Predictors of cognitive dysfunction after subarachnoid hemorrhage

Evaluating the Recovery of Cognitive Impairment in Subarachnoid Hemorrhage Taking Into Consideration the Practice Effects

BACKGROUND:

It is not completely clear whether there are differences in the evolution of the neuropsychological outcomes between the 2 intervention procedures (surgery and endovascular coiling) used in subarachnoid aneurysmatic hemorrhage. Some studies have investigated this topic but without completely controlling the effect of learning the tests.

OBJECTIVE:

To analyze our data using 2 different statistical procedures that attempt to solve this problem.

METHODS:

The sample consists of 70 patients who have suffered a subarachnoid hemorrhage: 40 treated by means of surgery and 30 by means of endovascular coiling. Two cognitive evaluations were performed at 4 and 12 months after the invention. Twenty-seven healthy subjects were also evaluated twice with a delay of 8 months. The data were analyzed using 2 different statistical procedures: one by Samra et al (2007) using z scores and the other by Crawford and Garthwaite (2007) using the regbuild.exe program.

RESULTS:

The results indicate there are no important differences between the 2 treatment groups in the evolution of the cognitive alterations. Despite an improvement in cognitive scores on repeat testing at 12 months, neither of the 2 treatment groups showed the same level of test-retest learning as healthy control subjects.

CONCLUSION:

The recovery of neuropsychological functions after a subarachnoid hemorrhage is similar with the 2 interventions. It is important to control the learning effect produced by the repeated administration of tests.

Early global brain oedema in relation to clinical admission parameters and outcome in patients with aneurysmal subarachnoid haemorrhage

BACKGROUND

Previous studies on spontaneous aneurysmal subarachnoid haemorrhage (SAH) treatment have found the presence of global cerebral oedema on the first CT scan to be a predictor of poor outcome. We have reviewed our own experience with SAH in order to evaluate the relation of global cerebral oedema to clinical parameters at admission and to functional outcome.

METHODS

One hundred ninety patients with spontaneous aneurysmal SAH were included in the study. The first CT scan for each patient was evaluated for signs of global cerebral oedema. Clinical status on admission was assessed according to the Hunt & Hess score and the World Federation of Neurosurgical Societies (WFNS) grade and functional outcome using the Glasgow Outcome Scale (GOS). Clinical condition at admission was dichotomised as 'better' (Hunt & Hess 1-2, WFNS 1-2) or 'worse' (Hunt & Hess 3-5, WFNS 3-5) and outcome as 'favourable' (GOS 4-5) or 'poor' (GOS 1-3). The amount of blood on the CT scan was assessed using the Fisher scale. Comparisons were made between patients with and without global cerebral oedema on the first CT regarding clinical condition, age, gender, mode of aneurysm treatment, outcome, 6-month mortality, amount of blood on the CT scan and time lag to the first CT scan.

RESULTS

Global cerebral oedema was observed in 57% of patients admitted with aneurysmal SAH, which is a much higher frequency than has been reported previously. Patients with oedema were admitted in a worse clinical status, but there was no difference between patients with and without oedema regarding other clinical parameters or outcome. The median time between the haemorrhage and the first CT scan was short compared to earlier studies, 2.5 h for those with oedema and 3.4 for those without. This difference was significant, suggesting that global cerebral oedema can be a very early phenomenon after SAH, and may be missed in later CT scans.

SUMMARY

Early global brain oedema, occurring within a few hours of bleeding, may be more common than previously thought. In aneurysmal SAH patients, the presence of global cerebral oedema was associated with a worse clinical condition at admission which in turn could indicate a more severe initial injury. The clinical significance of early oedema may differ from that of late oedema, which may explain the lack of an association between global oedema and poor outcome in this study. However, the nature of the oedema as well as its relation to the clinical course has to be further studied in separate studies.

Surgical management of aneurysmal subarachnoid hemorrhage

Aneurysmal subarachnoid hemorrhage (aSAH) is a common and often devastating condition that requires prompt neurosurgical evaluation and intervention. Modern management of aSAH involves a multidisciplinary team of subspecialists, including vascular neurosurgeons, neurocritical care specialists and, frequently, neurointerventional radiologists. This team is responsible for stabilizing the patient on presentation, diagnosing the offending ruptured aneurysm, securing the aneurysm, and managing the patient through a typically prolonged and complicated hospital course. Surgical intervention has remained a definitive treatment for ruptured cerebral aneurysms since the early 1900s. Over the subsequent decades, many innovations in microsurgical technique, adjuvant maneuvers, and intraoperative and perioperative medical therapies have advanced the care of patients with aSAH. This report focuses on the modern surgical management of patients with aSAH. Following a brief historical perspective on the origin of aneurysm surgery, the topics discussed include the timing of surgical intervention after aSAH, commonly used surgical approaches and craniotomies, fenestration of the lamina terminalis, intraoperative neurophysiological monitoring, intraoperative digital subtraction and fluorescent angiography, temporary clipping, deep hypothermic cardiopulmonary bypass, management of acute hydrocephalus, cerebral revascularization, and novel clip configurations and microsurgical techniques. Many of the topics highlighted in this report represent some of the more debated techniques in vascular neurosurgery. The popularity of such techniques is constantly evolving as new studies are performed and data about their utility become available.

Comparison of postoperative cognitive function in patients undergoing surgery for ruptured and unruptured intracranial aneurysm

BACKGROUND

Patients with SAH often experience cognitive decline. Previous studies used normal volunteers, published normal test values, and orthopedic patients as controls to identify factors for postoperative cognitive decline. The present study excluded the effects of surgery by comparing cognitive function after surgical repair in patients with aneurysmal SAH and patients with unruptured intracranial aneurysm.

METHODS

This study recruited 117 patients with SAH due to ruptured aneurysm and 39 patients with incidentally found unruptured intracranial aneurysms. The cognitive test battery consisted of the Japanese translation of the WAIS-R, the Japanese translation of the WMS, and the recall trial of the ROCF. Postoperative neuropsychological test scores for the patients with SAH and control subjects were compared using group-rate and event-rate analysis. The relationship between clinical variable and postoperative cognitive decline in the patients with SAH was evaluated by univariate analysis using the Mann-Whitney U test or chi(2) test.

