Long-term domain-specific improvement following poor grade aneurysmal subarachnoid hemorrhage

Health-related quality of life of patients with aneurysmal subarachnoid hemorrhage who were classified as having "good outcomes"

BACKGROUND

This study aimed to understand the health-related quality of life (HRQoL) of patients with aneurysmal subarachnoid hemorrhage (aSAH) classified as having "good outcomes" and determine associated sociodemographic, psychological, and clinical factors.

METHODS

Participants were 86 patients with aSAH with modified Rankin Scale (mRS) scores of 0-2 in our hospital between February 2003 and April 2014. Participants completed self-report questionnaires examining sociodemographic characteristics and the following self-rating scales: the hospital anxiety and depression scale, Pittsburgh sleep quality index, and EuroQoL-5 Dimension Index (EQ-5D). Further, we retrospectively reviewed clinical data from medical records and radiologic images. Average EQ-5D scores for each variable were compared using Student's t-test and analysis of variance. Correlations between EQ-5D and continuous variables were examined using Pearson correlation analysis. Factors associated with EQ-5D were then examined using univariate and stepwise multivariate analyses through simple and multiple regression.

RESULTS

The mean age of the 86 participants was 56.87 ± 10.28 years (range: 29-79 years), while the mean EQ-5D value was 0.738 ± 0.169. There were 54 women (62.8 %) and 33 men (37.2 %). The participants had depressive symptoms (30.2 %), anxiety (10.5 %), and sleep problems (51.2 %). Regarding sociodemographic variables, educational level (p = 0.017) and monthly income (p = 0.037) were positively correlated with HRQoL. Depressive symptoms (r = -0.505, p < 0.001), anxiety (r = -0.498, p < 0.001), sleep problems (r = -0.265, p = 017), and mRS (r = -0.352, p = 0.001) were negatively correlated with HRQoL. Depressive symptoms, diabetes mellitus, and past psychiatric history explained 48.8 % of the variance in HRQoL in good outcome aSAH according to stepwise multiple regression analysis.

CONCLUSIONS

Patients with good outcome aSAH had low EQ-5D values, which were negatively correlated with depressive symptoms, anxiety, and sleep problems. In addition, HRQoL in good outcome aSAH is associated with depressive symptoms, diabetes mellitus, and past psychiatric disease history. Depressive symptoms, anxiety, and sleep problems are frequent in patients with good outcome aSAH, and mediation of these factors may help improve HRQoL.

Clinical Characteristics of Poor-Grade Aneurysmal Subarachnoid Hemorrhage Treatment

Background The initial clinical status after aneurysm rupture, whether primary or secondary, determines the final outcome. The most common cause of patient deterioration is a high Hunt and Hess (HH) score, which correlates closely with a high mortality rate. Poor-grade aneurysmal subarachnoid hemorrhage (SAH) is determined as an HH score 4 or 5. The aim of this study was to evaluate the clinical characteristics of poor graded aneurysmal SAH at our institution.

Patients and Methods During the 5-year period, 415 patients with intracranial aneurysm were admitted to our institution. Patients with poor-grade aneurysmal SAH accounted 31.08% (n = 132) of the total number of ruptured aneurysms. Interventional treatment was predominantly in the form of surgery, whereas conservative treatment included medication and external ventricular drainage. Final outcome was assessed with a modified Rankin score (mRs). Statistical analysis was performed using SPSS version 23.0 with a significance level set to 5% (α = 0.05).

Results The majority of patients (57.6%) were in the age range from 51 to 69 years. Twenty-five patients (18.9%) had an HH score of 4, whereas 107 patients (81.1%) had an HH score of 5. Depending on the location, the majority of patients (n = 43) had an aneurysm on the medial cerebral artery (MCA). The final aneurysm occlusion was performed in 71 patients, of whom 94.36% were treated surgically. A positive outcome (mRs 0–4) was found in 49.25% of patients who underwent primarily surgical, treatment with a mortality of 42.3%. Although the outcome was better in patients with an HH score 4, both groups benefited from surgical treatment.

