Mini-Mental State Examination versus Montreal Cognitive Assessment: Rapid assessment tools for cognitive and functional outcome after aneurysmal subarachnoid hemorrhage

A Comparison of Test-Retest Reliability and Practice Effects of Short Portable Mental State Questionnaire and Montreal Cognitive Assessment in Patients with Stroke

OBJECTIVE

To compare the test-retest reliabilities and minimal detectable change (MDC) of the Short Portable Mental State Questionnaire (SPMSQ) and the Montreal Cognitive Assessment (MoCA) in patients with stroke.

METHODS

63 patients were recruited from 1 medical center. The SPMSQ and MoCA were administered twice, 2 weeks apart.

RESULTS

Both measures showed high intraclass correlation coefficients (SPMSQ: 0.87; MoCA: 0.89) and acceptable MDC%s (SPMSQ: 14.8%; MoCA: 19.6%). A small correlation (r = 0.30) was found between the absolute difference and average in each pair of assessments in the SPMSQ, which was close to the criterion of heteroscedasticity. A small practice effect was observed in the MoCA (Cohen's d = 0.30).

CONCLUSION

The SPMSQ demonstrated smaller random measurement error and an absence of practice effect. When comparing the psychometric properties of the SPMSQ and MoCA as outcome measures for assessing cognitive function in patients with stroke, the SPMSQ appears to be a more suitable choice than the MoCA.

Predictive value of cerebrovascular time constant for delayed cerebral ischemia after aneurysmal subarachnoid hemorrhage

Time constant of the cerebral arterial bed (τ) is a transcranial Doppler (TCD) based metric that is expected to quantify the transit time of red blood cells from the insonation point to the arteriole-capillary boundary during a cardiac cycle. This study aims to assess the potential of τ as an early predictor of delayed cerebral ischemia (DCI). Consecutive patients (56 ± 15 years) treated for aneurysmal subarachnoid haemorrhage were included in the study. τ was assessed through a modelling approach that involved simultaneous recordings of arterial blood pressure and cerebral blood flow velocity (CBFV) from TCD's first recordings. 71 patients were included. 17 patients experienced DCI. τ was significantly shorter in patients who later developed DCI: 187 ± 64 ms vs. 249 ± 184 ms; p = 0.040 with moderate effect size (rG = 0.24). Logistic regression showed that there was a significant association between increased CBFV, shortened τ, and the development of DCI (χ2 = 11.54; p = 0.003) with AUC for the model 0.75. Patients who had both shortened τ and increased CBFV were 20 times more likely to develop DCI (OR = 20.4 (2.2-187.7)). Our results suggest that early alterations in τ are associated with DCI after aSAH. The highest performance of the model including both CBFV and τ may suggest the importance of both macrovascular and microvascular changes assessment.

Long-term neuropsychiatric complications of aneurysmal subarachnoid hemorrhage: a narrative review

This review focuses on the often-neglected long-term neuropsychiatric consequences of aneurysmal subarachnoid hemorrhage (aSAH), beyond traditional randomized trial outcomes of mortality and retreatment. While current guidelines recommend screening for these sequalae, it may not be routinely practiced. This review will underscore the prevalence and management of common neuropsychiatric sequalae, including anxiety, depression, cognitive dysfunction, headaches, seizures, and sexual dysfunction, all of which can significantly impact the quality of life of survivors of aSAH. We emphasize the critical role neurointerventionalists can play by going beyond the customary practice of radiological monitoring for treated aneurysms by screening for and helping guide management of these common neuropsychiatric complications.

Intimal Hemorrhage of Basilar Artery Induced by Severe Vasospasm Following Subarachnoid Hemorrhage: The Experimental Analysis

BACKGROUND

 Cerebral vasospasm, a serious complication of subarachnoid hemorrhage (SAH), has been extensively studied for its neurochemical and pathophysiologic mechanisms. However, the contribution of inner elastic membrane dissection and subintimal hemorrhage to basilar artery occlusion remains underexplored. This study investigates inner elastic membrane-related changes in the basilar artery after SAH.

METHODS

 Twenty-four hybrid rabbits were divided into control, sham, and SAH groups, with SAH induced by autologous blood injection. After 2 weeks, basilar artery changes, vasospasm indexes (VSIs), and dissections were evaluated.

RESULTS

 The SAH group showed significantly higher VSI, with vascular wall thickening, luminal narrowing, convoluted smooth muscle cells, intimal elastic membrane disruption, endothelial cell desquamation, and apoptosis. Some SAH animals exhibited subintimal hemorrhage, inner elastic membrane dissection, and ruptures. Basilar arteries with subintimal hemorrhage had notably higher VSI.

CONCLUSIONS

 These findings highlight the role of subintimal hemorrhage and inner elastic membrane dissection in basilar artery occlusion post-SAH, offering valuable insights into vasospasm pathophysiology.

Three Pillars of Recovery After Aneurysmal Subarachnoid Hemorrhage: A Narrative Review

Aneurysmal subarachnoid hemorrhage (aSAH) is a devastating neurologic disease with high mortality and disability. There have been global improvements in survival, which has contributed to the prevalence of patients living with long-term sequelae related to this disease. The focus of active research has traditionally centered on acute treatment to reduce mortality, but now there is a great need to study the course of short- and long-term recovery in these patients. In this narrative review, we aim to describe the core pillars in the preservation of cerebral function, prevention of complications, the recent literature studying neuroplasticity, and future directions for research to enhance recovery outcomes following aSAH.

Feasibility and user-experience of a virtual environment for social connection and education after stroke: A pilot study

OBJECTIVES

To evaluate the feasibility and usability of stroke survivor participation in an 8-week virtual environment intervention that provides opportunities for social support exchanges, social network interactions, and recovery education.

MATERIALS AND METHODS

A single-group, pre- and post-test measure design was used. Descriptive statistics were used to examine enrollment and retention rates, proportion of questionnaires completed, and virtual environment process data (e.g., number of log-ins) and usability scores. Changes in pre- and post-intervention questionnaire (e.g., usability, social support, depression, anxiety, loneliness, and self-efficacy) scores were explored using Wilcoxon signed-rank tests and paired t-test.

RESULTS

Fifteen (65 %) of the eligible stroke survivors enrolled (60 % white, 27 % black), 12 (80 %) had an ischemic stroke, ages ranged from 33 to 74 years (mean 44 years), and mean months since stroke was 33 ± 23. Retention and questionnaire completion rates were both 93 % (n = 14). Survivors logged into the virtual environment a total of 122 times, logged an average of 49 min/log-in, and 12 (80 %) attended support groups and social activities. Median usability score indicated lower than average usability. Improvement trends in social support, loneliness, and depressive symptoms were found, but significant changes in mean questionnaire scores were not found.

CONCLUSIONS

Overall, the results suggest that using a virtual environment to foster social support exchanges, social network interactions, and recovery education after stroke is feasible. Similar to other chronic disease populations, stroke survivor adoption of a virtual environment likely requires ongoing technical assistance, repetition of instructions, and opportunities for practice to reinforce engagement.

TRIAL REGISTRATION

NCT05487144.

Comment on the 2023 Guidelines for the Management of Patients With Aneurysmal Subarachnoid Hemorrhage

Aneurysmal subarachnoid hemorrhage can be a devastating disease, with an in-hospital mortality rate of up to 20%. The American Heart Association/American Stroke Association 2023 Aneurysmal Subarachnoid Hemorrhage Guidelines provide a comprehensive update to the 2012 Guidelines based on a systematic review of the intervening evidence. The guidelines are broad in scope, covering prehospital care, aneurysm treatment modality, medical complications, detection and treatment of delayed cerebral ischemia, and recovery. Here, we comment on salient aspects of aneurysmal subarachnoid hemorrhage care, compare these guidelines with the 2023 Neurocritical Care aneurysmal subarachnoid hemorrhage guidelines, and review relevant updates.

P300 Event-Related Potential Predicts Cognitive Dysfunction in Patients with Vestibular Disorders

OBJECTIVE

Our aim was to determine the correlation between cognitive impairment and P300 event-related potential (ERP) in older adults with vertigo and imbalance, which further provides a reference for clinical diagnosis and patients' rehabilitation.