RESULTS

Group-rate analysis showed that the WAIS-R and ROCF scores were significantly lower in the SAH group than in the control group. Event-rate analysis demonstrated that the incidence of cognitive decline in the patients with SAH (73 [62.4%] of the 117 patients) was significantly higher than that in the control subjects (12 [30.8%] of 39 patients). The Hunt and Hess grade was significantly higher in patients with postoperative cognitive decline.

CONCLUSION

The cognitive function after SAH was significantly correlated with Hunt and Hess grade on admission when using patients with postoperative unruptured intracranial aneurysm as the control group.

Theoretical model for quantifying the operative benefit of unruptured cerebral aneurysms by location, age and size

Aim: The indications for surgery on unruptured asymptomatic cerebral aneurysms are still unclear. Previous mathematical models that have addressed this issue group all aneurysm sizes and locations into one category and report one average rupture and surgical complication rate. In this report the authors used a comprehensive review of the literature and mathematical models to create an online open-access program to quantify the benefit of surgery on unruptured aneurysms according to age, size and location. Materials and methods: Using 5-year prospective International Study of Unruptured Intracranial Aneurysms data and a literature search of 30 additional studies (10,545 patients), we calculated annual rupture rates and operative complication rates for aneurysms by size (5–25 mm), patient age (40–70 years) and 14 common locations. Using this location-, size- and age-specific data, a mathematical model was created by solving differential equations measuring the survival rate of a patient with and without an unruptured aneurysm. Operative benefit was calculated by comparing the quality-adjusted life year outcomes of surgical versus conservative management. Results: We focused on three controversial, high prevalence aneurysm locations (supraclinoid, cavernous and basilar bifurcation). Despite vastly different operative mortality rates and annual rupture rates, 5 mm supraclinoid internal carotid artery aneurysms and basilar bifurcation aneurysms revealed similar operative indications. Small basilar and supraclinoid aneurysms (∼5 mm) only yielded operative benefits in young patients (∼40 years of age). By contrast, larger aneurysms (10 and 15 mm) yielded an operative benefit for a wider range of ages. There was no age and size combination that yielded an operative benefit for cavernous aneurysms. Conclusion: In any mathematical model, some simplifications are inevitable. However, we believe this model is successful in providing helpful estimates and guidelines when delegating patients to surgical or medical management.

Cerebral inflammatory response and predictors of admission clinical grade after aneurysmal subarachnoid hemorrhage

Poor admission clinical grade is the most important determinant of outcome after aneurysmal subarachnoid hemorrhage (aSAH); however, little attention has been focused on independent predictors of poor admission clinical grade. We hypothesized that the cerebral inflammatory response initiated at the time of aneurysm rupture contributes to ultra-early brain injury and poor admission clinical grade. We sought to identify factors known to contribute to cerebral inflammation as well as markers of cerebral dysfunction that were associated with poor admission clinical grade. Between 1997 and 2008, 850 consecutive SAH patients were enrolled in our prospective database. Demographic data, physiological parameters, and location and volume of blood were recorded. After univariate analysis, significant variables were entered into a logistic regression model to identify significant associations with poor admission clinical grade (Hunt-Hess grade 4-5). Independent predictors of poor admission grade included a SAH sum score >15/30 (odds ratio [OR] 2.3, 95% confidence interval [CI] 1.5-3.6), an intraventricular hemorrhage sum score >1/12 (OR 3.1, 95% CI 2.1-4.8), aneurysm size >10mm (OR 1.7, 95% CI 1.1-2.6), body temperature 38.3 degrees C (OR 2.5, 95% CI 1.1-5.4), and hyperglycemia >200mg/dL (OR 2.7, 95% CI 1.6-4.5). In a large, consecutive series of prospectively enrolled patients with SAH, the inflammatory response at the time of aneurysm rupture, as reflected by the volume and location of the hemoglobin burden, hyperthermia, and perturbed glucose metabolism, independently predicts poor admission Hunt-Hess grade. Strategies for mitigating the inflammatory response to aneurysmal rupture in the hyper-acute setting may improve the admission clinical grade, which may in turn improve outcomes.

PREDICTORS OF GLOBAL COGNITIVE IMPAIRMENT 1 YEAR AFTER SUBARACHNOID HEMORRHAGE

OBJECTIVE

We sought to determine the frequency, risk factors, and impact on functional outcome and quality of life (QOL) of global cognitive impairment 1 year after subarachnoid hemorrhage.

METHODS

We prospectively evaluated global cognitive status 3 and 12 months after hospitalization with the Telephone Interview for Cognitive Status in 232 subarachnoid hemorrhage survivors. Cognitive impairment was defined as a score of 30 or less (scaled 0 = worst, 51 = best). Logistic regression was performed to calculate adjusted odds ratios (AORs) for impairment at 1 year. Basic activities of daily living were evaluated with the Barthel Index, instrumental activities of daily living were assessed with the Lawton scale, and QOL was evaluated with the Sickness Impact Profile.

RESULTS

The frequency of cognitive impairment was 27% at 3 months and 21% at 12 months. After the effects of age, education, and race/ethnicity were controlled for, risk factors for cognitive impairment at 12 months included anemia treated with transfusion (AOR, 3.4; P = 0.006), any temperature level higher than 38.6°C (AOR, 2.7; P = 0.016), and delayed cerebral ischemia (AOR, 3.6; P = 0.01). Among cognitively impaired patients at 3 months, improvement at 1 year occurred in 34% and was associated with more than 12 years of education and the absence of fever higher than 38.6°C during hospitalization (P = 0.015). Patients with cognitive impairment at 1 year had worse concurrent QOL and less ability to perform instrumental and basic activities of daily living (all P < 0.001).

CONCLUSION

Global cognitive impairment affects more than 20% of subarachnoid hemorrhage survivors at 1 year, is predicted by fever, anemia treated with transfusion, and delayed cerebral ischemia, and adversely affects functional recovery and QOL.

Atrophic enlargement of CSF volume after subarachnoid hemorrhage: correlation with neuropsychological outcome

BACKGROUND AND PURPOSE

Ventricular dilation and sulcal enlargement are common sequelae after aSAH. Our aim was to quantify the late ventricular dilation and volumes of the CSF spaces after aSAH and to determine if they correlate with neurologic and cognitive impairments frequently detected in these patients.

