinnati/Northern Kentucky region at least 20 years of age were identified and verified via study physician review in 5 distinct year-long study periods between 1988 and 2010. We abstracted demographics, care patterns, and outcomes, and we compared incidence and case-fatality rates across the study periods.
  
  
  RESULTS
  The incidence of SAH in the 5 study periods (age-, race-, and sex-adjusted to the 2000 US population) was 8.8 (95% confidence interval 6.8-10.7), 9.2 (7.2-11.2), 10.0 (8.0-12.0), 9.0 (7.1-10.9), and 7.7 (6.0-9.4) per 100,000, respectively; the trend in incidence rates from 1988 to 2010 was not statistically significant (p = 0.22). Advanced neurovascular imaging, endovascular coiling, and neurologic intensive care unit availability increased significantly over time. All-cause 5-day (32%-18%, p = 0.01; for trend), 30-day (46%-25%, p = 0.001), and 90-day (49%-29%, p = 0.001) case-fatality rates declined from 1988 to 2010. When we included only proven or highly likely aneurysmal SAH, the declines in case-fatality were no longer statistically significant.
  
  
  CONCLUSIONS
  Although the incidence of SAH remained stable in this population-based region, 5-day, 30-day, and 90-day case-fatality rates declined significantly. Advances in surgical and medical management, along with systems-based changes such as the emergence of neurocritical care units, are potential explanations for the reduced case-fatality.
authors: From the Department of Neurology (J.M.), Indiana University School of Medicine, Indianapolis; Division of Biostatistics and Epidemiology (J.C.K.), Cincinnati Children's Hospital; Departments of Neurology (K.A., C.J.M., B.M.K., M.L.F., D.W., S.F., F.D.L.R.L.R., P.K., J.P.B., D.K.), Emergency Medicine (O.A.), and Neurosurgery (M.Z.), University of Cincinnati College of Medicine, OH; Department of Neurology (F.D.L.R.L.R.), University of New Mexico Health Sciences Center, Albuquerque; and Department of Neurology (S.M.), Baylor College of Medicine, Houston, TX. jsmackey@iupui.edu.
authors: Jason
authors: J
authors: Mackey
authors: From the Department of Neurology (J.M.), Indiana University School of Medicine, Indianapolis; Division of Biostatistics and Epidemiology (J.C.K.), Cincinnati Children's Hospital; Departments of Neurology (K.A., C.J.M., B.M.K., M.L.F., D.W., S.F., F.D.L.R.L.R., P.K., J.P.B., D.K.), Emergency Medicine (O.A.), and Neurosurgery (M.Z.), University of Cincinnati College of Medicine, OH; Department of Neurology (F.D.L.R.L.R.), University of New Mexico Health Sciences Center, Albuquerque; and Department of Neurology (S.M.), Baylor College of Medicine, Houston, TX.
authors: Jane C
authors: JC
authors: Khoury
authors: From the Department of Neurology (J.M.), Indiana University School of Medicine, Indianapolis; Division of Biostatistics and Epidemiology (J.C.K.), Cincinnati Children's Hospital; Departments of Neurology (K.A., C.J.M., B.M.K., M.L.F., D.W., S.F., F.D.L.R.L.R., P.K., J.P.B., D.K.), Emergency Medicine (O.A.), and Neurosurgery (M.Z.), University of Cincinnati College of Medicine, OH; Department of Neurology (F.D.L.R.L.R.), University of New Mexico Health Sciences Center, Albuquerque; and Department of Neurology (S.M.), Baylor College of Medicine, Houston, TX.
authors: Kathleen
authors: K
authors: Alwell
authors: From the Department of Neurology (J.M.), Indiana University School of Medicine, Indianapolis; Division of Biostatistics and Epidemiology (J.C.K.), Cincinnati Children's Hospital; Departments of Neurology (K.A., C.J.M., B.M.K., M.L.F., D.W., S.F., F.D.L.R.L.R., P.K., J.P.B., D.K.), Emergency Medicine (O.A.), and Neurosurgery (M.Z.), University of Cincinnati College of Medicine, OH; Department of Neurology (F.D.L.R.L.R.), University of New Mexico Health Sciences Center, Albuquerque; and Department of Neurology (S.M.), Baylor College of Medicine, Houston, TX.