METHODS

A total of 79 older adult patients with vertigo and imbalance in our outpatient department from January 2022 to December 2022 were selected and divided into the mild group (n = 20), moderate group (n = 39), and severe group (n = 20) according to the Dizziness Handicap Inventory (DHI). The auditory P300 component of event-related potentials (ERPs), Generalized Anxiety Disorder Questionnaire-7 (GAD-7), Patient Health Questionnaire-9 (PHQ-9), and Mini-Mental State Examination (MMSE) were used to evaluate depression, anxiety, and cognitive function in these patients, respectively.

RESULTS

The P300 latencies of the different severity groups were 292 ± 10 ms, 301 ± 8 ms, and 328 ± 5 ms, respectively, and the differences were statistically significant (p = 0.010). The P300 amplitudes of the different severity groups were 14.4 ± 2.6 μV, 3.9 ± 0.8 μV, and 5.1 ± 1.4 μV, respectively, and the differences were also statistically significant (p = 0.004). There was no statistically significant difference in the DHI evaluation or VAS visual simulation scoring between the two groups (p = 0.625, and 0.878, respectively). Compared with the short-course group, the long-course group showed prolonged P300 latency and decreased amplitude, higher scores in PHQ-9 and GAD-7, and lower scores in MMSE, and all the differences were statistically significant (p = 0.013, 0.021, 0.006, 0.004, and 0.018, respectively).

CONCLUSION

Older patients with more severe symptoms of vertigo and imbalance are at higher risk of developing abnormal cognitive function. The P300 can be used as an objective neurophysiological test for the assessment of cognitive function relevant to elderly patients with vertigo and imbalance.

Pretreatment and Posttreatment Factors Associated with Shunt-Dependent Hydrocephalus After Aneurysmal Subarachnoid Hemorrhage: A Systematic Review and Meta-Analysis

BACKGROUND

Hydrocephalus is a common complication after aneurysmal subarachnoid hemorrhage (aSAH). This study aimed to evaluate novel preoperative and postoperative risk factors for shunt-dependent hydrocephalus (SDHC) after aSAH via a systematic review and meta-analysis.

METHODS

A systematic search was conducted using PubMed and Embase databases for studies pertaining to aSAH and SDHC. Articles were assessed by meta-analysis if the number of risk factors for SDHC was reported by >4 studies and could be extracted separately for patients who did or did not develop SDHC.

RESULTS

Thirty-seven studies were included, comprising 12,667 patients with aSAH (SDHC 2214 vs. non-SDHC 10,453). In a primary analysis of 15 novel potential risk factors, 8 were identified to be significantly associated with increased prevalence of SDHC after aSAH, including high World Federation of Neurological Surgeons grades (odds ratio [OR], 2.43), hypertension (OR, 1.33), anterior cerebral artery (OR, 1.36), middle cerebral artery (OR, 0.65), and vertebrobasilar artery (2.21) involvement, decompressive craniectomy (OR, 3.27), delayed cerebral ischemia (OR, 1.65), and intracerebral hematoma (OR, 3.91).

CONCLUSIONS

Several new factors associated with increased odds of developing SDHC after aSAH were found to be significant. By providing evidence-based risk factors for shunt dependency, we describe an identifiable list of preoperative and postoperative prognosticators that may influence how surgeons recognize, treat, and manage patients with aSAH at high risk for developing SDHC.

2023 Guideline for the Management of Patients With Aneurysmal Subarachnoid Hemorrhage: A Guideline From the American Heart Association/American Stroke Association

AIM

The "2023 Guideline for the Management of Patients With Aneurysmal Subarachnoid Hemorrhage" replaces the 2012 "Guidelines for the Management of Aneurysmal Subarachnoid Hemorrhage." The 2023 guideline is intended to provide patient-centric recommendations for clinicians to prevent, diagnose, and manage patients with aneurysmal subarachnoid hemorrhage.

METHODS

A comprehensive search for literature published since the 2012 guideline, derived from research principally involving human subjects, published in English, and indexed in MEDLINE, PubMed, Cochrane Library, and other selected databases relevant to this guideline, was conducted between March 2022 and June 2022. In addition, the guideline writing group reviewed documents on related subject matter previously published by the American Heart Association. Newer studies published between July 2022 and November 2022 that affected recommendation content, Class of Recommendation, or Level of Evidence were included if appropriate. Structure: Aneurysmal subarachnoid hemorrhage is a significant global public health threat and a severely morbid and often deadly condition. The 2023 aneurysmal subarachnoid hemorrhage guideline provides recommendations based on current evidence for the treatment of these patients. The recommendations present an evidence-based approach to preventing, diagnosing, and managing patients with aneurysmal subarachnoid hemorrhage, with the intent to improve quality of care and align with patients' and their families' and caregivers' interests. Many recommendations from the previous aneurysmal subarachnoid hemorrhage guidelines have been updated with new evidence, and new recommendations have been created when supported by published data.

Intersectionality in Alzheimer's Disease: The Role of Female Sex and Black American Race in the Development and Prevalence of Alzheimer's Disease

It is well known that vascular factors and specific social determinants of health contribute to dementia risk and that the prevalence of these risk factors differs according to race and sex. In this review, we discuss the intersection of sex and race, particularly female sex and Black American race. Women, particularly Black women, have been underrepresented in Alzheimer's disease clinical trials and research. However, in recent years, the number of women participating in clinical research has steadily increased. A greater prevalence of vascular risk factors such as hypertension and type 2 diabetes, coupled with unique social and environmental pressures, puts Black American women particularly at risk for the development of Alzheimer's disease and related dementias. Female sex hormones and the use of hormonal birth control may offer some protective benefits, but results are mixed, and studies do not consistently report the demographics of their samples. We argue that as a research community, greater efforts should be made to not only recruit this vulnerable population, but also report the demographic makeup of samples in research to better target those at greatest risk for the disease.

Microvascular cerebral blood flow response to intrathecal nicardipine is associated with delayed cerebral ischemia

One of the common complications of non-traumatic subarachnoid hemorrhage (SAH) is delayed cerebral ischemia (DCI). Intrathecal (IT) administration of nicardipine, a calcium channel blocker (CCB), upon detection of large-artery cerebral vasospasm holds promise as a treatment that reduces the incidence of DCI. In this observational study, we prospectively employed a non-invasive optical modality called diffuse correlation spectroscopy (DCS) to quantify the acute microvascular cerebral blood flow (CBF) response to IT nicardipine (up to 90 min) in 20 patients with medium-high grade non-traumatic SAH. On average, CBF increased significantly with time post-administration. However, the CBF response was heterogeneous across subjects. A latent class mixture model was able to classify 19 out of 20 patients into two distinct classes of CBF response: patients in Class 1 (n = 6) showed no significant change in CBF, while patients in Class 2 (n = 13) showed a pronounced increase in CBF in response to nicardipine. The incidence of DCI was 5 out of 6 in Class 1 and 1 out of 13 in Class 2 (p < 0.001). These results suggest that the acute (<90 min) DCS-measured CBF response to IT nicardipine is associated with intermediate-term (up to 3 weeks) development of DCI.

A comprehensive program of cognitive stimulation with digital inclusion, physical activity and social interaction can modify BDNF levels and improve cognition in adults over 50: a randomized controlled pilot study

OBJECTIVES

To analyze the effect of a comprehensive program of cognitive stimulation with digital inclusion, physical activity and social interaction, called "Oficina da Lembrança" (OL), on the cognitive status and concentration of biomarkers of neuroplasticity, neurodegeneration in adults aged 50 years and over attending a Memory Clinic.

METHODS

In this pilot randomized controlled study, 64 patients without dementia aged 45 to 79 years, seen at a University Memory Clinic in Southern Brazil, were randomly allocated to the intervention and control groups. The intervention consisted of participation in OL for 12 weeks. Serum biomarkers (brain-derived neurotrophic factor [BDNF], S100β, and neuron-specific enolase [NSE]) and cognitive status were analyzed as primary and secondary outcomes. The Wilcoxon test and Generalized Estimating Equations (GEE) were applied.

RESULTS

Of the 64 patients invited to participate in the study, 33 (intervention: 17, control: 16) completed the study with all data. Improvement of cognitive status was significant in the intervention group (22.6 to 24.5) but not in the control group (20.1 to 21.1). There was a significant reduction of BDNF in OL participants, but no significant change was observed in the neurodegenerative biomarkers S100β or NSE. The concentration of BDNF decreased significantly post-OL in the intervention group (-288.1, 95%CI -362.1 to -94.1), even after adjusting for sex, age, and educational level. Cognitive status was significantly improved in OL participants.