MATERIALS AND METHODS

3D T1-weighted images needed for volumetry were available in 76 patients 1 year after aSAH, along with 75 neuropsychological assessments. Volumes of CSF segments and ICV were quantified by SPM in 76 patients and 30 control subjects to determine CSF/ICV ratios. The mCMI was calculated to roughly evaluate the ventricular dilation. The contributing factors for enlarged ventricles and CSF volumes were reviewed from radiologic, clinical, and neuropsychological perspectives.

RESULTS

The mCMI was higher in patients with aSAH (0.23 +/- 0.06) compared with control subjects (0.20 +/- 0.04; P = .020). In line with these planimetric measurements, the SPM-based CSF/ICV ratios were higher in patients with aSAH (35.58 +/- 7.0) than in control subjects (30.36 +/- 6.25; P = .001). Preoperative hydrocephalus, higher HH and Fisher grades, and focal parenchymal lesions on brain MR imaging, but not the treatment technique, were associated with ventricular enlargement. The clinical outcome and presence of neuropsychological deficits correlated significantly with CSF enlargement.

CONCLUSIONS

Ventricular and sulcal enlargement, together with reduced GM volumes, after aSAH may indicate general atrophy rather than hydrocephalus. Enlarged CSF spaces correlate with cognitive deficits after aSAH. A simple measure, mCMI proved to be a feasible tool to assess the diffuse atrophic brain damage after aSAH.

Neurological and neurobehavioral assessment of experimental subarachnoid hemorrhage

About 50% of humans with aneurysmal subarachnoid hemorrhage (SAH) die and many survivors have neurological and neurobehavioral dysfunction. Animal studies usually focused on cerebral vasospasm and sometimes neuronal injury. The difference in endpoints may contribute to lack of translation of treatments effective in animals to humans. We reviewed prior animal studies of SAH to determine what neurological and neurobehavioral endpoints had been used, whether they differentiated between appropriate controls and animals with SAH, whether treatment effects were reported and whether they correlated with vasospasm. Only a few studies in rats examined learning and memory. It is concluded that more studies are needed to fully characterize neurobehavioral performance in animals with SAH and assess effects of treatment.

Simvastatin for the prevention of symptomatic cerebral vasospasm following aneurysmal subarachnoid hemorrhage: a single-institution prospective cohort study

OBJECT

Vasospasm is the major cause of disability and death after aneurysmal subarachnoid hemorrhage (aSAH). Although the results of 2 randomized clinical trials demonstrated that statin decreases the incidence of symptomatic cerebral vasospasm after aSAH, retrospective studies have failed to confirm this. The authors conducted a prospective observational study to determine whether a standardized regimen of simvastatin would reduce the incidence of cerebral vasospasm and improve neurological outcomes in patients with aSAH.

METHODS

Since 1991, all patients with aSAH admitted to the authors' institution have been prospectively followed up with standardized outcomes recording. Starting in September 2005, all patients admitted with aSAH were given enteral simvastatin (80 mg/day for 14 days) in addition to the standard care. The incidence of symptomatic cerebral vasospasm, length of hospitalization, in-hospital mortality rate, and discharge Glasgow Outcome Scale scores in these 170 patients were compared to data obtained in 170 consecutive patients who underwent treatment in our unit prior to the introduction of statin therapy.

RESULTS

The 5-year study period included 340 consecutively treated patients (170 who received statins and 170 who did not). Patients who received simvastatin therapy were more frequently male (29 vs 20%) and had a smaller median aneurysm diameter (6 vs 7 mm). Baseline characteristics were otherwise similar between the cohorts. There were no differences in the incidence of symptomatic vasospasm (25.3 vs 30.5%; p = 0.277), in-hospital mortality rate (18 vs 15%; p = 0.468), length of hospitalization (21 +/- 15 vs 19 +/- 12 days; p = 0.281), or poor outcome at discharge (Glasgow Outcome Scale Scores 1-2: 21.7 vs 18.2%; p = 0.416) between the simvastatin and nonstatin cohorts. There were no statin-related complications.

CONCLUSIONS

The uniform introduction of simvastatin did not reduce the incidence of symptomatic cerebral vasospasm, death, or poor outcome in patients with aSAH. Simvastatin was well tolerated, but its benefit may be less than has been previously reported.

RESUSCITATION AND CRITICAL CARE OF POOR-GRADE SUBARACHNOID HEMORRHAGE

AS OUTCOMES HAVE improved for patients with aneurysmal subarachnoid hemorrhage, most mortality and morbidity that occur today are the result of severe diffuse brain injury in poor-grade patients. The premise of this review is that aggressive emergency cardiopulmonary and neurological resuscitation, coupled with early aneurysm repair and advanced multimodality monitoring in a specialized neurocritical care unit, offers the best approach for achieving further improvements in subarachnoid hemorrhage outcomes. Emergency care should focus on control of elevated intracranial pressure, optimization of cerebral perfusion and oxygenation, and medical and surgical therapy to prevent rebleeding. In the postoperative period, advanced monitoring techniques such as continuous electroencephalography, brain tissue oxygen monitoring, and microdialysis can detect harmful secondary insults, and may eventually be used as end points for goal-directed therapy, with the aim of creating an optimal physiological environment for the comatose injured brain. As part of this paradigm shift, it is essential that aggressive surgical and medical support be linked to compassionate end-of-life care. As neurosurgeons become confident that comfort care can be implemented in a straightforward fashion after a failed trial of early maximal intervention, the usual justification for withholding treatment (survival with neurological devastation) becomes less relevant, and lives may be saved as more patients recover beyond expectations.

Cognitive impairment and preferences for current health

BACKGROUND

We assessed preferences for current health using the visual analogue scale (VAS), standard gamble (SG), time trade-off (TTO), and willingness to pay (WTP) in patients with cerebral aneurysms, a population vulnerable to cognitive deficits related to aneurysm bleeding or treatment.

METHODS

We measured VAS, SG, TTO, and WTP values for current health in 165 outpatients with cerebral aneurysms. We assessed cognitive impairment with the Mini Mental State Examination (MMSE; scores < 24 = cognitive impairment). We examined the distributions of preference responses stratified by cognitive status, and the relationship between preferences and cognitive impairment, patient characteristics, and aneurysm history.

