Depressed mood and quality of life after subarachnoid hemorrhage

Emotional distress, social support, and functional dependence predict readiness for hospital discharge in a prospective sample of cognitively intact cardiac arrest survivors

AIM

To inform screening, referral and treatment initiatives, we tested the hypothesis that emotional distress, social support, functional dependence, and cognitive impairment within 72 hours prior to discharge predict readiness for discharge in awake and alert cardiac arrest (CA) survivors.

METHODS

This was a secondary analysis of a prospective single-center cohort of CA survivors enrolled between 4/2021 and 9/2022. We quantified emotional distress using the Posttraumatic Stress Disorder Checklist-5 and PROMIS Emotional Distress - Anxiety and Depression Short Forms 4a; perceived social support using the ENRICHD Social Support Inventory; functional dependence using the modified Rankin Scale; and cognitive impairment using the Telephone Interview for Cognitive Status. Our primary outcome was readiness for discharge, measured using the Readiness for Hospital Discharge Scale. We used multivariable linear regression to test the independent association of each survivorship factor and readiness for discharge.

RESULTS

We included 110 patients (64% male, 88% white, mean age 59 [standard deviation ± 13.1 years]). Emotional distress, functional dependence, and social support were independently associated with readiness for discharge (adjusted β's [absolute value]: 0.25-0.30, all p < 0.05).

CONCLUSIONS

Hospital systems should consider implementing routine in-hospital screening for emotional distress, social support, and functional dependence for CA survivors who are awake, alert and approaching hospital discharge, and prioritize brief in hospital treatment or post-discharge referrals.

Depression Negatively Impacts Dyadic Quality of Life Following Neuro-ICU Admission: A Prospective Study of Cognitively Intact Patients and Caregivers

BACKGROUND

Admission to a neurological intensive care unit (Neuro-ICU) can increase risk for depressive and anxiety symptoms for both patients and caregivers. To better understand the long-term mental health impact of a Neuro-ICU admission, we examined the dyadic interdependence between depression and anxiety at Neuro-ICU admission with 3-month quality of life (QoL) for patients and caregivers in a longitudinal, observational cohort study.

METHOD

We assessed depressive and anxiety symptoms (Hospital Anxiety and Depression Scale; HADS) reported by neurologically intact patients (n = 72) and their caregivers (n = 72) within 2 weeks of Neuro-ICU admission (baseline) and 3-months post-discharge (follow-up). We examined the longitudinal association between dyadic depression and anxiety at Neuro-ICU admission and 3-month QoL (World Health Organization; QOL-BREF) across four domains (Physical, Psychological, Social relationships, and Environmental QoL) in separate actor-partner interdependence models (APIM) for patients and caregivers.

RESULTS

In the overall models, patients' own baseline depression levels were negatively associated with their own 3-month QoL in all domains (β =  - 0.53 to - 0.64, p < 0.001), and for caregivers, only in the psychological (β =  - 0.73, p < .001) and social relationships (β =  - 0.56, p < .001) domains. No actor effects were found for one's own baseline anxiety impacting one's own 3-month QoL. Partner effects for one's own depression were significant for caregivers on patients' 3-month psychological (β =  - 0.26, p < .02) and environmental (β =  - 0.29, p < .03) QoL, as well as for patients on caregiver's 3-month psychological QoL (β = 0.25, p < .02). No partner effects were significant in association with baseline anxiety and 3-month QoL in both patients and caregivers.

CONCLUSION

Neuro-ICU patients' and caregivers' baseline depression has significant negative impacts on their own long-term QoL. Caregivers demonstrate significant negative impacts on patient long-term QoL in domains related to emotional distress and caregiver burden. Early identification of mental health symptoms, especially depression, during Neuro-ICU admission may provide an intervention opportunity to improve QoL post-discharge for both dyad members.

Depression screening in patients with aneurysmal subarachnoid haemorrhage and their caregivers: A systematic review

BACKGROUND

Depression commonly occurs after aneurysmal subarachnoid haemorrhage (aSAH) which can negatively impact patients and their caregivers. Identification and validation of depression screening instruments specifically for patients with aSAH and their caregivers has not been performed.

OBJECTIVES

The objectives of this study were to identify the common depression screening tools in patients with aSAH and their caregivers and to determine if they are validated for use in these populations.

METHODS

Medical Subject Headings and keyword search terms were used in five electronic databases to identify randomised controlled, quasi-experimental and observational studies published between 1 January 2010 and 26 June 2022. Screening, data extraction and study quality assessments were conducted by two independent reviewers.

RESULTS

Of the 3440 identified studies, 61 met inclusion, with 2 of 61 (3%) RCTs, 2 of 61 (3%) quasi-experimental, and 57 of 61 (93%) observational studies included. The majority of studies (58/61 [95%]) reported patient-only depression screening, 1 of 61 (2%) reported both patients' and caregivers' depression screening, and 2 of 61 (3%) reported caregiver-only depression screening. Nine depression screening instruments were identified. The Beck Depression Inventory-II (BDI-II) was the most commonly used (13/59; 22%), followed by the Hospital Anxiety and Depression Scale (HADS) (12/59; 20%). In the ischaemic stroke population, the BDI-II was reported to have excellent sensitivity (0.85) and specificity (0.75); the HADS was also found to have good sensitivity (0.62) and specificity (0.83) in the ischaemic stroke population. Only two depression screening instruments for caregivers were identified: HADS and Goldberg Depression Scale. Both were found to have good sensitivity (>0.80) and specificity (>0.80) in the general population.

CONCLUSION

The BDI-II and HADS were the most commonly used depression screening instruments in patients with aSAH. Neither of these instruments has been specifically validated in an aSAH population. None of the nine depression instruments were validated for patients with aSAH. Due to an insufficient number of studies in caregivers' population, validity was unable to be determined.