Conclusion Poor-grade aneurismal SAH is a condition of the middle and older age, with most patients with an HH 5 score and deep comatose state. There was better outcome in patients with an HH score of 4 compared to an HH score of 5 and both groups benefited from surgical treatment, which resulted in a positive outcome in almost 50% of surgically treated patients.

Subarachnoid Hemorrhage

PURPOSE OF REVIEW

Subarachnoid hemorrhage (SAH) remains an important cause of mortality and long-term morbidity. This article uses a case-based approach to guide readers through the fundamental epidemiology and pathogenesis of SAH, the approach to diagnosis and management, the results of clinical trials and evidence to date, prognostic considerations, controversies, recent developments, and future directions in SAH.

RECENT FINDINGS

Historically, management of SAH focused on prevention and treatment of subsequent cerebral vasospasm, which was thought to be the primary cause of delayed cerebral ischemia. Clinical and translational studies over the past decade, including several therapeutic phase 3 randomized clinical trials, suggest that the pathophysiology of SAH-associated brain injury is multiphasic and multifactorial beyond large vessel cerebral vasospasm. The quest to reduce SAH-associated brain injury and improve outcomes is shifting away from large vessel cerebral vasospasm to a new paradigm targeting multiple brain injury mechanisms, including early brain injury, delayed cerebral ischemia, microcirculatory dysfunction, spreading cortical depolarization, inflammation, and the brain-body interaction in vascular brain injury with critical illness.Despite multiple negative randomized clinical trials in search of potential therapeutic agents ameliorating the downstream effects after SAH, the overall outcome of SAH has improved over recent decades, likely related to improvements in interventional options for ruptured cerebral aneurysms and in critical care management. Emerging clinical evidence also suggests potential harmful impact of historic empiric treatments for SAH-associated vasospasm, such as prophylactic induction of hypertension, hypervolemia, and hemodilution (triple H therapy).With decreasing mortality, long-term SAH survivorship and efforts to reduce chronic morbidity and to improve quality of life and patient-centered outcome are growing areas of unmet need. Despite existing guidelines, significant variabilities in local and regional practices and in scientific terminologies have historically limited advancement in SAH care and therapeutic development. Large global collaborative efforts developed harmonized SAH common data elements in 2019, and studies are under way to examine how existing variabilities in SAH care impact long-term SAH outcomes.

SUMMARY

Although the overall incidence and mortality of SAH is decreasing with advances in preventive and acute care, SAH remains a major cause of long-term morbidity in survivors. Significant variabilities in care settings and empiric treatment protocols and inconsistent scientific terminologies have limited advancement in patient care and therapeutic clinical studies. Large consensus efforts are under way to introduce clinical guidelines and common data elements to advance therapeutic approaches and improve patient outcome.

Clusters Across Multiple Domains of Health-Related Quality of Life Reveal Complex Patient Outcomes After Subarachnoid Hemorrhage

Supplemental Digital Content is available in the text.

Patients with aneurysmal subarachnoid hemorrhage (ruptured brain aneurysm) often have reduced health-related quality of life at follow-up in multiple domains (e.g., cognitive function and social function). We tested the hypothesis that there are distinct patterns of patient outcomes across domains of health-related quality of life, “complex patient outcomes,” in survivors of subarachnoid hemorrhage.

Dynamics of outcome after aneurysmal subarachnoid hemorrhage

In this observational study, we analyzed and described the dynamics of the outcome after aneurysmal subarachnoid hemorrhage (SAH) in a collective of 203 cases. We detected a significant improvement of the mean aggregate modified Rankin Score (mRS) in every time interval from discharge to 6 months and up to 1 year. Every forth to fifth patient with potential of recovery (mRS 1-5) at discharge improved by 1 mRS point in the time interval from 6 month to 1 year (22.6%). Patients with mRS 3 at discharge had a remarkable late recovery rate (73.3%, p = 0.000085). Multivariate analysis revealed age ≤ 65 years (odds ratio 4.93; p = 0.0045) and "World Federation of Neurological Surgeons" (WFNS) grades I and II (odds ratio 4.77; p = 0.0077) as significant predictors of early improvement (discharge to 6 months). Absence of a shunting procedure (odds ratio 8.32; p = 0.0049) was a significant predictor of late improvement (6 months to 1 year), but not age ≤ 65 years (p = 0.54) and WFNS grades I and II (p = 0.92). Thus, late recovery (6 month to 1 year) is significant and independent from age and WFNS grade.