RESULTS

Eleven patients (7%) had MMSE scores < 24. The distribution of preferences responses from patients with cognitive impairment had greater variance (SG, 0.39 vs. 0.21, P = 0.001; TTO, 0.36 vs. 0.24, P = 0.017) and altered morphology (VAS, P = 0.012; SG, P = 0.023) compared to the responses of unimpaired patients. There was good correlation between most preference measures for unimpaired patients (VAS:TTO, rho = 0.19, P = 0.018; SG:TTO, rho = 0.36, P < 0.001; SG:WTP, rho = -0.33, P < 0.001) and a trend towards significance with another pairing (VAS:WTP, rho = 0.16, P = 0.054). In subjects with cognitive impairment, there was a significant correlation only between VAS and TTO scores (rho = 0.76, P = 0.023). Separate regression models showed that cognitive impairment was associated with lower preferences on the VAS (beta = -0.12, P = 0.048), SG (beta = -0.23, P = 0.002), and TTO (beta = -0.17, P = 0.035).

CONCLUSION

Cognitive impairment is associated with lower preferences for current health in patients with cerebral aneurysms. Cognitively impaired patients have poor inter-preference test correlations and different response distributions compared to unimpaired patients.

Quality of life and brain damage after microsurgical clip occlusion or endovascular coil embolization for ruptured anterior communicating artery aneurysms: neuropsychological assessment

Object

For anterior communicating artery (ACoA) aneurysms, endovascular coil embolization constitutes a safe alternative therapeutic procedure to microsurgical clip occlusion. The authors' aim in this study was to evaluate the quality of life (QOL), cognitive function, and brain structure damage after the treatment of ruptured ACoA aneurysms in a group of patients who underwent microsurgical clipping (36 patients) compared with a reference group who underwent endovascular coiling (14 patients).

Methods

At 14 months posttreatment all patients underwent evaluations by independent observers. These observers evaluated global efficacy, executive functions using a frontal assessment battery of tests (Trail making test, Stroop tasks, dual task of Baddeley, verbal fluency, and Wisconsin Card Sorting test), behavior dysexecutive syndrome (the Inventaire du Syndrome Dysexécutif Comportemental questionnaire [ISDC]), and QOL by using the Reintegration To Normal Living Index. Brain damage was analyzed using MR imaging.

Results

In the microsurgical clipping and endovascular coiling groups, the distribution on the modified Rankin Scale (p = 0.19) and mean QOL score (85.4 vs 83.4, respectively) were similar. Moreover, the proportion of executive dysfunctions (19.4 vs 28.6%, respectively) and the mean score on the ISDC questionnaire (8.9 vs 8.5, respectively) were not significant, but verbal memory was more altered in the microsurgical clipping group (p = 0.055). Magnetic resonance imaging revealed that the incidence of local encephalomalacia and the median number of lesions per patient increased significantly in the microsurgical clipping group (p = 0.003).

Conclusions

In the 2 groups, no significant difference was observed regarding QOL, executive functions, and behavior. Despite the significant decrease in verbal memory after microsurgical clipping, the interdisciplinary approach remains a safe and useful strategy.

Screening for familial intracranial aneurysms: decision and cost-effectiveness analysis

RATIONALE AND OBJECTIVES

To evaluate the potential benefits, harms, and cost-effectiveness of screening for asymptomatic, unruptured intracranial aneurysms in family members of patients with aneurysmal subarachnoid hemorrhage (SAH).

MATERIALS AND METHODS

Using a Markov model, we performed a decision and cost-effectiveness analysis comparing magnetic resonance (MR) angiography screening for asymptomatic, unruptured intracranial aneurysms to no screening in family members of patients with aneurysmal SAH. Treatment of unruptured intracranial aneurysms was determined according to patient age and aneurysm size and location. Cohort age was taken as 40 years.

RESULTS

In family members with two or more affected first-degree relatives, screening compared with no screening had an incremental cost-effectiveness ratio (ICER) of $37,400 per quality-adjusted life-year (QALY). With screening, life expectancy increased from 39.44 years to 39.55 years. The ICER of screening was >$50,000 per QALY if age at screening was > or =50 years. In family members with one affected first-degree relative, screening compared with no screening had an ICER of $56,500 per QALY.

CONCLUSIONS

The results suggest that MR angiography screening for asymptomatic, unruptured intracranial aneurysms in family members with two or more affected first-degree relatives is cost-effective. The benefit and cost-effectiveness are dependent on age at screening.

Small-volume resuscitation with hyperoncotic albumin: a systematic review of randomized clinical trials

Background

Small-volume resuscitation can rapidly correct hypovolemia. Hyperoncotic albumin solutions, long in clinical use, are suitable for small-volume resuscitation; however, their clinical benefits remain uncertain.

Methods

Randomized clinical trials comparing hyperoncotic albumin with a control regimen for volume expansion were sought by multiple methods, including computer searches of bibliographic databases, perusal of reference lists, and manual searching. Major findings were qualitatively summarized. In addition, a quantitative meta-analysis was performed on available survival data.

Results

In all, 25 randomized clinical trials with a total of 1,485 patients were included. In surgery, hyperoncotic albumin preserved renal function and reduced intestinal edema compared with control fluids. In trauma and sepsis, cardiac index and oxygenation were higher after administration of hydroxyethyl starch than hyperoncotic albumin. Improved treatment response and renal function, shorter hospital stay and lower costs of care were reported in patients with liver disease receiving hyperoncotic albumin. Edema and morbidity were decreased in high-risk neonates after hyperoncotic albumin administration. Disability was reduced by therapy with hyperoncotic albumin in brain injury. There was no evidence of deleterious effects attributable to hyperoncotic albumin. Survival was unaffected by hyperoncotic albumin (pooled relative risk, 0.95; 95% confidence interval 0.78 to 1.17).

Conclusion

In some clinical indications, randomized trial evidence has suggested certain benefits of hyperoncotic albumin such as reductions in morbidity, renal impairment and edema. However, further clinical trials are needed, particularly in surgery, trauma and sepsis.