Neurocognitive Sequelae and Rehabilitation after Subarachnoid Hemorrhage: Optimizing Outcomes

Subarachnoid hemorrhage (SAH) is a medical emergency that requires immediate intervention. The etiology varies between cases; however, rupture of an intracranial aneurysm accounts for 80% of medical emergencies. Early intervention and treatment are essential to prevent long-term complications. Over the years, treatment of SAH has drastically improved, which is responsible for the rapid rise in SAH survivors. Post-SAH, a significant number of patients exhibit impairments in memory and executive function and report high rates of depression and anxiety that ultimately affect daily living, return to work, and quality of life. Given the rise in SAH survivors, rehabilitation post-SAH to optimize patient outcomes becomes crucial. The review addresses the current rehabilitative strategies to combat the neurocognitive and behavioral issues that may arise following SAH.

Incidence and Prediction of Chronic Depression Following Aneurysmal Subarachnoid Hemorrhage: A Single-Center 17-Year Experience

OBJECTIVE

The incidence and risk factors for chronic depression after aneurysmal subarachnoid hemorrhage (aSAH) are described.

METHODS

Patients with aSAH treated at a single institution (January 1, 2003-December 31, 2019) and a modified Rankin Scale score ≤3 at follow-up who were evaluated for chronic depression were analyzed. Chronic depression was defined using a depression screening questionnaire as ≥5 positive answers for symptoms lasting >2 weeks. A predictive model was designed for the primary outcome of depression.

RESULTS

Among 1419 patients with aSAH, 460 patients were analyzed; 130 (28%) had major depressive disorder. Mean follow-up was >6 years. Higher depression rates were associated with tobacco smoking (odds ratio [OR] = 2.64, P < 0.001), illicit drug use (OR = 2.35, P = 0.007), alcohol use disorder (1.92, P = 0.04), chronic obstructive pulmonary disease (COPD) (OR=2.68, P = 0.03), and vasospasm requiring angioplasty (OR=2.09, P = 0.048). The predictive model included tobacco smoking, illicit drug use, liver disease, COPD, diabetes, nonsaccular aneurysm type, anterior communicating artery or anterior cerebral artery aneurysm location, refractory spasm requiring angioplasty, and a modified Rankin Scale score at discharge of >1 (P ≤ 0.03). The model performed with appropriate goodness of fit and an area under the receiver operator curve of 0.70 for depression. Individual independent predictors of depression were tobacco smoking, COPD, diabetes, and nonsaccular aneurysm.

CONCLUSIONS

A substantial percentage of patients had symptoms of depression on follow-up. The proposed predictive model for depression may be a useful clinical tool to identify patients at high risk for developing depression who warrant early screening and evaluation.

Economic and Humanistic Burden of Cerebral Vasospasm and Its Related Complications after Aneurysmal Subarachnoid Hemorrhage: A Systematic Literature Review

Introduction

Cerebral vasospasm (VSP) is the leading risk factor of neurological deterioration (i.e., delayed cerebral ischemia [DCI] and cerebral infarction) after aneurysmal subarachnoid hemorrhage (aSAH) and a cause of morbidity and mortality. The objective of this systematic literature review is to summarize the economic and humanistic burden of VSP and its related complications after aSAH.

Methods

A predefined protocol was designed, and Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines were followed. Systematic searches were conducted in MEDLINE, Embase, and Cochrane (in January 2021) to identify studies reporting economic and/or humanistic (i.e., health-related quality of life [HRQoL]) outcomes for patients with asymptomatic and symptomatic VSP after aSAH. Related conferences and additional sources were searched manually. Dual screening, data extraction, and qualitative analysis were conducted.

Results

Of 3818 abstracts identified for review, 43 full-text articles representing 42 single studies met the inclusion criteria and were included. Most studies (33) were observational; nine were randomized clinical trials (RCTs). Economic outcomes were reported in 31 studies, and alongside HRQoL outcomes in 4 studies; 7 studies reported HRQoL outcomes only. Forty studies were conducted in single countries, while only 2 RCTs were conducted in multiple countries. Patients diagnosed with VSP or DCI spent between 2.1 and 7.4 days longer in intensive care and between 4.7 and 17 days longer in hospital (total) compared with patients without VSP or DCI. A significantly higher cost burden of US$33,945 (2021 £26,712) was identified for patients with VSP and £9370 (2021 £13,733) for patients with DCI compared with patients without. Patients with DCI were also disadvantaged by being employed for 62 fewer days (during 24-month follow-up), with an estimated mean cost of £3821 (2021 £5600) for days off work. Poor HRQoL was associated with ≥ 1 days with VSP symptoms (odds ratio [OR]: 2.8, 95% confidence interval [CI]: 1.4–5.3), symptomatic VSP (OR: 1.9, 95% CI: 1.0–3.6), and DCI (OR: 2.3, 95% CI: 1.3–4.2), although this was not consistent across all studies. Symptomatic VSP and DCI were identified as significant risk factors for depressed mood (OR: 2.2, 95% CI: 1.0–4.9) and global cognitive impairment (OR: 2.3) at 12 months, respectively. The severity of VSP was a critical predictor of post-aSAH economic and humanistic burden. Similar trends in economic and humanistic burden were identified in the general aSAH patient population. Study design and patient heterogeneity precluded direct metaanalysis of the results.

Conclusion

A substantial direct and indirect economic burden is linked to VSP and its related complications after aSAH. Although limited evidence was identified for humanistic burden, these patients seem to suffer from poor HRQoL with long-lasting burden. Overall, there is an urgent need to understand better the concept of “burden of illness” of VSP and its related complications after aSAH.

Supplementary Information

The online version contains supplementary material available at 10.1007/s40120-022-00348-6.

Aneurysmal subarachnoid hemorrhage is a sudden, life-threatening emergency caused by bleeding in the subarachnoid space between the brain and skull. Vasospasm of the arteries surrounding the hemorrhage occurs in most patients and may lead to permanent brain damage. This study summarizes the published literature to describe the burden that patients may experience due to vasospasm and its related complications after aneurysmal subarachnoid hemorrhage, focusing on financial and life quality aspects. We show that the burden of vasospasm, and its related complications, is huge. Patients often experience reduced quality of life due to their poor health and are more likely to suffer from depression and intellectual impairment. There is also a substantial financial burden linked to vasospasm and its related complications, driven by the need for more intensive care, hospitalization, and higher investigative costs associated with the treatment and management of these patients. In addition, days off work and unemployment can cause a substantial indirect financial burden. Our study highlights the need for additional research to understand further the “burden of illness” of vasospasm and its related complications after aneurysmal subarachnoid hemorrhage.