Long-term and delayed functional recovery in patients with severe cerebrovascular and traumatic brain injury requiring tracheostomy

OBJECTIVE

Data on long-term functional recovery (LFR) following severe brain injury are essential for counseling of surrogates and for appropriate timing of outcome assessment in clinical trials. Delayed functional recovery (DFR) beyond 3-6 months is well documented following severe traumatic brain injury (sTBI), but there are limited data on DFR following severe cerebrovascular brain injury. The objective of this study was to assess LFR and DFR in patients with sTBI and severe stroke dependent on tracheostomy and tube feeding at the time of discharge from the intensive care unit (ICU).

METHODS

The authors identified patients entered into their tracheostomy database 2008-2013 with sTBI and severe stroke, encompassing SAH, intracerebral hemorrhage (ICH), and acute ischemic stroke (AIS). Eligibility criteria included disease-specific indicators of severity, Glasgow Coma Scale score < 9 at time of tracheostomy, and need for tracheostomy and tube feeding at ICU discharge. Assessment was at 1-3 months, 6-12 months, 12-24 months, and 24-36 months after initial injury for presence of tracheostomy, ability to walk, and ability to perform basic activities of daily living (B-ADLs). Long-term functional recovery (LFR) was defined as recovery of the ability to walk or perform B-ADLs by the 24- to 36-month follow-up. Delayed functional recovery (DFR) was defined as progression in functional milestones between any 2 time points beyond the 1- to 3-month follow-up.

RESULTS

A total of 129 patients met the eligibility criteria. Functional outcomes were available for 129 (100%), 97 (75%), 83 (64%), and 80 (62%) patients, respectively, from assessments at 1-3, 6-12, 12-24 and 24-36 months; 33 (26%) died by 24-36 months. Fifty-nine (46%) regained the ability to walk and 48 (37%) performed B-ADLs at some point during their recovery. Among survivors who had not achieved the respective milestone at 1-3 months, 29/58 (50%) were able to walk and 28/74 (38%) performed B-ADLs at 6-12 months. Among survivors who had not achieved the respective milestone at 6-12 months, 5/16 (31%) were able to walk and 13/30 (43%) performed B-ADLs at 12-24 months. There was no significant difference in rates of LFR or DFR between patients with sTBI and those with severe stroke.

CONCLUSIONS

Among patients with severe brain injury requiring tracheostomy and tube feeding at ICU discharge, 46% regained the ability to walk and 37% performed B-ADLs 2-3 years after injury. DFR beyond 1-3 and 6-12 months was seen in over 30% of survivors, with no significant difference between sTBI and severe stroke.

Clinical Outcomes After Endovascular Coiling in High-Grade Aneurysmal Hemorrhage

Object:

Our experience in Calgary was reviewed to determine the safety and clinical effectiveness of coiling in patients with high-grade aneurysmal subarachnoid hemorrhage (SAH).

Methods:

Patients with Hunt-Hess grades IV and V aneurysmal subarachnoid hemorrhage who underwent endovascular coiling between January 1999 and April 2009 at Foothills Medical Centre, Calgary, Alberta, Canada were reviewed. The primary outcome measure was the Modified Rankin Score after at least six months. Secondary outcome measures included extent of aneurysm occlusion and peri-procedural complications. In patients with favourable functional outcomes, Barthel's Index (BI), Re-integration to normal living index (RINL), and Zung depression scale (ZDS) were determined.