The clinical significance of acute brain injury in subarachnoid hemorrhage and opportunity for intervention

Aneurysmal subarachnoid hemorrhage (SAH) is a devastating neurological event that accounts for 3-7% of all strokes and carries a mortality rate as high as 40%. Delayed cerebral vasospasm has traditionally been recognized as the most treatable cause of morbidity and mortality from SAH. However, evidence is mounting that the physiological and cellular events of acute brain injury, which occur during the 24-72 h following aneurysm rupture, make significant contributions to patient outcomes, and may even be a more significant factor than delayed cerebral vasospasm. Acute brain injury in aneurysmal SAH is the result of physiological derangements such as increased intracranial pressure and decreased cerebral blood flow that result in global cerebral ischemia, and lead to the acute development of edema, oxidative stress, inflammation, apoptosis, and infarction. The consequence of these events is often death or significant neurological disability. In this study of acute brain injury, we elucidate some of the complex molecular signaling pathways responsible for these poor outcomes. Continued research in this area and the development of therapies to interrupt these cascades should be a major focus in the future as we continue to seek effective therapies for aneurysmal SAH.

Higher hemoglobin is associated with improved outcome after subarachnoid hemorrhage

OBJECTIVE

There are few data regarding anemia and transfusion after subarachnoid hemorrhage (SAH). We addressed the hypothesis that higher hemoglobin (HGB) levels are associated with less death and disability after SAH.

DESIGN

Prospective registry with automated data retrieval.

PATIENTS

Six hundred eleven patients enrolled in the Columbia University SAH Outcomes Project between August 1996 and June 2002.

SETTING

Neurologic intensive care unit.

INTERVENTIONS

Patients were treated according to standard management protocols.

MEASUREMENTS AND MAIN RESULTS

We electronically retrieved all HGB readings during the acute hospital stay for 611 consecutively admitted SAH patients. Outcomes were measured with the modified Rankin Scale at 14 days or discharge, and at 3 months. Patients who were independent (modified Rankin Scale, 0-3) at discharge or 14 days had higher mean (11.7 +/- 1.5 vs. 10.9 +/- 1.2, p < .001) and nadir (9.9 +/- 2.1 vs. 8.6 +/- 1.8, p < .001) HGB, and had higher HGB values every day in the hospital. There were similar results when patients were stratified by mortality. Higher HGB was associated with reduced risk of poor outcome (modified Rankin Scale, 4-6) at 14 days/discharge and 3 months after correcting for Hunt and Hess grade, age, history of diabetes, and cerebral infarction. Length of stay and HGB interacted such that lower HGB has a more pronounced effect with length of stay > 14 days.

CONCLUSIONS

Higher HGB values are associated with improved outcomes after SAH at 14 days/discharge and 3 months. In contrast to general critical care patients, SAH patients may benefit from higher HGB. Determination of the optimal goal HGB after SAH will require separate prospective research.

The systemic implications of aneurysmal subarachnoid hemorrhage

Aneurysmal subarachnoid hemorrhage (SAH) is analogous to a pathophysiological watershed, disrupting brain integrity and function and precipitating an array of systemic derangements including cardiovascular, respiratory, endocrine, hematological, and immune dysfunction. Extracerebral organ dysfunction is closely linked to the magnitude of the primary neurological insult, suggesting neurogenic, neuroendocrine and neuroimmunomodulatory mechanisms. Systemic organ involvement is associated with increased mortality and neurological impairment, even after adjustment for other outcome predictors such as the severity of the initial neurological injury. This may be a reflection of secondary brain injury precipitated by hypoxemia, circulatory failure, fever, or hyperglycemia, all of which have been linked to adverse clinical outcomes. Interventions to avert or reverse these and other perturbations need to be tested in clinical trials as they represent opportunities to improve survival and neurological recovery in patients with SAH.

Conceptualizing Functional Cognition in Stroke

Background. Up to 65% of individuals demonstrate poststroke cognitive impairments, which may increase hospital stay and caregiver burden. Randomized stroke clinical trials have emphasized physical recovery over cognition. Neuropsychological assessments have had limited utility in randomized clinical trials. These issues accentuate the need for a measure of functional cognition (the ability to accomplish everyday activities that rely on cognitive abilities, such as locating keys, conveying information, or planning activities). Objective. The aim of the study was to present the process used to establish domains of functional cognition for development of computer adaptive measure of functional cognition for stroke. Methods. Functional cognitive domains involved in identifying relevant neuropsychological constructs from the literature were conceptualized and finalized after advisory panel feedback from experts in neurology, neuropsychology, aphasiology, clinical trials, and epidemiology. Results. The following 17 domains were proposed: receptive aphasia, expressive aphasia, agraphia, alexia, calculation, visuospatial, visuoperceptual, visuoconstruction, attention, language usage, executive functions, orientation, processing speed, memory, working memory, mood, awareness and abstract reasoning. The advisory panel recommended retaining the first 12 domains. Recommended changes included: to address only encoding and retrieval of recent information in the memory domain; to add domains for limb apraxia and poststroke depression; and to keep orientation as a separate domain or reclassify it under memory or attention. The final 10 domains included: language, reading and writing, numeric/calculation, limb praxis, visuospatial function, social use of language, emotional function, attention, executive function, and memory. Conclusion. Conceptualizing domains of functional cognition is the first step in developing a computer adaptive measure of functional cognition for stroke. Additional steps include developing, refining, and field-testing items, psychometric analysis, and computer adaptive test programming.

Neuropsychological evaluation of the treatments applied to intracranial aneurysms in a Spanish sample

Very few studies have examined the neuropsychological differences between the two types of aneurysm treatment, and these studies come from different countries. The purpose of this study is to compare the neuropsychological differences between surgical treatment and endovascular treatment in a Spanish sample of patients who have experienced an aneurysmal subarachnoid hemorrhage. The sample is composed of three groups: 40 patients who underwent surgical intervention, 24 who were treated by means of coiling, and a group of 29 healthy participants. An extensive neuropsychological evaluation was performed. The results presented show that no neuropsychological differences were found between the two types of treatment for aneurysms and that the most affected function was memory. This result coincides with findings from other studies.

Treatment of unruptured intracranial aneurysms: decision and cost-effectiveness analysis

PURPOSE

To prospectively perform a decision and cost-effectiveness analysis of surgical and endovascular treatments of unruptured intracranial aneurysms, with incorporation of the results of the prospective International Study of Unruptured Intracranial Aneurysms.

MATERIALS AND METHODS

With use of a Markov model, a decision and cost-effectiveness analysis was performed for comparison of surgical or endovascular treatment with no treatment. Twelve clinical scenarios were defined on the basis of aneurysm size and location. Probabilistic sensitivity analyses were performed for 50- and 40-year-old patient cohorts. Treatment was considered to be cost-effective at an incremental cost-effectiveness ratio less than $100,000 per quality-adjusted life-year.