Understanding the interplay between lifestyle factors and emotional distress for hemorrhagic stroke survivors and their informal caregivers: Protocol for a mixed methods dyadic natural history study

Emotional distress (depression, anxiety, and PTS) and unhealthy lifestyle factors (e.g., smoking, alcohol consumption, poor diet, limited physical activity, medication adherence) are common in hemorrhagic stroke (HS) survivors and may increase risk for recurrence, morbidity, and mortality. Emotional distress and unhealthy lifestyle factors tend to be interdependent between survivors and their informal caregivers (e.g., family and friends who provide unpaid care; together called dyads), such that one partner's lifestyle and coping behaviors influence the other's behaviors, yet no research has closely examined this relationship in HS dyads over time. We will conduct a mixed methods study to quantitatively and qualitatively understand the longitudinal relationship between emotional distress and lifestyle factors across time in this population (HS dyads) to identify treatment targets to prevent emotional distress chronicity and stroke recurrence. In aim 1, we will assess emotional distress (i.e., depression, anxiety, and PTS) and lifestyle factors (smoking, alcohol consumption, poor diet, limited physical activity medication adherence/blood pressure control) in dyads of survivors of HS and their caregivers (N = 80), at three separate time points (hospitalization in the Neuro-ICU, 1, and 3 months later). We hypothesize that 1) lifestyle factors and emotional distress will be interrelated within and across time for both survivors and caregivers, and 2) lifestyle factors and emotional distress will be interdependent between survivors and caregivers. We also aim to explore the nuanced interplay between lifestyle factors and emotional distress and gain in depth information on barriers and facilitators for a dyadic intervention to optimize lifestyle behaviors and emotional functioning in HS dyads. Eligible patients will be adults who have a caregiver also willing to participate. Patients will be referred for study participation by the nursing team who will ensure that they are cognitively able to meaningfully participate. Multilevel dyadic modeling (i.e., actor-partner interdependence model; APIM) with distinguishable dyads will be used to determine influences of these factors onto each other over time. In Aim 2, we will conduct live video qualitative dyadic interviews (N = 20 or until theme saturation) at all time points from the same participants with and without emotional distress and at least one lifestyle risk factor, to understand the nuanced relationships between emotional distress and lifestyle behaviors, and barriers and facilitators to engagement in a skills-based psychosocial intervention. Interviews will be analyzed using inductive and deductive approaches. The present study is currently ongoing. So far, we enrolled 2 participants. Recruitment will end October 2022 with plans to analyze data by December 2022. The findings from this study will be used to further develop psychosocial interventions and inform novel treatments for survivors of HS and their informal caregivers.

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.

Associations Between Baseline Total PTSD Symptom Severity, Specific PTSD Symptoms, and 3-Month Quality of Life in Neurologically Intact Neurocritical Care Patients and Informal Caregivers

BACKGROUND

The objective is to pilot test the feasibility of assessing severity of posttraumatic stress disorder (PTSD) symptoms, as well as specific lower-order PTSD symptoms, experienced during neurological intensive care unit (neuro-ICU) admission and their relationship with 3-month quality of life (QoL) scores in multiple domains (i.e., physical, psychological, social, and environmental) in both patients and caregivers.

METHODS

Between 2015 and 2016, we enrolled neurologically intact patients and informal caregivers of patients who reported demographics and PTSD symptoms (PTSD Checklist-Specific; PCL-S) during neuro-ICU admission and completed a QoL assessment (World Health Organization Quality of Life; WHOQOL-BREF) 3 months later. Clinical data were extracted from medical records. We ran two bivariate correlation matrices among PTSD symptom dimensions in patients and caregivers. Then, we used multiple linear regression to examine the prospective association of total PCL-S scores with each QoL domain in both patients and caregivers after adjusting for clinically important variables. Next, we explored differential associations between the 4 PTSD symptom dimensions and each QoL domain in both patients and caregivers, adjusting for sex and age.

RESULTS

A total of 70 patients (45.7% women, 84.3% white, mean age 52.08 years) and 64 caregivers (64.1% women, 90.6% white, mean age 53.12 years) were included. PTSD symptom dimensions were moderately strongly correlated among patients (r = 0.65-0.79, p < 0.001) and caregivers (r = 0.55-0.78, p < 0.001). For both patients and caregivers, greater PTSD symptom severity was prospectively associated with lower QoL in all domains (β = - 0.289 to - 0.622; p < 0.05). Our exploratory analysis revealed that greater numbing symptoms were associated with lower psychological QoL in patients (β: - 0.397, p = 0.038), and lower physical (β: - 0.409, p = 0.014), psychological (β: - 0.519, p = 0.001), and social QoL (β: - 0.704, p < 0.001) in caregivers. Greater re-experiencing symptoms were associated with lower physical QoL in both patients (β: - 0.422, p = 0.047) and caregivers (β: - 0.4, p = 0.041).

CONCLUSIONS

Our preliminary results indicated that greater severity of PTSD symptoms, and specifically numbing and re-experiencing symptoms, experienced by patients and caregivers during neuro-ICU admission was predictive of worse 3-month QoL. Continued study is needed to identify treatment targets for PTSD and QoL in this population.

Depression after Subarachnoid Hemorrhage: A Systematic Review

Background and Purpose

Depression is common and debilitating illness accompanying many neurological disorders including non-traumatic subarachnoid hemorrhage (SAH). The aim of this systematic review was to identify and critically appraise all published studies that have reported the frequency, severity and time course of depression after SAH, the factors associated with its development and the impact of depression on patients’ quality of life after SAH.

