Association between time-to-presentation and clinical outcome in patients with subarachnoid hemorrhage: an observational study.

BACKGROUND: Headache is the most common presenting symptom of subarachnoid hemorrhage (SAH), ranging from mild headache to the "worst headache of my life". As headache is often non-specific, patients may not seek immediate medical attention, though prompt medical and surgical management is expected to improve clinical outcomes. In this study, we explore the independent association between duration from onset of symptoms to presentation at an emergency department (ED) and clinical outcomes after SAH. METHODS: Participants with a primary diagnosis of nontraumatic SAH were identified from consecutive patients at 11 regional stroke centres participating in the Registry of the Canadian Stroke Network (RCSN, 2003-2005). Hunt and Hess score (H+H), and modified Rankin Scale (mRS) at discharge were collected on SAH cases by trained nurse-abstractors. For analysis, patients were categorized into patients with mild-moderate dependency (mRS 0-3) and those with severe dependence or death (mRS 4-6) at hospital discharge. Multivariable regression analyses were used to determine the association between 'time to presentation' and clinical outcomes, independent of comorbidities. RESULTS: Of 721 SAH patients included in the RCSN, 642 (89.0%) had the interval between 'time last seen normal' and time of ED presentation recorded. Mean duration from symptom onset to ED arrival was 27.04 hours (+/- 2.02). One hundred and sixty-six patients (25.9%) presented to the ED more than 24 hours after onset of symptoms. On multivariable analysis, there was no association between time to presentation and severe disability or death at hospital discharge (OR 1.0 [95% CI 0.95-1.01]); 30-day mortality (OR 1.0 [95% CI 0.91-1.02]; or six-month mortality (OR 1.0 [95% CI 1.0-1.02]). Increasing H+H score and age were significantly associated with increased odds of death and severe dependence at hospital discharge. CONCLUSIONS: In this observational study, duration from symptom onset to hospital presentation was not independently associated with death or severe disability at hospital discharge following SAH. Age and H+H score were independent predictors of clinical outcome after non-traumatic SAH.