RESULTS

In 50-year-old patients, no treatment was the most cost-effective strategy for aneurysms located in the cavernous carotid artery. For aneurysms smaller than 7 mm located in the anterior circulation, no treatment was the most cost-effective strategy. Endovascular treatment was the most cost-effective option for 7-24-mm aneurysms, whereas surgical treatment was the most cost-effective option for aneurysms 25 mm or larger. For aneurysms smaller than 7 mm or 25 mm or larger located in the posterior circulation, no treatment was the most cost-effective strategy. Surgical treatment was the most cost-effective option for 7-12-mm aneurysms, whereas endovascular treatment was the most cost-effective option for 13-24-mm aneurysms.

CONCLUSION

For 50-year-old patients, treatment of aneurysms that are small (<7 mm), that are located in the cavernous carotid artery, or that are large (>or=25 mm) and located in the posterior circulation is ineffective or not cost-effective.

Cognitive outcome after aneurysmal subarachnoid hemorrhage: time course of recovery and relationship to clinical, radiological, and management parameters

OBJECTIVE

Although many patients show a satisfactory physical outcome after aneurysmal subarachnoid hemorrhage (SAH), disabling cognitive dysfunction may still be present. This study focuses on the time course of cognitive recovery during the first year after aneurysmal SAH, and relates the neuropsychological test results to clinical, radiological, and management parameters.

METHODS

Thirty-two patients were followed prospectively with neuropsychological examinations at 3, 6, and 12 months after SAH. Test results were compared with clinical entry variables, management variables, and pre- and postoperative radiological findings.

RESULTS

The time course of cognitive recovery after aneurysmal SAH is heterogeneous, with motor and psychomotor functions recovering within the first 6 months, whereas verbal memory did not improve significantly until at least 6 months after the ictus. Clinical and radiological parameters reflecting the impact of the bleed were related to memory function, intelligence, and aphasia. The site of aneurysm and mode of treatment could not be linked to neuropsychological outcome. The time length of volume-controlled mechanical ventilation as a reflector of the aggregated consequences of being subjected to an aneurysm rupture correlated with both motor and psychomotor functioning and memory performance, predominantly 6 to 12 months after SAH, but was not linked to intelligence or aphasia.

CONCLUSION

The various cognitive functions have different time courses of recovery, with verbal memory requiring the longest time. Parameters reflecting the impact of the bleed and patient management can be linked to neuropsychological outcome.

Fever after subarachnoid hemorrhage: risk factors and impact on outcome

OBJECTIVE

To identify risk factors for refractory fever after subarachnoid hemorrhage (SAH), and to determine the impact of temperature elevation on outcome.

METHODS

We studied a consecutive cohort of 353 patients with SAH with a maximum daily temperature (T(max)) recorded on at least 7 days between SAH days 0 and 10. Fever (>38.3 degrees C) was routinely treated with acetaminophen and conventional water-circulating cooling blankets. We calculated daily T(max) above 37.0 degrees C, and defined extreme T(max) as daily excess above 38.3 degrees C. Global outcome at 90 days was evaluated with the modified Rankin Scale (mRS), instrumental activities of daily living (IADLs) with the Lawton scale, and cognitive functioning with the Telephone Interview of Cognitive Status. Mixed-effects models were used to identify predictors of T(max), and logistic regression models to evaluate the impact of T(max) on outcome.

RESULTS

Average daily T(max) was 1.15 degrees C (range 0.04 to 2.74 degrees C). The strongest predictors of fever were poor Hunt-Hess grade and intraventricular hemorrhage (IVH) (both p < 0.001). After controlling for baseline outcome predictors, daily T(max) was associated with an increased risk of death or severe disability (mRS > or = 4, adjusted OR 3.0 per degrees C, 95% CI 1.6 to 5.8), loss of independence in IADLs (OR 2.6, 95% CI 1.2 to 5.6), and cognitive impairment (OR 2.5, 95% CI 1.2 to 5.1, all p < or = 0.02). These associations were even stronger when extreme T(max) was analyzed.

CONCLUSION

Treatment-refractory fever during the first 10 days after subarachnoid hemorrhage (SAH) is predicted by poor clinical grade and intraventricular hemorrhage, and is associated with increased mortality and more functional disability and cognitive impairment among survivors. Clinical trials are needed to evaluate the impact of prophylactic fever control on outcome after SAH.

Mechanisms of early brain injury after subarachnoid hemorrhage

Apoptosis is the term given to programmed cell death, which has been widely connected to a number of intracranial pathologies including stroke, Alzheimer's disease, and more recently subarachnoid hemorrhage (SAH). Subarachnoid hemorrhage is a disease, without any form of effective treatment, that affects mainly the young and middle aged and as a result is responsible for severe disability in otherwise healthy and productive individuals. Despite intense research efforts in the field, we currently possess a very limited understanding of the underlying mechanisms that result in injury after SAH. However, a number of studies have recently indicated that apoptosis may be a major player in the pathogenesis of secondary brain injury after SAH. As a result, the apoptotic cascades present a number of potential therapeutic opportunities that may ameliorate secondary brain injury after SAH. Experimental data suggest that these cascades occur very early after the initial insult and may be related directly to physiologic sequela commonly associated with SAH. It is imperative, therefore, to obtain a thorough understanding of the early events that occur after SAH, which will enable future therapies to be developed.

Imaging dementing illnesses

Dementia is an impairment of mental ability representing a decline from that level previously reached by the individual. It is usually of insidious onset, associated with neurologic changes, and results in the inability to appropriately interact with one's environment. Dementias may be static, progressive, or reversible, and have many etiologies. One percent of the population above age 40 suffers from dementia and this figure rises to 7% above age 80 and 50% above age 90. Forty-five percent of dementias are due to Alzheimer disease (AD) followed closely by vascular dementia. A stage along the way to dementia is mild cognitive impairment (MCI). There are various definitions but the simplest ones refer to a person who has some memory problems but can continue to live independently. A more specific description refers to deficits in two or more areas of cognition >1.5 SD below mean for the individuals age and education. Although previously considered a part of normal aging, a recent study has shown MCI to be a precursor of Alzheimer disease (1). In a cohort of nuns and priests studied annually until they developed MCI or dementia and died. 180 brains in this study have already been autopsied (37 MCI, 60 with no impairment, 53 with dementia). Pathologists measured theamount of AD pathology and cerebral infarcts. Of 37 with MCI, more than half had AD by pathology, 1/3 had infarcts (5 with both) and 14 did not have either pathology. One third of the 180 with average age of 85 had no cognitive decline! Since this study showed MCI patients to have Alzheimer disease pathology in their brains, recognition of MCI clinically is important for institution of therapy, although there has not yet been an effective therapy developed.