Methods

The PubMed database was searched for studies published in English that recruited at least 40 patients (>18 years old) after SAH who were also diagnosed with depression.

Results

Altogether 55 studies covering 6,327 patients met study entry criteria. The frequency of depression ranged from 0% to 61.7%, with a weighted proportion of 28.1%. Depression remained common even several years after the index SAH. Depression after SAH was associated with female sex, premorbid depression, anxiety, substance use disorders or any psychiatric disorders, and coping styles. Comorbid cognitive impairment, fatigue, and physical disability also increased the risk of depression. Aneurysmal SAH and infarction may be related to depression as well. Depression reduces the quality of life and life satisfaction in patients after SAH.

Conclusions

Depression is common after SAH and seems to persist. Further research is needed to clarify its time course and identify the neuroendocrine and neurochemical factors and brain circuits associated with the development of post-SAH depression. Randomized controlled treatment trials targeting SAH-related depression are warranted.

Aneurysmal subarachnoid haemorrhage: Effect of CRHR1 genotype on mental health-related quality of life

Quality of life (QoL) disturbances are common after aneurysmal subarachnoid hemorrhage (aSAH) both in physical and mental health domains and their causes are not clearly understood. Corticotropin-releasing hormone receptor 1 (CRHR1) is involved in stress reactivity and development of mental health disturbances after negative life-events. We performed a retrospective cohort study of long-term QoL outcomes among 125 surgically treated aSAH patients (2001-2013). QoL was assessed with Short Form Health Survey (SF-36) and compared to an age and gender matched general population. Genotyping of CRHR1 single nucleotide polymorphisms was performed (Rs7209436, Rs110402, Rs242924) and their effect on QoL scores was explored. aSAH patients experienced a reduced quality of life in all domains. CRHR1 minor genotype was associated with higher SF-36 mental health (OR = 1.31-1.6, p < 0.05), role-emotional (OR = 1.57, p = 0.04) and vitality scores (OR = 1.31-1.38, p < 0.05). Association of all studied SNP's with vitality and Rs242924 with mental health scores remained statistically significant after Bonferroni correction. Mental quality of life scores were associated with physical state of patients, antidepressant history and CRHR1 genotype. Predisposition to mental health disturbances after stressful life-events might be associated with reduced mental QoL after aSAH and selected patients could be provided advanced counselling in the recovery phase.

Symptoms and consequences of subarachnoid haemorrhage after 7 years

Objectives

Short‐term follow‐up studies after a subarachnoid haemorrhage (SAH) have shown impaired cognition, fatigue, depression and anxiety, but less is known regarding long‐term consequences. The aim of this study was to investigate health outcomes in persons 7 years after SAH.

Materials and Methods

This is a descriptive cohort follow‐up study of persons with non‐traumatic SAH treated at Sahlgrenska University Hospital, Gothenburg, Sweden. The follow‐up was conducted 7 years post‐treatment and included home visits using forms and questionnaires about health outcomes; the Barthel Index (BI), modified Rankin Scale (mRS), National Institutes of Health Stroke Scale (NIHSS), Hospital Anxiety and Depression Scale (HADS), Montreal Cognitive Assessment (MoCA) and Multidimensional Fatigue Inventory (MFI).

Results

Seven years post‐SAH, 33 persons fulfilled the inclusion criteria, of whom 18 (55%) participated (median age 63 years). Cognitive impairment was present in 11 participants, assessed with the MoCA, where the item of delayed recall was most difficult. The majority (n = 16) were independent in activities of daily living (ADL), and few (n = 3) had physical symptoms according to the NIHSS. However, three participants were free from disability according to the mRS. Nearly, half of the participants had symptoms of anxiety (n = 8). Three had symptoms of depression and more than half experienced fatigue.

Conclusion

The physical function and independency in ADL is high among long‐term SAH survivors. Despite this, only a few were completely free from disability, and the main problems 7 years after SAH were cognitive impairment and anxiety.

Preventable Readmissions and Predictors of Readmission After Subarachnoid Hemorrhage

OBJECTIVE

To estimate rates of all-cause and potentially preventable readmissions up to 90 days after discharge for aneurysmal subarachnoid hemorrhage (SAH) and medical comorbidities associated with readmissions BACKGROUND: Readmission rate is a common metric linked to compensation and used as a proxy to quality of care. Prior studies in SAH have reported 30-day readmission rates of 7-17% with a higher readmission risk among those with the higher SAH severity, ≥ 3 comorbidities, and non-home discharge. Intermediate-term rates, up to 90-days, and the proportion of these readmissions that are potentially preventable are unknown. Furthermore, the specific medical comorbidities associated with readmissions are unknown.

METHODS

Index SAH admissions were identified from the 2013 Nationwide Readmissions Database. All-cause readmissions were defined as any readmission during the 30-, 60-, and 90-day post-discharge period. Potentially preventable readmissions were identified using Prevention Quality Indicators developed by the US Agency for Healthcare Research and Quality. Unadjusted and adjusted Poisson models were used to identify factors associated with increased readmission rates.

RESULTS

Out of 9987 index admissions for SAH, 7949 (79%) survived to discharge. The percentage of 30-, 60-, and 90-day all-cause readmissions were 7.8, 16.6, and 26%, respectively. Up to 14% of readmissions in the first 30 days were considered potentially preventable and acute conditions (dehydration, bacterial pneumonia, and urinary tract infections) accounted for over half, whereas acute cerebrovascular disease was the most common cause for neurological return. In multivariable analysis, significant predictors of a higher readmission rate included diabetes (rate ratio [RR] 1.09, 95% confidence interval [CI] 1.03-1.15), congestive heart failure (RR 1.09, 1.003-1.18), and renal impairment (RR 1.35, 1.13-1.61). Only discharge home was associated with a lower readmission rate (RR 0.89, 0.85-0.93).

CONCLUSIONS

SAH has a 30-day readmission rate of 7.8% which continues to rise into the intermediate-term. A low but constant proportion of readmissions are potentially preventable. Several chronic medical comorbidities were associated with readmissions. Prospective studies are warranted to clarify causal relationships.