Results:

Thirty-three patients were identified (median age of 57 years; 73% female) and 69% were Hunt-Hess grade IV subarachnoid hemorrhage and 22 % were grade V Endovascular coiling resulted in absence of residual flow into the aneurysm fundus in 91%. Only seven procedure-related complications occurred with no deaths attributed to the procedure. Vasospasm, hydrocephalus, and pneumonia were the most common non-procedural complications. Average follow-up was 27 +/- 17 months. Overall mortality was 32%, but 53% of patients had good functional outcome (mRS<3). Nine patients completed the BI, RINL, and ZDS with average BI 99 +/- 2, RINL 89 +/- 14, ZDS 33 +/-11, suggesting minimal deficits in function and mood.

Conclusions:

Endovascular coiling in patients with high-grade subarachnoid hemorrhage is safe. While the morbidity and mortality from high-grade aneurysmal subarachnoid hemorrhage remains significant, favourable radiologic and functional outcomes can be achieved in a significant proportion of these critically ill patients.

Elevated high-sensitive troponin T on admission is an indicator of poor long-term outcome in patients with subarachnoid haemorrhage: a prospective observational study

BACKGROUND

Patients with subarachnoid haemorrhage (SAH) frequently develop cardiac complications in the acute phase after the bleeding. Although a number of studies have shown that increased levels of cardiac biomarkers after SAH are associated with a worse short-term prognosis, no prospective, consecutive study has assessed the association between biomarker release and long-term outcome. We aimed to evaluate whether the cardiac biomarkers, high-sensitive troponin T (hsTnT) and N-terminal pro B-type natriuretic peptide (NTproBNP), were associated with poor 1-year neurological outcome and cerebral infarction due to delayed cerebral ischaemia (CI-DCI).

METHODS

In this single-centre prospective observational study, all consecutive patients admitted to our neurointensive care unit from January 2012 to December 2013 with suspected/verified SAH with an onset of symptoms <72 hours were enrolled. Blood samples for hsTnT and NTproBNP were collected during three consecutive days following admission. Patients were followed-up after 1 year using the Glasgow Outcome Scale Extended (GOSE). Poor neurological outcome was defined as GOSE ≤ 4.

RESULTS

One hundred and seventy seven patients with suspected SAH were admitted during the study period; 143 fulfilled inclusion criteria and 126 fulfilled follow-up. Forty-one patients had poor 1-year outcome and 18 had CI-DCI. Levels of hsTnT and NTproBNP were higher in patients with poor outcome and CI-DCI. In multivariable logistic regression modelling age, poor neurological admission status, cerebral infarction of any cause and peak hsTnT were independently associated with poor late outcome. Both peak hsTnT and peak NTproBNP were independently associated with CI-DCI.

CONCLUSION

Increased serum levels of the myocardial damage biomarker hsTnT, when measured early after onset of SAH, are independently associated with poor 1-year outcome. Furthermore, release of both hsTnT and NTproBNP are independently associated with CI-DCI. These findings render further support to the notion that troponin release after SAH is an ominous finding. Future studies should evaluate whether there is a causal relationship between early release of biomarkers of myocardial injury after SAH and neurological sequelae.

Time course of recovery following poor-grade SAH: the incidence of delayed improvement and implications for SAH outcome study design

OBJECT

Data regarding the time course of recovery after poor-grade subarachnoid hemorrhage (SAH) is lacking. Most SAH studies assess outcome at a single time point, often as early as 3 or 6 months following SAH. The authors hypothesized that recovery following poor-grade SAH is a dynamic process and that early outcomes may not always approximate long-term outcomes. To test this hypothesis, they analyzed long-term outcome data from a cohort of patients with poor-grade aneurysmal SAH to determine the incidence and predictors of early and delayed neurological improvement.

METHODS

The authors reviewed outcome data from 88 poor-grade SAH patients enrolled in a prospective SAH treatment trial (the Barrow Ruptured Aneurysm Trial). They assessed modified Rankin Scale (mRS) scores at discharge, 6 months, 12 months, and 36 months after treatment to determine the incidence and predictors of neurological improvement during each interval.