authors: Charles J
authors: CJ
authors: Moomaw
authors: From the Department of Neurology (J.M.), Indiana University School of Medicine, Indianapolis; Division of Biostatistics and Epidemiology (J.C.K.), Cincinnati Children's Hospital; Departments of Neurology (K.A., C.J.M., B.M.K., M.L.F., D.W., S.F., F.D.L.R.L.R., P.K., J.P.B., D.K.), Emergency Medicine (O.A.), and Neurosurgery (M.Z.), University of Cincinnati College of Medicine, OH; Department of Neurology (F.D.L.R.L.R.), University of New Mexico Health Sciences Center, Albuquerque; and Department of Neurology (S.M.), Baylor College of Medicine, Houston, TX.
authors: Brett M
authors: BM
authors: Kissela
authors: From the Department of Neurology (J.M.), Indiana University School of Medicine, Indianapolis; Division of Biostatistics and Epidemiology (J.C.K.), Cincinnati Children's Hospital; Departments of Neurology (K.A., C.J.M., B.M.K., M.L.F., D.W., S.F., F.D.L.R.L.R., P.K., J.P.B., D.K.), Emergency Medicine (O.A.), and Neurosurgery (M.Z.), University of Cincinnati College of Medicine, OH; Department of Neurology (F.D.L.R.L.R.), University of New Mexico Health Sciences Center, Albuquerque; and Department of Neurology (S.M.), Baylor College of Medicine, Houston, TX.
authors: Matthew L
authors: ML
authors: Flaherty
authors: From the Department of Neurology (J.M.), Indiana University School of Medicine, Indianapolis; Division of Biostatistics and Epidemiology (J.C.K.), Cincinnati Children's Hospital; Departments of Neurology (K.A., C.J.M., B.M.K., M.L.F., D.W., S.F., F.D.L.R.L.R., P.K., J.P.B., D.K.), Emergency Medicine (O.A.), and Neurosurgery (M.Z.), University of Cincinnati College of Medicine, OH; Department of Neurology (F.D.L.R.L.R.), University of New Mexico Health Sciences Center, Albuquerque; and Department of Neurology (S.M.), Baylor College of Medicine, Houston, TX.
authors: Opeolu
authors: O
authors: Adeoye
authors: From the Department of Neurology (J.M.), Indiana University School of Medicine, Indianapolis; Division of Biostatistics and Epidemiology (J.C.K.), Cincinnati Children's Hospital; Departments of Neurology (K.A., C.J.M., B.M.K., M.L.F., D.W., S.F., F.D.L.R.L.R., P.K., J.P.B., D.K.), Emergency Medicine (O.A.), and Neurosurgery (M.Z.), University of Cincinnati College of Medicine, OH; Department of Neurology (F.D.L.R.L.R.), University of New Mexico Health Sciences Center, Albuquerque; and Department of Neurology (S.M.), Baylor College of Medicine, Houston, TX.
authors: Daniel
authors: D
authors: Woo
authors: From the Department of Neurology (J.M.), Indiana University School of Medicine, Indianapolis; Division of Biostatistics and Epidemiology (J.C.K.), Cincinnati Children's Hospital; Departments of Neurology (K.A., C.J.M., B.M.K., M.L.F., D.W., S.F., F.D.L.R.L.R., P.K., J.P.B., D.K.), Emergency Medicine (O.A.), and Neurosurgery (M.Z.), University of Cincinnati College of Medicine, OH; Department of Neurology (F.D.L.R.L.R.), University of New Mexico Health Sciences Center, Albuquerque; and Department of Neurology (S.M.), Baylor College of Medicine, Houston, TX.
authors: Simona
authors: S
authors: Ferioli
authors: From the Department of Neurology (J.M.), Indiana University School of Medicine, Indianapolis; Division of Biostatistics and Epidemiology (J.C.K.), Cincinnati Children's Hospital; Departments of Neurology (K.A., C.J.M., B.M.K., M.L.F., D.W., S.F., F.D.L.R.L.R., P.K., J.P.B., D.K.), Emergency Medicine (O.A.), and Neurosurgery (M.Z.), University of Cincinnati College of Medicine, OH; Department of Neurology (F.D.L.R.L.R.), University of New Mexico Health Sciences Center, Albuquerque; and Department of Neurology (S.M.), Baylor College of Medicine, Houston, TX.