Antidepressants and nose-to-brain delivery: drivers, restraints, opportunities and challenges

Why is nose-to-brain delivery considered to be a strategy that directly allows the access of antidepressants to the brain? In which circumstances can the intranasal pathway be applicable? Are there any requirements to follow? What triggers the antidepressant market? Which constraints are imposed during discovery programs? What opportunities can arise and what is their current status of development? Are they already translated into clinical practice? Which challenges are expected from recent development strategies? This review aims at providing a critical appraisal of nose-to-brain delivery of antidepressants, framed within a comprehensive analysis of drivers, restraints, opportunities and challenges.

Quality of life and depression 3 months after intracerebral hemorrhage

OBJECTIVES

Quality of life (QoL) after intracerebral hemorrhage (ICH) is poorly known. This study investigated factors affecting QoL and depression after spontaneous ICH.

MATERIALS AND METHODS

This prospective study included patients admitted to Helsinki University Hospital between May 2014 and December 2016. Health-related QoL (HRQoL) at 3 months after ICH was measured using the European Quality of Life Scale (EQ-5D-5L), and the 15D scale. Logistic regression analyses were used to test factors affecting HRQoL. EQ-5D-5L anxiety/depression dimension was used to analyze factors associated with anxiety/depression.

RESULTS

Of 277 patients, 220 were alive, and sent QoL questionnaire. The questionnaire was returned by 124 patients. Nonreturners had more severe strokes with admission National Institutes of Health Stroke Scale (NIHSS) 7.8 (IQR 3.0-14.8) versus 5.0 (IQR 2.3-11.0); p = 0.018, and worse outcome assessed as modified Rankin Scale 3-5 at 3 months 59.4% versus 44.4% (p = 0.030). Predictors for lower HRQoL by both scales were higher NIHSS with OR 1.28 (95% CI 1.13-1.46) for EQ-5D-5L, and OR 1.28 (1.15-1.44) for 15D, older age (OR 1.10 [1.03-1.16], and OR 1.09 [1.03-1.15]), and chronic heart failure (OR 18.12 [1.73-189.27], and OR 12.84 [1.31-126.32]), respectively. Feeling sad/depressed for more than 2 weeks during the year prior to ICH was predictor for lower EQ-5D-5L (OR 10.64 [2.39-47.28]), and history of ICH for lower 15D utility indexes (OR 11.85 [1.01-138.90]). Prior feelings of sadness/depression were associated with depression/anxiety at 3 months after ICH with OR 3.62 (1.14-11.45).

CONCLUSIONS

In this cohort of ICH patients with milder deficits, HRQoL was affected by stroke severity, comorbidities and age. Feelings of depression before ICH had stronger influence on reporting depression/anxiety after ICH than stroke severity-related and outcome parameters. Thus, simple questions on patient's premorbid feelings of sadness/depression could be used to identify patients at risk of depression after ICH for focusing follow-up and treatment.

A reduced concentration of brain interstitial amino acids is associated with depression in subarachnoid hemorrhage patients

The amino-acids tryptophan, phenylalanine and tyrosine seem to play an important role in the pathophysiology of depressive disorders. We measured daily brain extracellular levels of these amino-acids using cerebral microdialysis (CMD) and high performance liquid chromatography in 26 consecutive subarachnoid hemorrhage (SAH) patients and associated them with the presence of depressive disorders. Patients were grouped as follows: medical history of depression (prior to SAH), antidepressant intake 12 months after SAH (but not before), or neither. CMD-tryptophan, CMD-phenylalanine and CMD-tyrosine levels were significantly lower in patients with preexisting depressive disorders compared to those without depression (p < 0.01). Disease severity and SAH-related complications were not associated with amino-acid concentrations. We found a positive correlation between nutritionally administered and brain interstitial levels of tryptophan and phenylalanine in non-depressed patients (R = 0.26 and R = 0.24, p < 0.05), which was not present in patients with preexisting depression (p > 0.1). In conclusion, brain interstitial levels of tryptophan, phenylalanine and tyrosine measured in the context of the clinical management of SAH were significantly decreased in patients with a medical history of depression. This study supports the hypothesis that the availability of these neurotransmitter precursor amino-acids in the human brain may play an important role in the pathophysiology of depressive disorders.

Cognitive Outcomes After Anterior Communicating Artery Aneurysm Repair

Background The long-term cognitive and quality-of-life (QoL) outcomes after treatment of ruptured anterior communicating artery (ACoA) aneurysms are unknown. Methods Potential participants were all consecutive patients with ruptured ACoA aneurysms who were treated at one institution from July 1992 to December 2008. All potential participants were asked to complete the Cognitive Failures Questionnaire (CFQ), Center for Epidemiology Studies-Depression (CES-D) questionnaire, Short Form 36 (SF-36) questionnaire, and Telephone Interview for Cognitive Status-Modified (TICS-M). Patient charts were retrospectively reviewed for baseline demographics and clinical status, intra-operative details, and post-operative course. Reporting of cognitive and QoL assessment results was stratified by treatment method (endovascular coil embolization and surgical clipping by pterional craniotomy or orbitocranial craniotomy). Results In total, 82 patients (18 treated with coiling, 27 by orbitocranial craniotomy, and 37 by pterional craniotomy) were included in this study. In total, 32 patients (9 treated by coiling, 11 by orbitocranial craniotomy, and 16 by pterional craniotomy) completed follow-up cognitive and QoL questionnaires. The mean follow-up for patients who completed the questionnaires was 8.64±3.81 years. The three groups did not differ in questionnaires assessing cognitive status (TICS-M p=0.114, CFQ p=0.111). Moreover, there were no observed differences in QoL or depression scores between the three groups. Conclusions At long-term follow-up, QoL, cognitive, and depression test scores of patients with ruptured ACoA aneurysms are similar across open surgery and coiling modalities. Our results emphasize the importance of considering long-term outcomes with validated daily measures of functioning when reporting on outcomes after treatment for ruptured intracranial aneurysms. Larger prospective studies are required to further explore the results.