CONCLUSION

The OL program improved cognitive status, reduced serum BDNF levels, and empowered digitally excluded older adults. There was no effect of this intervention on S100β or NSE.

CLINICAL TRIAL REGISTRATION

This study has a Universal Trial Number (UTN) U1111-1195-2642 and was registered in the Brazilian Clinical Trials Registry (ReBEC), number RBR-38X665.

Montreal Cognitive Assessment for Evaluating Cognitive Impairment in Subarachnoid Hemorrhage: A Systematic Review

Subarachnoid hemorrhage (SAH) is a severe condition with high mortality and extensive long-term morbidity. Although research has focused mainly on physical signs and disability for decades, in recent years, it has been increasingly recognized that cognitive and psychological impairments may be present in many patients with SAH, negatively impacting their quality of life. We performed a systematic review aiming to provide a comprehensive report on the diagnostic accuracy of the Montreal Cognitive Assessment (MoCA) test for evaluating the presence of cognitive impairment in patients with SAH. Using appropriate search terms, we searched five databases (PubMed, Scopus, PsychINFO, Web of Sciences, and Latin American and Caribbean Health Sciences Literature) up to January 2022. Two cross-sectional studies investigated the accuracy of MoCA in SAH patients in the subacute and chronic phase. We appraised the quality of the included studies using the Quality Assessment of Diagnostic Accuracy Studies 2 (QUADAS-2) criteria. The MoCA test provides information about general cognitive functioning disturbances. However, a lower threshold than the original cutoff might be needed as it improves diagnostic accuracy, lowering the false positive rates. Further research is necessary for an evidence-based decision to use the MoCA in SAH patients.

Longitudinal neuropsychological assessment after aneurysmal subarachnoid hemorrhage and its relationship with delayed cerebral ischemia: a prospective Swiss multicenter study

OBJECTIVE

While prior retrospective studies have suggested that delayed cerebral ischemia (DCI) is a predictor of neuropsychological deficits after aneurysmal subarachnoid hemorrhage (aSAH), all studies to date have shown a high risk of bias. This study was designed to determine the impact of DCI on the longitudinal neuropsychological outcome after aSAH, and importantly, it includes a baseline examination after aSAH but before DCI onset to reduce the risk of bias.

METHODS

In a prospective, multicenter study (8 Swiss centers), 112 consecutive alert patients underwent serial neuropsychological assessments (Montreal Cognitive Assessment [MoCA]) before and after the DCI period (first assessment, < 72 hours after aSAH; second, 14 days after aSAH; third, 3 months after aSAH). The authors compared standardized MoCA scores and determined the likelihood for a clinically meaningful decline of ≥ 2 points from baseline in patients with DCI versus those without.

RESULTS

The authors screened 519 patients, enrolled 128, and obtained complete data in 112 (87.5%; mean [± SD] age 53.9 ± 13.9 years; 66.1% female; 73% World Federation of Neurosurgical Societies [WFNS] grade I, 17% WFNS grade II, 10% WFNS grades III-V), of whom 30 (26.8%) developed DCI. MoCA z-scores were worse in the DCI group at baseline (-2.6 vs -1.4, p = 0.013) and 14 days (-3.4 vs -0.9, p < 0.001), and 3 months (-0.8 vs 0.0, p = 0.037) after aSAH. Patients with DCI were more likely to experience a decline of ≥ 2 points in MoCA score at 14 days after aSAH (adjusted OR [aOR] 3.02, 95% CI 1.07-8.54; p = 0.037), but the likelihood was similar to that in patients without DCI at 3 months after aSAH (aOR 1.58, 95% CI 0.28-8.89; p = 0.606).

CONCLUSIONS

Aneurysmal SAH patients experiencing DCI have worse neuropsychological function before and until 3 months after the DCI period. DCI itself is responsible for a temporary and clinically meaningful decline in neuropsychological function, but its effect on the MoCA score could not be measured at the time of the 3-month follow-up in patients with low-grade aSAH with little or no impairment of consciousness. Whether these findings can be extrapolated to patients with high-grade aSAH remains unclear. Clinical trial registration no.: NCT03032471 (ClinicalTrials.gov).

Primary results of the Vesalio NeVa VS for the Treatment of Symptomatic Cerebral Vasospasm following Aneurysm Subarachnoid Hemorrhage (VITAL) Study

BACKGROUND

Cerebral vasospasm (CV) after aneurysmal subarachnoid hemorrhage (aSAH) is linked to worse neurological outcomes. The NeVa VS is a novel cerebral dilation device based on predicate stent retrievers. We report the results of the Vesalio NeVa VS for the Treatment of Symptomatic Cerebral Vasospasm following aSAH (VITAL) Study.

METHODS

This was a single-arm prospective multicenter trial to assess the safety and probable benefit of the NeVa VS device to treat CV. Patients were screened and treated if they had CV >50% on non-invasive imaging confirmed by cerebral angiography. The vessel diameters were measured before and after treatment by an independent core laboratory. The primary endpoint was ≥50% vessel diameter immediately after treatment with the NeVa VS device.

RESULTS

Thirty patients with a mean age of 52±11 years and mean Hunt-Hess grade of 3.1±0.9 were enrolled. A total of 74 vessels were treated with an average of 1.3 deployments per vessel (95 deployments total). The mean pre-treatment narrowing of the target vessel (n=74) was 65.6% with reduction of the narrowing to 29.4% after treatment. The primary endpoint was achieved in 64 of 74 vessels (86.5%). In three of 95 total deployments (3.2%), thrombus at the site of deployment was observed during the procedure without apparent neurological sequelae.

CONCLUSIONS

The NeVa VS device appears to be a safe treatment to regain vessel diameter in severely narrowed intracranial arteries secondary to CV associated with aSAH. This treatment offers a new tool that allows for controlled vessel expansion to treat CV.

Platelet Receptor Activity for Predicting Survival in Patients with Intracranial Bleeding

Blood coagulation disorders in patients with intracranial bleeding as a result of head injuries or ruptured aneurysms are a diagnostic and therapeutic problem and appropriate assessments are needed to limit CNS damage and to implement preventive measures. The aim of the study was to monitor changes in platelet aggregation and to assess the importance of platelet dysfunction for predicting survival. Platelet receptor function analysis was performed using the agonists arachidonic acid (ASPI), adenosine diphosphate (ADP), collagen (COL), thrombin receptor activating protein (TRAP), ristocetin (RISTO) upon admission to the ICU and on days 2, 3, and 5. On admission, the ASPI, ADP, COL, TRAP, and RISTO tests indicated there was reduced platelet aggregation, despite there being a normal platelet count. In ‘Non-survivors’, the platelet response to all agonists was suppressed throughout the study period, while in ‘Survivors’ it improved. Measuring platelet function in ICU patients with intracranial bleeding is a strong predictor related to outcome: patients with impaired platelet aggregation had a lower 28-day survival rate compared to patients with normal platelet aggregation (log-rank test p = 0.014). The results indicated that measuring platelet aggregation can be helpful in the early detection, diagnosis, and treatment of bleeding disorders.

Sickness absence, disability pension and economic situation after a spontaneous subarachnoid haemorrhage among people of working age: a Swedish longitudinal nationwide cohort study

OBJECTIVES

The aim was to describe the course of sickness absence (SA), disability pension (DP) and work-related economic situation defined as earnings (EA) and disposable income (DI), after spontaneous subarachnoid haemorrhage (SAH). Associations of SA, DP, EA and DI with demographic factors were also studied.

DESIGN

A longitudinal cohort study of all 1932 people in Sweden who in January 2005 to December 2010 had a first time SAH when aged 17 to 64 years and survived during the 3-year follow-up. Microdata from four nationwide administrative registers were used.

MAIN OUTCOME MEASURES

Primary outcome was the presence of SA and DP and how this changed during the study period of 5 years (the year before, the year of SAH and the following 3 years). The secondary outcome was the development of the income variables EA and DI. Demographic factors analysed were sex, age, source of bleeding, country of birth, family situation, educational level and type of living area.

RESULTS

The year before the SAH, 7.9% of women and 4.6% of men had some SA registered (p<0.004). A model consisting of female sex, higher education and living single predicted having SA that year. At the end of the follow-up, 39.2% of women and 28.3% of men had SA and/or DP (p<0.0001). A model consisting of female sex, living in a village/ rural area and having a defined bleeding source for the SAH was predicting having SA and/or DP at end of follow-up. The levels of EA decreased, while DI increased during follow-up and were at the end of follow-up associated with age, sex, type of living area, country of birth, educational level and family situation. The women's EA was lower than the men's during all years.