Cognitive Functioning in Patients with Cerebral Aneurysms Measured with the Mini Mental State Examination and the Telephone Interview for Cognitive Status

BACKGROUND:

Clinicians and researchers use brief instruments, such as the Mini Mental State Examination (MMSE) and the Telephone Interview for Cognitive Status (TICS), to measure cognitive functioning in patients with cerebral aneurysms. MMSE and TICS scores are often dichotomized to classify patients as cognitively impaired or not. Frequently, after an initial MMSE face-to-face evaluation, the TICS is used for follow-up assessments by telephone.

METHODS:

A cross-sectional cohort of patients with cerebral aneurysms completed the MMSE at baseline and the MMSE or TICS at the 12-month follow-up examination. Multivariate logistic regression adjusting for demographics was used to model cognitive impairment. MMSE and TICS results were compared using the MMSE as the “gold standard.”

RESULTS:

Eleven out of 171 (6%) patients had baseline MMSE scores less than 24, indicating cognitive impairment. Multivariate analysis showed that a history of subarachnoid hemorrhage was associated with cognitive impairment measured with the MMSE (odds ratio, 13.9; P = 0.021; C statistic = 0.87); there was no relationship between subarachnoid hemorrhage or treatment and TICS cognitive impairment (i.e., score &lt; 27). In patients without recent or interim invasive interventions that might affect cognition (n = 65), raw baseline MMSE and 12-month TICS scores had fair correlations (r = 0.30, P = 0.015); however, dichotomized scores had poor agreement, and TICS sensitivity and positive predictive value was 0% compared with the MMSE.

CONCLUSION:

The MMSE may be more sensitive than the TICS to the effects of subarachnoid hemorrhage on cognitive functioning. Raw MMSE and TICS scores are well correlated, but dichotomized MMSE and TICS scores are probably not interchangeable in this patient population.

Prognostic significance of continuous EEG monitoring in patients with poor-grade subarachnoid hemorrhage

INTRODUCTION

Predicting outcome in patients with poor-grade subarachnoid hemorrhage (SAH) may help guide therapy and assist in family discussions. The objective of this study was to determine if continuous electroencephalogram (cEEG) monitoring results are predictive of 3-month outcome in critically ill patients with SAH.

METHODS

We prospectively studied 756 patients with SAH over a 7-year period. Functional outcome was assessed at 3 months with the modified Rankin Scale (mRS). Patients that underwent cEEG monitoring were retrospectively identified and EEG findings were collected. Multivariate logistic regression analysis was performed to identify EEG findings associated with poor outcome, defined as mRS 4 to 6 (dead or moderately to severely disabled).

RESULTS

In 116 patients with SAH, cEEG monitoring and 3-month mRS were available. Of these patients, 88% had a Hunt & Hess grade of 3 or worse on admission. After controlling for age, Hunt & Hess grade, and presence of intraventricular hemorrhage on admission CT scan, poor outcome was associated with the absence of sleep architecture (80 versus 47%; odds ratio [OR] 4.3, 95%-confidence interval [CI] 1.1-17.2) and the presence of periodic lateralized epileptiform discharges (PLEDS) (91 versus 66% OR 18.8, 95%-CI 1.6-214.6). In addition, outcome was poor in all patients with absent EEG reactivity (n = 8), generalized periodic epileptiform discharges (n = 12), or bilateral independent PLEDs (n = 5), and in 92% (11 of 12) of patients with nonconvulsive status epilepticus.

CONCLUSIONS

cEEG monitoring provides independent prognostic information in patients with poor-grade SAH, even after controlling for clinical and radiological findings. Unfavorable findings include periodic epileptiform discharges, electrographic status epilepticus, and the absence of sleep architecture.

Dobutamine versus milrinone after subarachnoid hemorrhage

OBJECTIVE

Neurogenic stunned myocardium is a well-recognized complication of subarachnoid hemorrhage. Dobutamine and milrinone are both used for neurogenic stunned myocardium, but there are few data comparing them after subarachnoid hemorrhage.

METHODS

We compared the physiological dose response of dobutamine and milrinone in patients with subarachnoid hemorrhage requiring a pulmonary artery catheter. We located 11 patients who received either inotrope. Physiological data were fitted to a mixed model accounting for drug, dose, and between-patient variation.

RESULTS

There were 11 patients who had 152 pulmonary artery catheter measurements. Two received both inotropes (but not within 4 h of each other), 2 only milrinone, and 7 only dobutamine. The groups had similar clinical and physiological characteristics. After adjustment for vasopressin, milrinone was significantly more potent in increasing cardiac output (P <0.0001) and stroke volume (P=0.03), while decreasing vascular resistance (P <0.0001) and systolic blood pressure (P=0.008), than dobutamine.

CONCLUSION

These data suggest that milrinone and dobutamine should be used in different clinical situations. Milrinone may be more effective in patients with severely depressed systolic function but who have at least normal vascular resistance and blood pressure and in whom raising cardiac output is the primary goal. Dobutamine may be superior when vascular resistance or blood pressure is low.

Cerebrospinal fluid ferritin in chronic hydrocephalus after aneurysmal subarachnoid hemorrhage

OBJECTIVES

Subarachnoid hemorrhage (SAH) is a common cause of chronic hydrocephalus. Blood in the subarachnoid space is intracranially metabolized to bilirubin and iron, and free iron is thereafter detoxified by ferritin. However, no studies have reported the relationship between intracranial heme metabolism and chronic hydrocephalus after SAH. The goal of this prospective study was to clarify the relationship between intracranial heme metabolism and chronic hydrocephalus after SAH.

METHODS

The authors measured the levels of bilirubin, iron and ferritin in the cerebrospinal fluid (CSF) of 70 consecutive patients with aneurysmal SAH of Fisher computed tomography Group III, and determined the relationship between these substances' levels and hydrocephalus requiring ventriculoperitoneal shunting.