Significant Injury of the Mammillothalamic Tract without Injury of the Corticospinal Tract After Aneurysmal Subarachnoid Hemorrhage: A Retrospective Diffusion Tensor Imaging Study

OBJECTIVE

Little is known about the pathophysiologic mechanisms of white matter injury after aneurysmal subarachnoid hemorrhage (aSAH). The purpose of this study is to investigate whether the mammillothalamic tract (MTT) or corticospinal tract (CST) is more affected by aSAH in the same patients with good outcome (Grade 5 on Glasgow Outcome Scale at 3 months) using diffusion tensor imaging (DTI).

METHODS

Between June 2013 and September 2016, 21 patients with aSAH with good outcome and 21 sex- and age-matched normal healthy control participants were recruited. DTI was obtained at 8.92 ± 2.4 weeks after onset. Moreover, reconstruction of the CST and the MTT was completed with DTI-studio software. Apparent diffusion coefficient (ADC) and fractional anisotropy (FA) values were measured. In addition, the motricity index and Mini-Mental State Examination scores were obtained.

RESULTS

There was no statistically significant difference detected in the ADC and FA values of the CST between the patient and control groups (P > 0.05). On the contrary, there was a statistically significant difference in ADC and FA values of the MTT between the patient and control groups (P < 0.05). In addition, in the patient group, no correlation (P > 0.05) was observed between motricity index scores and DTI parameters (ADC and FA), whereas the Mini-Mental State Examination showed a positive correlation with FA (r = 0.591, P = 0.029) without correlation to ADC (r = 0.142, P = 0.628).

CONCLUSIONS

Patients with good outcomes (Grade 5 on Glasgow Outcome Scale at 3 months) after aSAH appeared to suffer an injury of the MTT without an associated injury of the CST compared with the control group. This injury showed a correlation with cognitive dysfunction.

Intranasal Stem Cell Treatment as a Novel Therapy for Subarachnoid Hemorrhage

Subarachnoid hemorrhage (SAH) represents a major health problem in Western society due to high mortality and morbidity, and the relative young age of patients. Currently, efficacious therapeutic options are very limited. Mesenchymal stem cell (MSC) administration has been shown to improve functional outcome and lesion size in experimental models of stroke and neonatal hypoxic-ischemic brain injury. Here, we studied the therapeutic potential of intranasally administered bone marrow-derived MSCs relatively late postinsult using a rat endovascular puncture model for SAH. Six days after induction of SAH, rats were treated with MSCs or vehicle through nasal administration. Intranasal MSC treatment significantly improved sensorimotor and mechanosensory function at 21 days after SAH. Gray and white matter loss was significantly reduced by MSC treatment and the number of NeuN⁺ neurons around the lesion increased due to MSC treatment. Moreover, intranasal MSC administration led to a sharp decrease in SAH-induced activation of astrocytes and microglia/macrophages in the lesioned hemisphere, especially of M2-like (CD206⁺) microglia/macrophages. Interestingly, MSC administration also decreased SAH-induced depression-like behavior in association with a restoration of tyrosine hydroxylase expression in the substantia nigra and striatum. We show here for the first time that intranasal MSC administration reverses the devastating consequences of SAH, including regeneration of the cerebral lesion, functional recovery, and treatment of comorbid depression-like behavior.

The Size of Ruptured Intracranial Aneurysms : A 10-Year Series from a Single Center

PURPOSE

There is a controversy concerning the risk of rupture of small intracranial aneurysms. We sought to determine the size and morphological features of ruptured intracranial aneurysms.

MATERIAL AND METHODS

The hospital files and images from all patients referred during one decade (2007-2016) to a specialized neurovascular center were retrospectively reviewed. Neck diameter, fundus depth and width as well as neck width based on catheter angiography were measured. Aneurysm morphology was classified as either regular, lobulated, irregular or fusiform.

RESULTS

A total of 694 consecutive patients with aneurysmal subarachnoid hemorrhage (aSAH) were identified (65.9% female, median age 54.3 years). The anterior communicating artery (AcomA) was the most frequent location of ruptured aneurysms. The medians for aneurysm depth, width and neck diameter were 5 mm, 4.5 mm and 3 mm, respectively. A regular contour of the aneurysm sac was found in 19%.

CONCLUSION

The majority of aSAH are caused by small intracranial aneurysms. There is no safety margin in terms of small aneurysm size of regular shape without daughter aneurysms. Treatment should also be offered to patients with small, regularly shaped intracranial aneurysms, together with an empirical risk-benefit assessment.

Delayed Cerebral Ischemia after Subarachnoid Hemorrhage: Beyond Vasospasm and Towards a Multifactorial Pathophysiology

PURPOSE OF REVIEW

Delayed cerebral ischemia (DCI) is common after subarachnoid hemorrhage (SAH) and represents a significant cause of poor functional outcome. DCI was mainly thought to be caused by cerebral vasospasm; however, recent clinical trials have been unable to confirm this hypothesis. Studies in humans and animal models have since supported the notion of a multifactorial pathophysiology of DCI. This review summarizes some of the main mechanisms under investigation including cerebral vascular dysregulation, microthrombosis, cortical spreading depolarizations, and neuroinflammation.

RECENT FINDINGS

Recent guidelines have differentiated between DCI and angiographic vasospasm and have highlighted roles of the microvasculature, coagulation and fibrinolytic systems, cortical spreading depressions, and the contribution of the immune system to DCI. Many therapeutic interventions are underway in both preclinical and clinical studies to target these novel mechanisms as well as studies connecting these mechanisms to one another. Clinical trials to date have been largely unsuccessful at preventing or treating DCI after SAH. The only successful pharmacologic intervention is the calcium channel antagonist, nimodipine. Recent studies have provided evidence that cerebral vasospasm is not the sole contributor to DCI and that additional mechanisms may play equal if not more important roles.