CONCLUSIONS

SAH influenced future SA, DP, as well as EA. Both SA, DP and the economic variables studied were predicted by models including sex.

Cognitive deficits among patients surviving aneurysmal subarachnoid hemorrhage. A contemporary systematic review

BACKGROUND

Subarachnoid hemorrhage (SAH) is associated with high rates of morbidity, including neurological and cognitive deficits that may be difficult to identify and quantify. This review provides an update on the cognitive deficits that may result from spontaneous aneurysmal SAH (aSAH) and identifies factors that may help predict and manage these deficits at discharge and thereafter.

MATERIALS AND METHODS

We conducted a systematic review of PubMed and Google Scholar to identify studies published between 2010 and 2019 that assessed cognitive deficits at discharge and during follow-up in patients with aSAH. Full-text articles were assessed for information regarding cognitive testing and factors that may be associated with functional outcomes in this population.

RESULTS

We reviewed 65 studies published since 2010 that described the cognitive deficits associated with non-traumatic aSAH. Such deficits may impact functional outcomes, quality of life, and return to work and may result in cognitive impairments, such as memory difficulties, speech problems, and psychiatric disorders.

CONCLUSIONS

Patients with aSAH, even those that appear normal at the time of hospital discharge, may harbor cognitive deficits that are difficult to detect, yet can interfere with daily functioning. Further research is needed to provide additional information and to identify stronger correlations to be used in the identification, treatment, and amelioration of long-term cognitive deficits in aSAH patients, including those who are discharged with good clinical outcomes scores.

Unfavorable Outcome After Good Grade Aneurysmal Subarachnoid Hemorrhage: Exploratory Analysis

OBJECTIVE

Patients with good-grade aneurysmal subarachnoid hemorrhage (aSAH) are thought to recover well, yet some do not. This work sought to identify predictors of unfavorable functional outcome after good-grade aSAH.

METHODS

We performed a post-hoc analysis of the CONSCIOUS-1 trial. Patients with World Federation of Neurosurgical Societies grades I or II aSAH were included. The primary outcome was unfavorable functional outcome (defined as a modified Rankin Scale score >2) at 12 weeks. Parametric and nonparametric testing were used as appropriate. Variables were classified as modifiable or nonmodifiable, depending on whether they were present at patient admission. Stepwise logistic regression models were created for modifiable and nonmodifiable predictors of outcome. Independent predictors in the respective multivariate analyses were combined into a final multivariate regression model.

RESULTS

We included 301 patients, 67 of whom (22%) had an unfavorable outcome. Of the nonmodifiable predictors, higher admission systolic blood pressure (P = 0.002) and female sex (P = 0.011) were independently associated with unfavorable outcome. Potentially modifiable independent predictors of outcome were delayed cerebral ischemia (P = 0.039), higher maximum temperature (0.036), suffering a respiratory system complication (P = 0.004), and suffering an intracranial hemorrhagic complication (P = 0.022). All variables found to be independently predictive of poor outcome in their respective models retained statistical significance in the combined multivariate analysis.

CONCLUSIONS

About 1 in 5 good-grade aSAH patients enrolled in CONSCIOUS-1 suffered an unfavorable functional outcome. Admission systolic blood pressure, female sex, hyperthermia, delayed cerebral ischemia, respiratory complications, and intracranial hemorrhagic complications may be predictive of outcome.

Reduced Self-Awareness Following a Combined Polar and Paramedian Bilateral Thalamic Infarction. A Possible Relationship With SARS-CoV-2 Risk of Contagion?

Reduced self-awareness is a well-known phenomenon investigated in patients with vascular disease; however, its impact on neuropsychological functions remains to be clarified. Importantly, selective vascular lesions provide an opportunity to investigate the key neuropsychological features of reduced self-awareness in neurocognitive disorders. Because of its rarity, we present an unusual case of a woman affected by a combined polar and paramedian bilateral thalamic infarction. The patient underwent an extensive neuropsychological evaluation to assess cognitive, behavioral, and functional domains, with a focus on executive functions. She was assessed clinically in the acute phase and after 6 months from the stroke, both clinically and by magnetic resonance imaging. The patient developed a cognitive impairment, characterised by prevalent executive dysfunction associated with reduced self-awareness and mood changes, in terms of apathy and depression. Such condition persisted after 6 months. In May 2020, the patient underwent the serology test in chemiluminescence to detect IgG antibodies against SARS-CoV-2. The result of the quantitative test highlighted a high probability of previous contact with the virus. We suggest that reduced self-awareness related to executive dysfunction and behavioral changes may be due to combined polar and paramedian bilateral thalamic lesion. Metacognitive–executive dysfunction affecting the instrumental abilities of everyday life might make people less able to take appropriate precautions, facilitating the risk of SARS-CoV-2 contagion.

Lessons from the CONSCIOUS-1 Study

After years of research on treatment of aneurysmal subarachnoid hemorrhage (aSAH), including randomized clinical trials, few treatments have been shown to be efficacious. Nevertheless, reductions in morbidity and mortality have occurred over the last decades. Reasons for the improved outcomes remain unclear. One randomized clinical trial that has been examined in detail with these questions in mind is Clazosentan to Overcome Neurological Ischemia and Infarction Occurring After Subarachnoid Hemorrhage (CONSCIOUS-1). This was a phase-2 trial testing the effect of clazosentan on angiographic vasospasm (aVSP) in patients with aSAH. Clazosentan decreased moderate to severe aVSP. There was no statistically significant effect on the extended Glasgow outcome score (GOS), although the study was not powered for this endpoint. Data from the approximately 400 patients in the study were detailed, rigorously collected and documented and were generously made available to one investigator. Post-hoc analyses were conducted which have expanded our knowledge of the management of aSAH. We review those analyses here.

Cognitive outcomes after unruptured intracranial aneurysm treatment with endovascular coiling

BACKGROUND

We aimed to determine the effects of endovascular coiling of unruptured intracranial aneurysms (UIAs) on cognition to inform treatment decisions. We present the first study using the Montreal Cognitive Assessment (MoCA) to determine neurocognitive changes after endovascular coiling.

METHODS

We prospectively collected data on all patients with UIAs undergoing endovascular coiling, primary or assisted. Patients completed the MoCA prior to intervention and 1 month and 6 months' post-procedure. A repeated measures linear mixed effects model was used to compare pre-procedure and post-procedure cognition.

RESULTS

Thirty-three patients with 33 aneurysms who underwent coiling from April 2017 to May 2020 were included (mean age 55.5, 81.8% female). All procedures used general anesthesia. There was no difference between baseline and post-procedure MoCA scores at any time interval (P>0.05). Mean MoCA scores at baseline, 1 month post-procedure, and 6 months' post-procedure were 25.4, 26.8, and 26.3 respectively. There was also no difference between pre- and post-procedure scores on any individual MoCA domain (visuospatial, naming, memory, attention, language, abstraction, delayed recall, and orientation) at any time interval (P>0.05). Seventeen patients had follow-up MRI or CT imaging, of which 11.8% showed radiographic changes or ischemia. 77.8% of patients with 6-month angiographic follow-up achieved class I, and 22.2% achieved class II Raymond-Roy Occlusion. Thirty-two out of 33 patients had follow-up mRS ≤2.

CONCLUSION

Our study suggests that endovascular coiling does not diminish neurocognitive function. Patients with UIAs in our cohort also had baseline MoCA scores below the cut-off for mild cognitive impairment despite pre-procedure mRS and NIHSS of 0.