RESULTS

The CSF concentrations of ferritin and inflammatory cells were significantly higher in shunted patients (n = 27) than in non-shunted patients (n = 43) on Days 3 and 4 (p < 0.05 in ferritin and p < 0.01 in inflammatory cells) and 11 to 14 (p < 0.005 in ferritin) post-SAH. These results were independent of other clinical factors. The occurrence of chronic hydrocephalus was not affected by the extent of the intracranial heme metabolism in terms of the bilirubin and iron levels.

CONCLUSIONS

This is the first study to show that patients who subsequently had chronic hydrocephalus requiring CSF shunting were associated with higher CSF levels of ferritin in the acute stage of SAH. Higher CSF ferritin levels may not reflect the amount of blood in the subarachnoid space that was intracranially metabolized, but rather more intense subarachnoid inflammatory reactions which may cause chronic hydrocephalus after SAH.

Cerebral vasospasm in subarachnoid hemorrhage

The treatment of vasospasm after subarachnoid hemorrhage remains a formidable challenge. The prompt recognition of this complication is essential to prevent ischemic damage. Initial orders should include adequate fluid and sodium supplementation to avoid volume depletion. Prophylactic hypervolemia is not effective in reducing the incidence of vasospasm and may be deleterious. Oral nimodipine (60 mg every 4 hours for 21 days) should be started on admission because it protects against delayed ischemic damage. Increasing blood flow velocities on serial transcranial Doppler studies are reliable indicators of early development of vasospasm. When symptomatic vasospasm occurs, hemodynamic augmentation therapy should be instituted. Crystalloids and colloids may be used to promote hypervolemia. Colloids may provide additional benefit by producing hemodilution. However, the rheological benefits of hemodilution may be offset by reduced oxygen carrying capacity when hematocrit drops below 28%. Hypertension may be induced by administering inotropic drugs and, in certain cases, cardiac output optimization using dobutamine also is necessary. When aggressive medical therapy fails to reverse ischemic deficits, prompt endovascular intervention is indicated. Focal vasospasm of larger vessels may be effectively treated with angioplasty and the benefits of this procedure are durable. Diffuse vasospasm involving smaller arterial branches may be treated with intra-arterial infusion of vasodilators, such as papaverine, verapamil, or nicardipine. Unfortunately, these dilatory effects tend to be short-lasting. In refractory cases, hypothermia may be considered, although value of this strategy remains largely unexplored.

Effect of Prior Statin Use on Functional Outcome and Delayed Vasospasm after Acute Aneurysmal Subarachnoid Hemorrhage: A Matched Controlled Cohort Study

OBJECTIVE

Hydroxymethylglutaryl coenzyme A reductase inhibitors (statins), which exhibit beneficial cerebrovascular effects by modulating inflammation and nitric oxide production, have not been evaluated in acute aneurysmal subarachnoid hemorrhage (SAH) patients. The effect of prior statin use on 14-day functional outcome and on prevention of vasospasm-induced delayed cerebral ischemia (DCI) or stroke during hospitalization was analyzed.

METHODS

We conducted a 1:2 matched (age, admission Hunt and Hess grade, vascular disease/risk history) cohort study of 20 SAH patients on statins and 40 SAH controls. The primary outcome was functional outcome at 14 days (Modified Lawton Physical Self-Maintenance Scale and Barthel Index scale scores). Secondary outcomes were 14-day mortality, Modified Rankin Scale score, DCI, DCI supported by angiography/transcranial Doppler [TCD], cerebral infarctions of any type, and TCD highest mean velocity elevation.

RESULTS

Statin users demonstrated a significant protective effect on 14-day Barthel Index scale and Modified Lawton Physical Self-Maintenance Scale scores (77 +/- 10 versus 39 +/- 8, P = 0.003; 12 +/- 7 versus 19 +/- 9, P = 0.03, respectively). Moreover, statin users demonstrated a significantly lower incidence of DCI and DCI supported by angiography/TCD (10% versus 43%, P = 0.02; 5% versus 35%, P = 0.01, respectively), cerebral infarctions of any type (25% versus 63%, P = 0.01), and baseline-to-final TCD highest mean velocity change of 50 cm/s or greater (18% versus 51%, P = 0.03).

CONCLUSION

SAH statin users demonstrated significant improvement in 14-day functional outcome, a significantly lower incidence of DCI and cerebral infarctions of any type, as well as prevention of TCD highest mean velocity elevation. However, we did not find a significant statin impact on mortality or global outcome (Modified Rankin Scale) in this small sample. This study provides clinical evidence for the potential therapeutic benefit of statins after acute SAH.

Epidemiology of traumatic brain injury and subarachnoid hemorrhage

Incidence rates of traumatic brain injury are high in both industrialized and non-industrialized countries and have been estimated variously to be between 150-250 cases per 100,000 population per year. The estimated incidence rates for subarachnoid hemorrhage (SAH) are between 10 to 25 cases per 100,000 population per year. Seasonal variation in the occurrence of subarachnoid hemorrhage has been reported in studies from different countries, with significant seasonal variations and peak periods for aneurysmal SAH differing widely. A differential racial distribution for SAH has been found as well as a higher mortality rate for women than for men. The cognitive and behavioral consequences of TBI and SAH are significant and affect the quality of life of patients and their families. Recent publications have informed of hypopituitary deficits in patients sustaining TBI or SAH. It is not clear whether the cognitive deficits found in these patients are due to the consequences of the brain injury itself or are related to the hypopituitary deficits. There is a need for research distinguishing the differential cognitive and behavioral effects of the brain injury and the endocrinological deficits in these patients, and for developing adequate treatment.

Intracerebral aneurysms: a review with special attention to geriatric aspects

Rupture of an intracranial aneurysm (ICA) remains a devastating complication associated with a high degree of morbidity and mortality. In the past 2 decades, older people were often excluded from active treatment on the unique basis of their chronological age. Recent developments of less-invasive techniques for the diagnosis and treatment of ruptured and unruptured ICAs suggest that this fatalistic attitude toward older patients should be reconsidered. Furthermore, taking into account the heterogeneity of the elderly population, the use of a comprehensive geriatric assessment approach, based on a multidisciplinary evaluation, appears particularly helpful in proposing the optimal treatment strategy for each older patient. This article reviews the geriatric features of epidemiological, physiopathological, as well as clinical and therapeutic aspects of ruptured and unruptured ICAs.