[Depression and depression-related disorders after a subarachnoid hemorrhage]

Psychiatric disorders often develop after subarachnoid hemorrhage (SAH); the most frequent of them are depression and depression-related disorders (anxiety, apathy, pathological fatigue, posttraumatic stress disorder, etc.). Both biological and psychological mechanisms may underlie the development of these disorders. Depression and depression-related disorders decrease patients' quality of life and prevent the full recovery after SAH. Identification and correction of these disorders should take a prominent place in the rehabilitation of post-SAH patients. More research is needed in this area.

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.

Hematologic counts as predictors of delayed cerebral ischemia after aneurysmal subarachnoid hemorrhage

PURPOSE

Aneurysmal subarachnoid hemorrhage (SAH) is associated with high morbidity and mortality, but currently no single clinical method or ancillary test can reliably predict which subset of patients will develop delayed cerebral ischemia (DCI). The aim of this study was to find hematologic derangements and clinical factors present during the first 7 days after bleeding that could help identify patients at risk for development of DCI.

MATERIALS AND METHODS

Databank analysis of patients with SAH admitted between 2010 and 2012 in a single center. Data from demographics, imaging, laboratory, and clinical factors were collected. Statistical testing was conducted to test for association to the outcome, and multivariate logistic regression was used to design a predictive model.

RESULTS

Of 55 patients, 14 developed DCI (25%). Anemia and leukocytosis on the third day after bleeding were significantly correlated with the outcome (for anemia: P<.032; confidence interval, 1.12-15.16; odds ratio, 4.12; for leukocytosis: P<.046; confidence interval, 1.03-26.13; odds ratio, 5.18). Anemia and leukocytosis were still statistically significant after adjustment for age, sex, modified Fisher scale, and Hunt-Hess scale.

CONCLUSION

The presence of leukocytosis and anemia during the third day after SAH was statistically correlated with the occurrence of DCI.

Antidepressant Use After Aneurysmal Subarachnoid Hemorrhage

Background and Purpose—

To elucidate the predictors of antidepressant use after subarachnoid hemorrhage from saccular intracranial aneurysm (sIA-SAH) in a population-based cohort with matched controls.

Methods—

The Kuopio sIA database includes all unruptured and ruptured sIA cases admitted to the Kuopio University Hospital from its defined catchment population in Eastern Finland, with 3 matched controls for each patient. The use of all prescribed medicines has been fused from the Finnish national registry of prescribed medicines. In the present study, 2 or more purchases of antidepressant medication indicated antidepressant use. The risk factors of the antidepressant use were analyzed in 940 patients alive 12 months after sIA-SAH, and the classification tree analysis was used to create a predicting model for antidepressant use after sIA-SAH.

Results—

The 940 12-month survivors of sIA-SAH had significantly more antidepressant use (odds ratio, 2.6; 95% confidence interval, 2.2–3.1) than their 2676 matched controls (29% versus 14%). Classification tree analysis, based on independent risk factors, was used for the best prediction model of antidepressant use after sIA-SAH. Modified Rankin Scale until 12 months was the most potent predictor, followed by condition (Hunt and Hess Scale) and age on admission for sIA-SAH.

Conclusions—

The sIA-SAH survivors use significantly more often antidepressants, indicative of depression, than their matched population controls. Even with a seemingly good recovery (modified Rankin Scale score, 0) at 12 months after sIA-SAH, there is a significant risk of depression requiring antidepressant medication.

Long-Term Functioning of Patients with Aneurysmal Subarachnoid Hemorrhage: A 4-yr Follow-up Study

OBJECTIVES

The aim was to study changes over time for multiple outcomes based on the International Classification of Functioning, Disability, and Health in patients with aneurysmal subarachnoid hemorrhage and to compare long-term outcomes with norms.

DESIGN

A prospective cohort study with 4-yr follow-up was conducted. Main outcome measures were as follows: Center for Epidemiologic Studies-Depression Scale, Fatigue Severity Scale, Trail Making Test A and B, Barthel Index, Sickness Impact Profile-68, Impact on Participation and Autonomy Questionnaire, Social Support List-12, Multidimensional Health Locus of Control Scales, COOP-WONCA Charts, and Short Form-36 Health Survey.

RESULTS

Seventy-six patients with aneurysmal subarachnoid hemorrhage were included. Measurements were done at T1 = 0.4 yrs (SD, 0.3 yrs) and T2 = 3.9 yrs (SD, 0.7 yrs) after onset. Significant improvements over time were found for Barthel Index (T1 = 18.5; T2 = 19.5; P = 0.023), Trail Making Test B (T1 = 119.4; T2 = 104.6; P = 0.025), Social Support List-12 total score (T1 = 31.1; T2 = 32.7; P = 0.042) and esteem support (T1 = 10.2; T2 = 10.9; P = 0.027), Multidimensional Health Locus of Control Scales (physician-orientation) (T1 = 21.8; T2 = 19.2; P = 0.020), and Short Form-36 Health Survey (role-emotional) (T1 = 54.6; T2 = 73.9; P = 0.048). Center for Epidemiologic Studies-Depression Scale, Fatigue Severity Scale, Sickness Impact Profile-68, and Short Form-36 Health Survey scores remained stable over time. A decline was found for COOP-WONCA (overall-health) (T1 = 2.3; T2 = 2.7; P = 0.021). At 4-yr follow-up, proportions of depression (27%) and fatigue (60%) were larger and scores on the Fatigue Severity Scale (mean [SE], 4.3 [0.2]), Trail Making Test A (mean [SE], 51.3 [3.9]), and Trail Making Test B (mean [SE], 104.4 [0.2]) were significantly worse than norm scores.

CONCLUSIONS

Many patients with aneurysmal subarachnoid hemorrhage had fairly good long-term outcomes, but problems in executive functioning, mood, and fatigue still exist at long-term follow-up.