Long-Term Complications and Influence on Outcome in Patients Surviving Spontaneous Subarachnoid Hemorrhage

Background: While the short-term clinical outcome of patients with subarachnoid hemorrhage (SAH) is well described, there are limited data on long-term complications and their impact on social reintegration. This study aimed to assess the frequency of complications post-SAH and to investigate whether these complications attribute to functional and self-reported outcomes as well as the ability to return to work in these patients. Methods: This retrospective single-center study included patients with atraumatic SAH over a 5-year period at a tertiary care center. Patients received a clinical follow-up for 12 months. In addition to demographics, imaging data, and parameters of acute treatment, the rate and extent of long-term complications after SAH were recorded. The functional outcome was assessed using the modified Rankin Scale (mRS; favorable outcome defined as mRS = 0–2). Further outcomes comprised self-reported subjective health measured by the EQ-5D and return to work for SAH patients with appropriate age. Multivariable analyses including in-hospital parameters and long-term complications were conducted to identify parameters independently associated with outcomes in SAH survivors. Results: This study cohort consisted of 505 SAH patients of whom 405 survived the follow-up period of 12 months (i.e., mortality rate of 19.8%). Outcome data were available in 359/405 (88.6%) patients surviving SAH. At 12 months, a favorable functional outcome was achieved in 287/359 (79.9%) and 145/251 (57.8%) SAH patients returned to work. The rates of post-acute complications were headache (32.3%), chronic hydrocephalus requiring permanent ventriculoperitoneal shunting (VP shunt 25.4%) and epileptic seizures (9.5%). Despite patient’s and clinical characteristics, both presence of epilepsy and need for VP shunt were independently and negatively associated with a favorable functional outcome (epilepsy: adjusted odds ratio [aOR] (95% confidence interval [95% CI]): 0.125 [0.050–0.315]; VP shunt: 0.279 [0.132–0.588]; both p < 0.001) as well as with return to work (aOR [95% CI]: epilepsy 0.195 [0.065–0.584], p = 0.003; VP shunt 0.412 [0.188–0.903], p = 0.027). Multivariable analyses revealed presence of headache, VP shunt, or epilepsy to be significantly related to subjective health impairment (aOR [95% CI]: headache 0.248 [0.143–0.430]; epilepsy 0.223 [0.085–0.585]; VP shunt 0.434 [0.231–0.816]; all p < 0.01). Conclusions: Long-term complications occur frequently after SAH and are associated with an impairment of functional and social outcomes. Further studies are warranted to investigate if treatment strategies specifically targeting these complications, including preventive aspects, may improve the outcomes after SAH.

Severe cognitive impairment in aneurysmal subarachnoid hemorrhage: Predictors and relationship to functional outcome

BACKGROUND

Cognitive impairment is common after aneurysmal subarachnoid hemorrhage (SAH). However, compared to predictors of functional outcome, meaningful predictors of cognitive impairment are lacking.

OBJECTIVE

Our goal was to assess which factors during hospitalization can predict severe cognitive impairment in SAH patients, especially those who might otherwise be expected to have good functional outcomes. We hypothesized that the degree of early brain injury (EBI), vasospasm, and delayed neurological deterioration (DND) would predict worse cognitive outcomes.

METHODS

We retrospectively reviewed SAH patient records from 2013 to 2019 to collect baseline information, clinical markers of EBI (Fisher, Hunt-Hess, and Glasgow Coma scores), vasospasm, and DND. Cognitive outcome was assessed by Montreal Cognitive Assessment (MoCA) and functional outcomes by modified Rankin Scale (mRS) at hospital discharge. SAH patients were compared to non-neurologic hospitalized controls. Among SAH patients, logistic regression analysis was used to identify predictors of severe cognitive impairment defined as a MoCA score <22.

RESULTS

We screened 288 SAH and 80 control patients. Cognitive outcomes assessed via MoCA at discharge were available in 105 SAH patients. Most of these patients had good functional outcome at discharge with a mean mRS of 1.8±1.3. Approximately 56.2% of SAH patients had MoCA scores <22 compared to 28.7% of controls. Among SAH patients, modified Fisher scale was an independent predictor of cognitive impairment after adjustment for baseline differences (OR 1.638, p=0.043). MoCA score correlated inversely with mRS (r=-0.3299, p=0.0006); however, among those with good functional outcome (mRS 0-2), 48.7% still exhibited cognitive impairment.

CONCLUSIONS

Severe cognitive impairment is highly prevalent after SAH, even among patients with good functional outcome. Higher modified Fisher scale on admission is an independent risk factor for severe cognitive impairment. Cognitive screening is warranted in all SAH patients, regardless of functional outcome.

Aneurysmal subarachnoid hemorrhage: A pilot study for using longitudinal cognitive and neuropsychological testing for functional outcomes

OBJECTIVES

Patients with aneurysmal subarachnoid hemorrhage (aSAH) often sustain substantial cognitive and functional impairment. Traditional outcome measures have emphasized radiographic and gross clinical outcomes, but cognitive and functional outcomes are less frequently documented. This pilot study assessed the feasibility of administering longitudinal cognitive and neuropsychological testing and tracked patterns of functional improvement in aSAH patients.

PATIENTS AND METHODS

Standardized cognitive and neuropsychological testing were administered to a prospective cohort of aSAH patients admitted for treatment to our tertiary care center. Thirty consecutive aSAH patients (Hunt and Hess score 1-3) were enrolled over 23-months and baseline evaluations were completed within 24-h after admission. Patients were followed prospectively after treatment (coiling or clipping) at 1-, 3-, 6-, and 12-months. Functional outcome measures included the Montreal Cognitive Assessment, the Neuropsychiatric Inventory-Questionnaire, and the Functional Activities Questionnaire.

RESULTS

Of the 30 patients, 23 (77%) followed-up at 3-months, 21 (70%) at 6-months, and 19 (63%) at 12-months. Improvement from baseline to follow-up at 12-months was noted for general cognitive function (p = .004), memory (p = .025), and executive function (p = .039), with the greatest improvement occurring within 6-months. Daily function also improved mostly within 6-months (p = .022) while changes in neuropsychological disturbances were insignificant from baseline to follow-up at 12-months (p = .216).

CONCLUSION

Standardized cognitive and neuropsychological testing provides metrics for evaluating functional outcomes following treatment of aSAH. The addition of a brief battery of tests to routine clinical and radiographic evaluations is feasible. The main limitations are related to practice and referral patterns, and future studies are needed to evaluate the impact of treatment modalities on functional outcomes.

Measuring the Impact of Delayed Cerebral Ischemia on Neuropsychological Outcome After Aneurysmal Subarachnoid Hemorrhage-Protocol of a Swiss Nationwide Observational Study (MoCA-DCI Study)

BACKGROUND

The exact relationship between delayed cerebral ischemia (DCI) following aneurysmal subarachnoid hemorrhage (aSAH) and neuropsychological impairment remains unknown, as previous studies lacked a baseline examination after aneurysm occlusion but before the DCI-period. Neuropsychological evaluation of acutely ill patients is often applied in a busy intensive care unit (ICU), where distraction represents a bias to the obtained results.

OBJECTIVE

To evaluate the relationship between DCI and neuropsychological outcome after aSAH by comparing the Montreal Cognitive Assessment (MoCA) results in aSAH patients with and without DCI at 3 mo with a baseline examination before the DCI-period (part 1). To determine the reliability of the MoCA, when applied in an ICU setting (part 2).

METHODS

Prospective, multicenter, and observational study performed at all Swiss neurovascular centers. For part 1, n = 240 consecutive aSAH patients and for part 2, n = 50 patients with acute brain injury are recruited.

EXPECTED OUTCOMES

Part 1: Effect size of the relationship between DCI and neuropsychological outcome (MoCA). Part 2: Reliability measures for the MoCA.

DISCUSSION

The institutional review boards approved this study on July 4, 2017 under case number BASEC 2017-00103. After completion, the results will be offered to an international scientific journal for peer-reviewed publication. This study determines the exact impact of DCI on the neuropsychological outcome after aSAH, unbiased by confounding factors such as early brain injury or patient-specific characteristics. The study provides unique insights in the neuropsychological state of patients in the early period after aSAH.

Predicting motor skill learning in older adults using visuospatial performance

Between-group comparisons of older and younger adults suggest that motor learning decreases with advancing age. However, such comparisons do not necessarily account for group differences in cognitive function, despite the co-occurrence of aging and cognitive decline. As such, cognitive differences may explain the observed age effects on motor learning. Recent work has shown that the extent to which a motor task is learned is related to visuospatial function in adults over age 65. The current study tested whether this relationship is replicable across a wider age range and with a brief, widely available cognitive test. Thirty-three adults (aged 39-89 years old) completed the Montreal Cognitive Assessment (MoCA) prior to practicing a functional upper extremity motor task; performance on the motor task was assessed 24 hours later to quantify learning. Backward elimination stepwise linear regression identified which cognitive domains significantly predicted retention. Consistent with previous findings, only the Visuospatial/Executive subtest score predicted change in performance 24 hours later, even when accounting for participant age. Thus, the age-related declines in motor learning that have been reported previously may be explained in part by deficits in visuospatial function that can occur with advancing age.