RESULTS

The mean aggregate mRS scores at 6 months (3.31 ± 2.1), 12 months (3.28 ± 2.2), and 36 months (3.17 ± 2.3) improved significantly compared with the mean score at hospital discharge (4.33 ± 1.3, p < 0.001), but they did not differ significantly among themselves. Between discharge and 6 months, 61% of patients improved on the mRS. The incidence of improvement between 6-12 months and 12-36 months was 18% and 19%, respectively. Hunt and Hess Grade IV versus V (OR 6.20, 95% CI 2.11-18.25, p < 0.001) and the absence of large (> 4 cm) (OR 2.76, 95% CI 1.02-7.55, p = 0.05) or eloquent (OR 5.17, 95% CI 1.89-14.10, p < 0.01) stroke were associated with improvement up to 6 months. Age ≤ 65 years (OR 5.56, 95% CI 1.17-26.42, p = 0.02), Hunt and Hess Grade IV versus V (OR 4.17, 95% CI 1.10-15.85, p = 0.03), and absence of a large (OR 8.97, 95% CI 2.65-30.40, p < 0.001) or eloquent (OR 4.54, 95% CI 1.46-14.08, p = 0.01) stroke were associated with improvement beyond 6 months. Improvement beyond 1 year was most strongly predicted by the absence of a large stroke (OR 7.62, 95% CI 1.55-37.30, p < 0.01).

CONCLUSIONS

A substantial minority of poor-grade SAH patients will experience delayed recovery beyond the point at which most studies assess outcome. Younger patients, those presenting in better clinical condition, and those without CT evidence of large or eloquent stroke demonstrated the highest capacity for delayed recovery.

Determinants of health-related quality of life after aneurysmal subarachnoid hemorrhage: a systematic review

BACKGROUND AND PURPOSE

Many persons with subarachnoid hemorrhage (SAH) from a ruptured intracranial aneurysm recover to functional independence but nevertheless experience reduced quality of life (QoL). The aim of this study was to summarize the evidence on determinants of reduced QoL in this diagnostic group.

METHODS

Databases PubMed, PsychINFO, and CINAHL were used to identify empirical studies reporting on quantitative relationships between possible determinants and QoL in persons with aneurysmal SAH and published in English. Determinants were classified using the International Classification of Functioning, Disability and Health (ICF).

RESULTS

Twenty studies met the inclusion criteria for this review, in which 13 different HRQoL questionnaires were used. Determinants related to Body Structure & Function (clinical condition at admission, fatigue, and disturbed mood), Activity limitations (physical disability and cognitive complaints), and Personal factors (female gender, higher age, neuroticism, and passive coping) are consistently related to worse HRQoL after aneurysmal SAH. Treatment characteristics were not consistently related to HRQoL.

CONCLUSION

This study identified a broad range of determinants of HRQoL after aneurysmal SAH. The findings provide clues to tailor multidisciplinary rehabilitation programs. Further research is needed on participation, psychological characteristics, and environmental factors as determinants of HRQoL after SAH.

Changes in the acute functional and cognitive disability states of severe hemorrhagic stroke patients

The purpose of this study was to characterize temporal patterns of functional and cognitive disability changes during the acute period in hemorrhagic stroke patients. The study subjects were 62 hemorrhagic stroke patients admitted to a surgical intensive care unit at a university hospital located in Incheon, South Korea. As outcome variables, functional disability, cognitive ability, and employment status were evaluated directly at 1, 3, and 6 months after admission. The results showed that significant improvements in functional and cognitive ability were observed between 1 and 6 months after admission. In terms of functional disability, subjects considered their overall functional ability (dependence on others) to be less recovered than the specific functional abilities (feeding, grooming, or toileting): 75% of the subjects stated that they were completely independent on others, whereas 92.9%, 83.9%, and 83.9% of subjects indicated that they were completely independent for feeding, grooming, and toileting at the 6-month assessments, respectively. In terms of cognitive ability, attention, communication, and memory recovery rates were found to be relatively good. However, the proportion of subjects that achieved complete problem solving and safety and social behavior recovery were lower than those that achieved attention, communication, and memory recovery. Our findings can provide the empirical evidences when neuroscience nurses use educational and supportive strategies for rehabilitation of hemorrhagic stroke patients.