Evaluation of quality of life in individuals with severe chronic motor disability: A major challenge

Diverse conditions causing a very heavy and chronic motor disability, such as an advanced amyotrophic lateral, advanced form of multiple sclerosis, high spinal cord injury or a locked-in syndrom, are now getting better medical care and benefit of life support technology with consequent prolonged survival. Quality of life (QoL) assessment is being considered increasingly important to globally apprehend their general well-being. However, the motor disability that affects them appears as a substantial limitation for the assessment of their QoL and consequently a major challenge for all the community that carries an interest for them. This review discussed several avenues to provide to patients and caregivers, clinicians and researchers, and health decision making authority: i) elements to determine the most appropriate QoL measure with regard to the interest of patient's point of view, the QoL instruments suitable for this category of patients and their acceptability, ii) some arguments of the clinical relevance and accuracy of QoL assessment: interpretations of the questionnaires, QoL determinants, particularity of QoL evaluation for individuals with cognitive impairment and the caregivers perceptions of patients QoL. In conclusion, evaluation of QoL in patients with severe chronic motor handicap is a challenge of major interest, with major ethical issues. It needs to use adapted QoL scales and longitudinal following because of adaptive phenomena to the degree of handicap.

Patient-reported outcome measures for patients with cerebral aneurysms acquired via social media: data from a large nationwide sample

Background

With greater survival rates, patient-reported outcome measures (PROMs) among survivors of ruptured cerebral aneurysm should be an increasing concern among neurointerventionalists. Prior studies were limited in scale and generalizability. Our study aims were to (1) evaluate the validity of cerebral aneurysm PROMs obtained from social media; (2) determine the persistence of PROMs over time; and (3) determine what PROMs still exist in those with no physical impairments.

Methods

By engaging national brain aneurysm support groups and using an online questionnaire modeled after the generic EQ-5D instrument, we asked respondents to classify their health in five dimensions including mobility, self-care, usual activities, pain/discomfort, and anxiety/depression using a 3-point Likert scale.

Results

In 2 months we received 604 responses from 46 states in the USA. Our cohort of ruptured aneurysm respondents reported PROMs similar to previously published series. Over time, headache and anxiety improved while depression, level of exercise, and return to work remained unchanged. We found that memory worsened after 2 years. Among those without any physical impairment, rates of 20.6%, 14.9%, 12.6%, and 23% were seen for significant headaches, significant memory loss, significant depression, and sense of life being negatively affected, respectively.

Conclusions

Despite this novel study design, we obtained results comparable to prior studies. These results suggest that many patients with ruptured cerebral aneurysms, regardless of whether they are >2 years after the event and/or free of physical impairment, struggle with a poor quality of life. The latency, scale, and low cost of this study design may accelerate future cerebral aneurysm PROM research.

Self-perceived health status following aneurysmal subarachnoid haemorrhage: a cohort study

OBJECTIVE

The objective of the study was to assess the long-term self-reported health status and quality of life (QoL) of patients following an aneurysmal subarachnoid haemorrhage (ASAH) using a self-completed questionnaire booklet.

DESIGN

A two-cohort study.

SETTING

A regional tertiary neurosurgical centre.

PARTICIPANTS

2 cohorts of patients with ASAH treated between 1998 and 2008 and followed up at approximately 1 year.

INTERVENTIONS

Routine care.

PRIMARY AND SECONDARY OUTCOMES

A range of standardised scales included: AKC Short Sentences Test, the Barthel Index, the Self-Report Dysexecutive Questionnaire, the Everyday Memory Questionnaire, Stroke Symptom Checklist, Wimbledon Self-Report Scale, Modified Rankin Score (MRS) and a new Stroke-QoL. The data from summated scales were fit to the Rasch measurement model to validate the summed score.

RESULTS

214 patients (48%) returned the questionnaires; the majority (76%) had a World Federation of Neurosurgeons grade of 1 or 2. The most frequent aneurysm type was that of the anterior communicating artery (28%) with approximately 90% of aneurysms of the anterior circulation. Of those previously in full or part-time employment, 48.9% were unemployed at follow-up. All summated scales satisfied the Rasch measurement model requirements, such that their summed scores were a sufficient statistic. Given this, one-third of patients were noted to have a significant mood disorder and 25% had significant dysexecutive function. Patients with an MRS of 3, 4 or 5 had significantly worse scores on most outcome measures, but a significant minority of those with a score of zero had failed to return to work and displayed significant mood disorder.

CONCLUSIONS

A range of self-reported cognitive and physical deficits have been highlighted in a cohort of patients with ASAH. While the MRS has been shown to provide a reasonable indication of outcome, in routine clinical follow-up it requires supplementation by instruments assessing dysexecutive function, memory and mood.

Development of a short form of Stroke-Specific Quality of Life Scale for patients after aneurysmal subarachnoid hemorrhage

BACKGROUND

The identification of aneurysmal subarachnoid hemorrhage (aSAH) patients with a decrease in health-related quality of life (HRQOL) is challenging. Stroke-Specific Quality of Life (SS-QOL) Scale is one of the commonest disease-specific quality of life measures initially developed and validated for ischemic stroke patients. A disadvantage is subject burden and a short form is more practical to use in clinical and research setting.

AIM

This study aimed to develop a short form (12-item) of a Chinese version of Stroke-Specific Quality of Life Scale for aSAH (SSQOL-a) for clinical and research applications.

METHODS

We carried out a prospective observational assessor-blinded multi-center study in Hong Kong. The study was registered at ClinicalTrials.gov of the U.S. National Institutes of Health (NCT01038193), and was approved by hospital ethics committees.

RESULTS

One hundred and eighty-six aSAH patients were recruited over a 30 month period during admission. One hundred (54%) aSAH patients completed the 12-month assessment battery and were included into the current study. The total score, physical component score, and psychosocial score of the 12-item Chinese version showed satisfactory internal consistency and explained high percentages of variance of the full Chinese version (92% to 96%). The 12-item Chinese version showed significant correlations with neurological, functional, generic quality of life, psychiatric, and cognitive outcome measures at 12 months. Chinese version calculated physical subscore had better discrimination in detecting complete recovery than the Dutch version calculated physical subscore in our Chinese population.

CONCLUSIONS

The 12-item Chinese version of SSQOL-a has a satisfactory internal consistency and criterion validity for SAH patients at 12 month assessments.