Screening tools for early neuropsychological impairment after aneurysmal subarachnoid hemorrhage

BACKGROUND

Although most aneurysmal subarachnoid hemorrhage (aSAH) patients suffer from neuropsychological disabilities, outcome estimation is commonly based only on functional disability scales such as the modified Rankin Scale (mRS). Moreover, early neuropsychological screening tools are not used routinely.

OBJECTIVE

To study whether two simple neuropsychological screening tools identify neuropsychological deficits (NPDs), among aSAH patients categorized with favorable outcome (mRS 0-2) at discharge.

METHODS

We reviewed 170 consecutive aSAH patients that were registered in a prospective institutional database. We included all patients graded by the mRS at discharge, and who had additionally been evaluated by a neuropsychologist and/or occupational therapist using the Montreal Cognitive Assessment (MoCA) and/or Rapid Evaluation of Cognitive Function (ERFC). The proportion of patients with scores indicative of NPDs in each test were reported, and spearman correlation tests calculated the coefficients between the both neuropsychological test results and the mRS.

RESULTS

Of the 42 patients (24.7%) that were evaluated by at least one neuropsychological test, 34 (81.0%) were rated mRS 0-2 at discharge. Among these 34 patients, NPDs were identified in 14 (53.9%) according to the MoCA and 8 (66.7%) according to the ERFC. The mRS score was not correlated with the performance in the MoCA or ERFC.

CONCLUSION

The two screening tools implemented here frequently identified NPDs among aSAH patients that were categorized with favorable outcome according to the mRS. Our results suggest that MoCA or ERFC could be used to screen early NPDs in favorable outcome patients, who in turn might benefit from early neuropsychological rehabilitation.

The influence of nimodipine and vasopressors on outcome in patients with delayed cerebral ischemia after spontaneous subarachnoid hemorrhage

OBJECTIVE

Delayed cerebral ischemia (DCI) is a major factor contributing to the inferior outcome of patients with spontaneous subarachnoid hemorrhage (SAH). Nimodipine and induced hypertension using vasopressors are an integral part of standard therapy. Consequences of the opposite effect of nimodipine and vasopressors on blood pressure on patient outcome remain unclear. The authors report the detailed general characteristics and influence of nimodipine and vasopressors on outcome in patients with SAH.

METHODS

The authors performed a 2-center, retrospective, clinical database analysis of 732 SAH patients treated between 2008 and 2016. Demographic and clinical data such as age, sex, World Federation of Neurosurgical Societies (WFNS) grade, BMI, Fisher grade, history of arterial hypertension and smoking, aneurysm location, C-reactive protein (CRP) level, and detailed dosage of vasopressors and nimodipine during the treatment period were evaluated. Clinical outcome was analyzed using the modified Rankin Scale (mRS) 6 months after treatment. Univariate and multivariate regression analyses were performed. Additionally, mean arterial pressure (MAP), age, nimodipine, and vasopressor dose cutoff were evaluated with regard to outcome. The level of significance was set at ≤ 0.05.

RESULTS

Follow-up was assessed for 397 patients, 260 (65.5%) of whom achieved a good outcome (defined as an mRS score of 0-3). Univariate and multivariate analyses confirmed that nimodipine (p = 0.049), age (p = 0.049), and CRP level (p = 0.002) are independent predictors of good outcome. WFNS grade, Fisher score, hypertension, initial hydrocephalus, and total vasopressor dose showed significant influence on outcome in univariate analysis, and patient sex, smoking status, BMI, and MAP showed no significant association with outcome. A subgroup analysis of patients with milder initial SAH (WFNS grades I-III) revealed that initial hydrocephalus (p = 0.003) and CRP levels (p = 0.001) had significant influence on further outcome. When evaluating only patients with WFNS grade IV or V, age, CRP level (p = 0.011), vasopressor dose (p = 0.030), and nimodipine dose (p = 0.049) were independent predictors of patient outcome. Patients with an MAP < 93 mm Hg, a nimodipine cutoff dose of 241.8 mg, and cutoff total vasopressor dose of 523 mg had better outcomes.

CONCLUSIONS

According to the authors' results, higher doses of vasopressors can safely provide a situation in which the maximum dose of nimodipine could be administered. Cutoff values of the total vasopressor dose were more than 3 times higher in patients with severe SAH (WFNS grade IV or V), while the nimodipine cutoff remained similar in patients with mild and severe SAH. Hence, it seems encouraging that a maximum nimodipine dosage can be achieved despite the need for a higher vasopressor dose in patients with SAH.

Prioritization and Timing of Outcomes and Endpoints After Aneurysmal Subarachnoid Hemorrhage in Clinical Trials and Observational Studies: Proposal of a Multidisciplinary Research Group

INTRODUCTION

In studies on aneurysmal subarachnoid hemorrhage (SAH), substantial variability exists in the use and timing of outcomes and endpoints, which complicates interpretation and comparison of results between studies. The aim of the National Institute of Health/National Institute of Neurological Disorders and Stroke/National Library of Medicine Unruptured Intracranial Aneurysm (UIA) and SAH common data elements (CDE) Project was to provide a common structure for future UIA and SAH research.

METHODS

This article summarizes the recommendations of the UIA and SAH CDE Outcomes and Endpoints subgroup, which consisted of an international and multidisciplinary ad hoc panel of experts in clinical outcomes after SAH. Consensus recommendations were developed by review of previously published CDEs for other neurological diseases and the SAH literature. Recommendations for CDEs were classified by priority into "Core," "Supplemental-Highly Recommended," "Supplemental," and "Exploratory."

RESULTS

The subgroup identified over 50 outcomes measures and template case report forms (CRFs) to be included as part of the UIA and SAH CDE recommendations. None was classified as "Core". The modified Rankin Scale score and Montreal Cognitive Assessment were considered the preferred outcomes and classified as Supplemental-Highly Recommended. Death, Glasgow Outcome Scale score, and Glasgow Outcome Scale-extended were classified as Supplemental. All other outcome measures were categorized as "Exploratory". We propose outcome assessment at 3 months and at 12 months for studies interested in long-term outcomes. We give recommendations for standardized dichotomization.

CONCLUSION

The recommended outcome measures and CRFs have been distilled from a broad pool of potentially useful CDEs, scales, instruments, and endpoints. The adherence to these recommendations will facilitate the comparison of results across studies and meta-analyses of individual patient data.

Can MoCA and MMSE Be Interchangeable Cognitive Screening Tools? A Systematic Review

BACKGROUND AND OBJECTIVES

Cognitive disorders may be an early sign of neuropsychiatric disorders; however, it remains unclear whether the screening measures are interchangeable. The aim of this study was to contrast the most commonly used screening tools-Mini-Mental State Examination (MMSE) and Montreal Cognitive Assessment (MoCA)-for early detection of neurocognitive disorder (NCD).

RESEARCH DESIGN AND METHODS

This study presents a descriptive systematic review and informative literature according to the Cochrane Foundation's guidelines. The keywords "Mini-Mental State Examination" and "Montreal Cognitive Assessment" were searched in the Web of Science, SciELO, and LILACS databases.

RESULTS

Fifty-one studies were selected including a total sample of 11,870 participants (8,360 clinical patients and 3,510 healthy controls). Most studies were published in the past 5 years using a cross-sectional design, carried out across the world. They were organized by age ranges (18-69 years and 20-89 years), years of schooling, and mental status (with and without mental and behavior disorders). Sixteen of 18 studies had participants aged 18-69 years, and 21 out of 33 studies within the older set suggested that the MoCA is a more sensitive tool for detecting NCD.

DISCUSSION AND IMPLICATIONS

Thirty-seven studies suggested that the MoCA is a more sensitive tool for NCD detection because it assesses executive function and visuospatial abilities. Some individuals who demonstrated normal cognitive function on the MMSE had lower performance on the MoCA. However, it seems necessary to establish different cutoffs based on years of schooling to avoid false positives. Future studies should contrast MoCA with other screening tools designed for NCD assessment.

Return to work after subarachnoid hemorrhage: The influence of cognitive deficits

INTRODUCTION

Cognitive deficits are frequently found after subarachnoid hemorrhage (SAH), but their influence on return to work is largely unknown. To improve identification of those patients at-risk for long-term return to work problems, we aimed to examine the value of cognitive deficits in the prediction of long-term return to work after subarachnoid hemorrhage.