authors: Felipe
authors: F
authors: De Los Rios La Rosa
authors: From the Department of Neurology (J.M.), Indiana University School of Medicine, Indianapolis; Division of Biostatistics and Epidemiology (J.C.K.), Cincinnati Children's Hospital; Departments of Neurology (K.A., C.J.M., B.M.K., M.L.F., D.W., S.F., F.D.L.R.L.R., P.K., J.P.B., D.K.), Emergency Medicine (O.A.), and Neurosurgery (M.Z.), University of Cincinnati College of Medicine, OH; Department of Neurology (F.D.L.R.L.R.), University of New Mexico Health Sciences Center, Albuquerque; and Department of Neurology (S.M.), Baylor College of Medicine, Houston, TX.
authors: Sharyl
authors: S
authors: Martini
authors: From the Department of Neurology (J.M.), Indiana University School of Medicine, Indianapolis; Division of Biostatistics and Epidemiology (J.C.K.), Cincinnati Children's Hospital; Departments of Neurology (K.A., C.J.M., B.M.K., M.L.F., D.W., S.F., F.D.L.R.L.R., P.K., J.P.B., D.K.), Emergency Medicine (O.A.), and Neurosurgery (M.Z.), University of Cincinnati College of Medicine, OH; Department of Neurology (F.D.L.R.L.R.), University of New Mexico Health Sciences Center, Albuquerque; and Department of Neurology (S.M.), Baylor College of Medicine, Houston, TX.
authors: Pooja
authors: P
authors: Khatri
authors: From the Department of Neurology (J.M.), Indiana University School of Medicine, Indianapolis; Division of Biostatistics and Epidemiology (J.C.K.), Cincinnati Children's Hospital; Departments of Neurology (K.A., C.J.M., B.M.K., M.L.F., D.W., S.F., F.D.L.R.L.R., P.K., J.P.B., D.K.), Emergency Medicine (O.A.), and Neurosurgery (M.Z.), University of Cincinnati College of Medicine, OH; Department of Neurology (F.D.L.R.L.R.), University of New Mexico Health Sciences Center, Albuquerque; and Department of Neurology (S.M.), Baylor College of Medicine, Houston, TX.
authors: Joseph P
authors: JP
authors: Broderick
authors: From the Department of Neurology (J.M.), Indiana University School of Medicine, Indianapolis; Division of Biostatistics and Epidemiology (J.C.K.), Cincinnati Children's Hospital; Departments of Neurology (K.A., C.J.M., B.M.K., M.L.F., D.W., S.F., F.D.L.R.L.R., P.K., J.P.B., D.K.), Emergency Medicine (O.A.), and Neurosurgery (M.Z.), University of Cincinnati College of Medicine, OH; Department of Neurology (F.D.L.R.L.R.), University of New Mexico Health Sciences Center, Albuquerque; and Department of Neurology (S.M.), Baylor College of Medicine, Houston, TX.
authors: Mario
authors: M
authors: Zuccarello
authors: From the Department of Neurology (J.M.), Indiana University School of Medicine, Indianapolis; Division of Biostatistics and Epidemiology (J.C.K.), Cincinnati Children's Hospital; Departments of Neurology (K.A., C.J.M., B.M.K., M.L.F., D.W., S.F., F.D.L.R.L.R., P.K., J.P.B., D.K.), Emergency Medicine (O.A.), and Neurosurgery (M.Z.), University of Cincinnati College of Medicine, OH; Department of Neurology (F.D.L.R.L.R.), University of New Mexico Health Sciences Center, Albuquerque; and Department of Neurology (S.M.), Baylor College of Medicine, Houston, TX.
authors: Dawn
authors: D
authors: Kleindorfer
mesh_terms: D000328:Adult; D000368:Aged; D005260:Female; D006801:Humans; D015994:Incidence; D007629:Kentucky / Q000453:epidemiology; D008297:Male; D008875:Middle Aged; D009820:Ohio / Q000453:epidemiology; D012189:Retrospective Studies; D020521:Stroke / Q000401:mortality; D013345:Subarachnoid Hemorrhage / Q000000981:diagnostic imaging / Q000401:mortality* / Q000628:therapy; D013997:Time Factors