Natural history and medical treatment of cognitive dysfunction after spontaneous subarachnoid haemorrhage: review of current literature with respect to aneurysm treatment

Aneurysmal subarachnoid haemorrhage (aSAH) has the highest mortality and morbidity among all types of stroke. Unfortunately, cognitive dysfunction remains a major problem to those who survive the acute crisis. Most studies focused on patients after microsurgical clipping, which turned out to be different from the modern patient cohorts. With the widespread introduction of endovascular surgery as the first choice of treatment, there was a hope that post-aSAH cognitive dysfunction could be markedly reduced. However, data showed that post-aSAH cognitive dysfunction remained a major burden to the survivors of our modern patient cohort that returned to the community more than nine months after the initial haemorrhage. There is, therefore, a need to further understand its pathophysiology and natural history, and to develop effective treatment strategy. The results are encouraging and further clinical studies are indicated. Collaborations between cognitive scientists, neurologists and neurosurgeons are essential to advance the understanding of the problem.

Which variables help explain the poor health-related quality of life after subarachnoid hemorrhage? A meta-analysis

OBJECTIVE

Patients with subarachnoid hemorrhage (SAH) are younger than typical stroke patients. Poor psychosocial outcome after SAH therefore leads to a disproportionately high impact on patients, relatives, and society. Addressing this problem requires an understanding of what causes poor psychosocial outcome. Numerous studies have examined potential predictors but produced conflicting results. We aim to resolve this uncertainty about the potential value of individual predictors by conducting a meta-analysis. This approach allows us to quantitatively combine the findings from all relevant studies to identify promising predictors of psychosocial outcome and determine the strength with which those predictors are associated with measures of psychosocial health.

METHODS

Psychosocial health was measured by health-related quality of life (HRQOL). We included in our analysis those predictors that were most frequently examined in this context, namely patient age, sex, neurologic state at the time of hospital admission, bleed severity, physical disability, cognitive impairment, and time between ictus and psychosocial assessment.

RESULTS

Only 1 of the traditional variables, physical disability, had any notable affect on HRQOL. Therefore, the cause of most HRQOL impairment after SAH remains unknown. The situation is even worse for mental HRQOL, an area that is often significantly affected in SAH patients. Here, 90% of the variance remains unexplained by traditional predictors.

CONCLUSION

Studies need to turn to new factors to account for poor patient outcome.

Cognitive Functioning and Health-Related Quality of Life 1 Year After Aneurysmal Subarachnoid Hemorrhage in Preoperative Comatose Patients (Hunt and Hess Grade V Patients)

OBJECTIVE

The objective of this study was to determine cognitive functioning and health-related quality of life 1 year after aneurysmal subarachnoid hemorrhage in preoperative comatose patients (Hunt and Hess Grade V patients).

METHODS

Patients who were comatose at hospital arrival and thereafter were investigated for 1 year using a comprehensive neuropsychological test battery and 2 HRQOL questionnaires.

RESULTS

Thirty-five of 70 patients survived the bleed, and 26 underwent neuropsychological testing. Two distinct patient groups emerged, one (n = 14) with good cognitive function, having mild deficits only, and the other (n = 12) with poor cognitive and poor motor function. Patients performing poorly were older (P = .04), had fewer years of education (P = .005) and larger preoperative ventricular scores, and were more often shunted (P = .02). There were also differences between the 2 groups in the Glasgow Outcome Scale (P = .001), the modified Rankin Scale (P = .001), and employment status. HRQOL was more reduced in patients with poor cognitive function.

CONCLUSION

A high fraction of survivors among preoperative comatose aneurysmal SAH patients (Hunt and Hess grade V) recover to good physical and cognitive function, enabling them to live a normal life.