METHODS

SAH patients (N = 71) who were employed before SAH and were able to undergo neuropsychological assessment, were included. Demographic characteristics and acute SAH-related variables (SAH-type and external cerebrospinal fluid drainage) were taken into account. Neuropsychological tests for memory, speed, attention, executive function, and emotion recognition and a questionnaire for executive functions were used. Return to work was assessed using the Role Resumption List.

RESULTS

Results showed that patients with incomplete return to work had significantly lower scores on neuropsychological measures for complex attention and executive functions (p < 0.05) compared to patients with complete return to work. Return to work could not be significantly predicted using only demographic characteristics and acute SAH-related variables, but adding measures of complex attention and executive functions resulted in a prognostic model that could reliably distinguish between complete and incomplete return to work. Statistically significant predictors in the final model were cerebrospinal fluid drainage and scores on a questionnaire for executive functions: patients with cerebrospinal fluid drainage and higher scores on the a questionnaire for executive functions were less likely to return to work.

DISCUSSION

Together, these findings show that neuropsychological measures, especially for complex attention and executive functions, have added value to acute SAH-related and demographic variables in the prediction of long-term return to work after SAH.

Influence of the Intensive Care Unit Environment on the Reliability of the Montreal Cognitive Assessment

Background: Neuropsychological screening becomes increasingly important for the evaluation of subarachnoid hemorrhage (SAH) and stroke patients. It is often performed during the surveillance period on the intensive (ICU), while it remains unknown, whether the distraction in this environment influences the results. We aimed to study the reliability of the Montreal Cognitive Assessment (MoCA) in the ICU environment. Methods: Consecutive stable patients with recent brain injury (tumor, trauma, stroke, etc.) were evaluated twice within 36 h using official parallel versions of the MoCA (ΔMoCA). The sequence of assessment was randomized into (a) busy ICU first or (b) quiet office first with subsequent crossover. For repeated MoCA, we determined sequence, period, location effects, and the intraclass correlation coefficient (ICC). Results: N = 50 patients were studied [n = 30 (60%) male], with a mean age of 57 years. The assessment's sequence ["ICU first" mean ΔMoCA -1.14 (SD 2.34) vs. "Office first" -0.73 (SD 1.52)] did not influence the MoCA (p = 0.47). On the 2nd period, participants scored 0.96 points worse (SD 2.01; p = 0.001), indicating no MoCA learning effect but a possible difference in parallel versions. There was no location effect (p = 0.31) with ΔMoCA between locations (Office minus ICU) of -0.32 (SD 2.21). The ICC for repeated MoCA was 0.87 (95% CI 0.79-0.92). Conclusions: The reliability of the MoCA was excellent, independent from the testing environment being ICU or office. This finding is helpful for patient care and studies investigating the effect of a therapeutic intervention on the neuropsychological outcome after SAH, stroke or traumatic brain injury.

Continuous infusion of low-dose unfractionated heparin after aneurysmal subarachnoid hemorrhage: a preliminary study of cognitive outcomes

OBJECTIVE

Cognitive dysfunction occurs in up to 70% of aneurysmal subarachnoid hemorrhage (aSAH) survivors. Low-dose intravenous heparin (LDIVH) infusion using the Maryland protocol was recently shown to reduce clinical vasospasm and vasospasm-related infarction. In this study, the Montreal Cognitive Assessment (MoCA) was used to evaluate cognitive changes in aSAH patients treated with the Maryland LDIVH protocol compared with controls.

METHODS

A retrospective analysis of all patients treated for aSAH between July 2009 and April 2014 was conducted. Beginning in 2012, aSAH patients were treated with LDIVH in the postprocedural period. The MoCA was administered to all aSAH survivors prospectively during routine follow-up visits, at least 3 months after aSAH, by trained staff blinded to treatment status. Mean MoCA scores were compared between groups, and regression analyses were performed for relevant factors.

RESULTS

No significant differences in baseline characteristics were observed between groups. The mean MoCA score for the LDIVH group (n = 25) was 26.4 compared with 22.7 in controls (n = 22) (p = 0.013). Serious cognitive impairment (MoCA ≤ 20) was observed in 32% of controls compared with 0% in the LDIVH group (p = 0.008). Linear regression analysis demonstrated that only LDIVH was associated with a positive influence on MoCA scores (β = 3.68, p =0.019), whereas anterior communicating artery aneurysms and fevers were negatively associated with MoCA scores. Multivariable linear regression analysis resulted in all 3 factors maintaining significance. There were no treatment complications.

CONCLUSIONS

This preliminary study suggests that the Maryland LDIVH protocol may improve cognitive outcomes in aSAH patients. A randomized controlled trial is needed to determine the safety and potential benefit of unfractionated heparin in aSAH patients.

Cognitive Impairment, Functional Outcome, and Delayed Cerebral Ischemia After Aneurysmal Subarachnoid Hemorrhage

BACKGROUND

Measures such as modified Rankin Scale (mRS) may not reflect cognitive outcome following aneurysmal subarachnoid hemorrhage. The aim of this study was to assess the relationship between functional outcome, measured by mRS, and cognition, measured by mini-mental state examination (MMSE), after aSAH. A secondary analysis evaluated the impact of delayed cerebral ischemia (DCI) on the proportion of patients who had cognitive impairment.

METHODS

We performed a post hoc analysis of the Clazosentan to Overcome Neurological Ischemia and Infarction Occurring After Subarachnoid Hemorrhage (CONSCIOUS-1) trial data. MMSE and mRS scores were compared using Kruskal-Wallis equality-of-populations rank test with pairwise comparison post hoc analysis. Cognitive impairment was defined as MMSE score <27. A stepwise logistic regression model evaluated whether DCI was a predictor of cognitive impairment.

RESULTS

CONSCIOUS-1 comprised 413 patients. Of these, 337 took an MMSE at their 12-week follow-up. Mean MMSE score was 27 with a median of 29 (range, 0-30; SD 5.4). There were no significant differences between MMSE scores of patients who had 12-week mRS scores of 0-2. On multivariate analysis, DCI was independently associated with cognitive impairment after aSAH.

CONCLUSIONS

Patients considered to have a good outcome on mRS had varying degrees of cognitive function on MMSE, whereas development of DCI was an independent predictor of cognitive impairment after aSAH. MMSE may not be sensitive enough to discern subtle defects in cognition, as the median score was 29 out of 30.

Risk Factors for Mild Cognitive Impairment in Patients with Aneurysmal Subarachnoid Hemorrhage Treated with Endovascular Coiling

OBJECTIVE

To assess the potential early risk factors of mild cognitive impairment after aneurysmal subarachnoid hemorrhage.

METHODS

We prospectively enrolled patients with aneurysmal subarachnoid hemorrhage treated with endovascular coiling during a 5-year period. The demographic characteristics and radiologic and laboratory data were collected. Cognitive assessments were carried out using the Montreal Cognitive Assessment at 6 months after ictus. Multivariate logistic regression was used to determine the risk factors associated with the development of mild cognitive impairment.

RESULTS

Of 152 patients, 59 patients (39%) developed cognitive impairment 6 months later. Univariate analysis showed that the patients with anterior communicating artery or anterior cerebral artery aneurysms (P < 0.001) with Glasgow Outcome Scale score of 7 or less at ictus (P = 0.002), Hunt and Hess grade of 3 or higher (P = 0.002), and Fisher grade of 3 or higher (P = 0.032) were more likely to develop mild cognitive impairment. The risk of mild cognitive impairment was increased for patients who had delayed cerebral ischemia (P = 0.040) and hydrocephalus (P = 0.002). In multivariate logistic regression analysis, mild cognitive impairment was independently associated with anterior communicating artery or anterior cerebral aneurysms (odds ratio [OR], 11.046; 95% confidence interval [CI], 3.371-36.198; P < 0.001), delayed cerebral ischemia (OR, 6.153; 95% CI, 1.587-23.855; P = 0.009), and hydrocephalus (OR, 8.768; 95% CI, 2.115-36.345; P = 0.003).

CONCLUSIONS

The location of the aneurysm, delayed cerebral ischemia, and hydrocephalus were independently associated with the occurrence of mild cognitive impairment after aneurysmal subarachnoid hemorrhage and can contribute to improved identification of patients at high risk for mild cognitive impairment.

Impact of Early Versus Late Intravenous Followed by Oral Nimodipine Treatment on the Occurrence of Delayed Cerebral Ischemia Among Patients With Aneurysm Subarachnoid Hemorrhage

BACKGROUND

Guidelines for aneurysm subarachnoid hemorrhage (aSAH) management recommend treatment with nimodipine to all patients to reduce delayed cerebral ischemia (DCI) and poor clinical outcome. However, it did not give the most beneficial time to start therapy and route of administration.

OBJECTIVES

To compare the DCI occurrence and clinical outcome among aSAH patients who received nimodipine treatment at different times.

METHODS

A retrospective cohort study was conducted by collecting data from medical chart reviews between August 30, 2010, and October 31, 2015, at Prasart Neurological Institute, Thailand. Patients were classified into 2 groups by time to receive nimodipine: early group and late group (<96 and >96 hours, respectively). All patients received intravenous (IV) followed by oral nimodipine to complete treatment course. Clinical outcome was graded using the Glasgow Outcome Scale at 21 days. The factors related to DCI were analyzed using multivariate logistic regression.

RESULTS

A total of 149 patients were recruited: early (n = 97) and late (n = 52). No difference in baseline characteristics between groups was observed. The occurrence of DCI was not statistically significantly different between groups (early group, 18.60%, vs late group, 20.80%; P = 0.74). The World Federation of Neurosurgical Societies IV to V was associated with DCI occurrence. The proportion of patients with good outcome, poor outcome, or death did not show any difference between groups.

CONCLUSIONS AND RELEVANCE

Receiving IV nimodipine 3 to 7 days following oral therapy after bleeding can be the alternative regimen in patients who did not start nimodipine within 96 hours.

Correlation Between Montreal Cognitive Assessment and Functional Outcome in Subacute Stroke Patients With Cognitive Dysfunction

Objective

To investigate the correlation between the Montreal Cognitive Assessment (MoCA) and functional outcome among subacute stroke patients with cognitive dysfunction.

Methods

Records of 61 inpatients were reviewed. Patients were divided into two groups based on their initial MoCA score. MoCA score of 11 was set as the differentiating criterion. We compared the improvements in Modified Barthel Index (MBI) from initial assessment to discharge between the two groups.

Results

There were no significant differences between the two groups in relation to age, duration from onset to admission, hospitalization period, or years of education. In a comparison of the results of Mini-Mental Status Examinations (MMSE) administered at admission and again at discharge, there was significantly more improvement in MMSE scores in the group with low MoCA scores than in the group with high MoCA scores. However, the group with high MoCA scores also showed high MBI scores at discharge and exhibited greater MBI improvement.

Conclusion

Higher initial MoCA scores (which reflect preservation of executive function) indicate better functional outcome in the subacute stroke phase.

The Role of Thromboinflammation in Delayed Cerebral Ischemia after Subarachnoid Hemorrhage

Delayed cerebral ischemia (DCI) is a major determinant of patient outcome following aneurysmal subarachnoid hemorrhage. Although the exact mechanisms leading to DCI are not fully known, inflammation, cerebral vasospasm, and microthrombi may all function together to mediate the onset of DCI. Indeed, inflammation is tightly linked with activation of coagulation and microthrombi formation. Thromboinflammation is the intersection at which inflammation and thrombosis regulate one another in a feedforward manner, potentiating the formation of thrombi and pro-inflammatory signaling. In this review, we will explore the role(s) of inflammation and microthrombi in subarachnoid hemorrhage (SAH) pathophysiology and DCI, and discuss the potential of targeting thromboinflammation to prevent DCI after SAH.

Neurodegenerative cerebrospinal fluid biomarkers tau and amyloid beta predict functional, quality of life, and neuropsychological outcomes after aneurysmal subarachnoid hemorrhage

Cerebrospinal fluid (CSF) biomarkers might be useful in predicting outcome after aneurysmal subarachnoid hemorrhage (aSAH). It was the aim to determine whether tau and amyloid beta CSF concentrations predict functional, health-related quality of life (hrQoL), and neuropsychological outcomes after aSAH. Ventricular CSF was obtained from n = 24 aSAH patients at admission (D0), day 2 (D2), and day 6 (D6). CSF total (t)Tau, phosphorylated (p)Tau_(181P), and amyloid beta_{(1-40 and 1-42)} (Aβ40/Aβ42) levels were compared between patients with favorable and unfavorable functional (modified Rankin Scale (mRS)), hrQoL (Euro-Qol (EQ-5D)), and neuropsychological outcomes at 3 (3 m) and 12 months (12 m). Patients with unfavorable functional (mRS 4-6) and hrQoL outcome (EQ-5D z-score ≤ - 1.0) at 3 and 12 m had higher CSF tTau/pTau and lower Aβ40/Aβ42 at D0, D2, and D6 with varying degrees of statistical significance. In terms of predicting neuropsychological outcome, CSF pTau showed a statistically significant correlation with the z-scores of executive function (r = - 0.7486, p = 0.008), verbal memory (r = - 0.8101, p = 0.002), attention (r = - 0.6498, p = 0.030), and visuospatial functioning (r = - 0.6944, p = 0.017) at 3 m. At 12 m, CSF pTau had statistically significant correlations with the z-scores of verbal memory (r = - 0.7473, p = 0.008) and visuospatial functioning (r = - 0.6678, p = 0.024). In conclusion, higher tTau/pTau and lower Aβ40/Aβ42 CSF levels predict unfavorable long-term functional and hrQoL outcomes. Neuropsychological deficits correlate with increased CSF tTau and pTau concentrations.

A Literature Review of Psychosocial Comorbidities Related to Working Capacity After Aneurysmal Subarachnoid Hemorrhage

OBJECTIVE

The aim of this study was to describe literature regarding the impact of psychosocial comorbidities on working capacity after aneurysmal subarachnoid hemorrhage (aSAH).

DESIGN/METHODS

This study is a review of the literature using PubMed, CINAHL, PyschINFO, and Google Scholar.

RESULTS

Patients with aSAH affected by depression, anxiety, cognitive impairment, or posttraumatic stress disorder are less likely to return to work, although there are mixed results. These may be due to inconsistent inclusion, adjustment of demographic and clinical variables shown to be associated with return to work, and differences in instrumentation and sample size.

CONCLUSIONS

Working capacity after aSAH is likely affected by poor psychosocial outcomes, but future research should consider the standardization of demographic and clinical data, use standardized measurement tools, and consider the interrelatedness between psychosocial comorbidities.

History of neurosurgery at University of Toronto: the St. Michael's story

In this paper, the authors describe the history of neurosurgery at St. Michael's Hospital, University of Toronto. St. Michael's has long been regarded as one of the top teaching and research hospitals in Canada. A detailed literature review of published and unpublished works was performed to formulate a succinct but in-depth review of its development, successes, and challenges. This fascinating 125-year history serves as a reminder of the importance of their institution's origins, and the authors hope that it will be a useful guide for developing programs around the world.

The test accuracy of the Montreal Cognitive Assessment (MoCA) by stroke lateralisation

BACKGROUND

The Montreal Cognitive Assessment (MoCA) is an increasingly popular screening tool for detecting cognitive impairment post-stroke. However its' test accuracy by stroke lateralisation is as yet unknown.

AIM

Our aim was to investigate whether the test accuracy of the MoCA differs by stroke lateralisation across different cognitive domains.

METHODS

We retrospectively examined the cognitive profiles of 228 subacute stroke patients (86 Left, 142 Right), comparing MoCA-total and domain-specific scores with performance on detailed neuropsychological assessment.

RESULTS

The prevalence of cognitive impairment detected on neuropsychological assessment was high and relatively comparable between the right and left hemisphere stroke groups (91% and 93% respectively). Notably however, 29% of the right stroke group and 6% of the left stroke group achieved a "cognitively-intact" MoCA score (≥25). A high proportion of right stroke patients who had an overall MoCA-intact score were found to be impaired in intellectual functioning, processing speed, executive functions and non-verbal memory on neuropsychological assessment. Furthermore, a high proportion of patients who scored full-marks within a MoCA-specified domain, irrespective of their overall score, were found to have impairment on corresponding neuropsychological assessment for both stroke groups.

CONCLUSIONS

Particular care needs to be taken in interpreting MoCA-intact performance for right hemisphere patients due to its poor sensitivity to right hemisphere deficits. Scoring maximum points within a MoCA-specified domain also does not necessarily indicate intact cognitive functioning in that domain. Clinicians should consider supplementing their MoCA assessment with additional tools to increase the test accuracy of detecting relevant cognitive impairments post-stroke.