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Zaki Ghali MG, Srinivasan VM, Wagner K, Rao C, Chen SR, Johnson JN, Kan P. Cognitive Sequelae of Unruptured and Ruptured Intracranial Aneurysms and their Treatment: Modalities for Neuropsychological Assessment. World Neurosurg 2018; 120:537-549. [PMID: 29966787 DOI: 10.1016/j.wneu.2018.06.178] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/21/2018] [Revised: 06/20/2018] [Accepted: 06/21/2018] [Indexed: 10/28/2022]
Abstract
BACKGROUND Cognitive sequelae frequently follow subarachnoid hemorrhage (SAH) and include deficits across multiple domains of executive function. This factor affects overall functional outcomes negatively, especially in younger patients. Several clinical correlates predict development and severity of cognitive dysfunction after SAH. Hypothetical mechanisms of cognitive dysfunction in the absence of radiographic lesion include cerebral hypoperfusion and blood breakdown products, resulting in perturbed interneuronal communication and network synchrony, excitotoxicity, and altered microRNA expression. METHODS The PubMed database was searched for articles discussing cognitive outcomes in patients with unruptured and ruptured intracranial aneurysmal disease, sequelae of treatment, and modalities for neuropsychologic testing. RESULTS Treatment of unruptured intracranial aneurysms, although capable of preventing SAH, comes with its own set of complications and may also affect cognitive function. Neuropsychological tests such as the Montreal Cognitive Assessment, Mini-Mental Status Examination, and others have proved useful in evaluating cognitive decline. Studies using functional neurologic imaging modalities have identified regions with altered activation patterns during various cognitive tasks. The sum of research efforts in this field has provided useful insights and an initial understanding of cognitive dysfunction after aneurysm treatment and SAH that should prove useful in guiding and rendering future investigations more fruitful. CONCLUSIONS Development of finer and more sensitive neuropsychological tests in evaluating the different domains of cognitive function after aneurysm treatment and SAH in general will be useful in accurately determining outcomes after ictus and comparing efficacy of different therapeutic strategies.
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Affiliation(s)
| | | | - Kathryn Wagner
- Department of Neurosurgery, Baylor College of Medicine, Houston, Texas, USA
| | - Chethan Rao
- Department of Neurosurgery, Baylor College of Medicine, Houston, Texas, USA
| | - Stephen R Chen
- Department of Neurosurgery, Baylor College of Medicine, Houston, Texas, USA
| | - Jeremiah N Johnson
- Department of Neurosurgery, Baylor College of Medicine, Houston, Texas, USA
| | - Peter Kan
- Department of Neurosurgery, Baylor College of Medicine, Houston, Texas, USA.
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Chung J, Seok JH, Kwon MA, Kim YB, Joo JY, Hong CK. Effects of preventive surgery for unruptured intracranial aneurysms on attention, executive function, learning and memory: a prospective cohort study. Acta Neurochir (Wien) 2016; 158:197-205. [PMID: 26602237 DOI: 10.1007/s00701-015-2641-z] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/31/2015] [Accepted: 11/12/2015] [Indexed: 11/25/2022]
Abstract
BACKGROUND We prospectively evaluated the effects of preventive surgery for unruptured intracranial aneurysms on attention, executive function, learning and memory. METHODS Between March 2012 and June 2013, 56 patients were recruited for this study. Fifty-one patients met the inclusion criteria and were enrolled. Inclusion criteria were as follows: (1) age ≤65 years and (2) planned microsurgery or endovascular surgery for unruptured intracranial aneurysm. Exclusion criteria were as follows: (1) preoperative intelligence quotient <80 (n = 3); (2) initial modified Rankin scale ≥1 (n = 1); (3) loss to follow-up (n = 1). An auditory controlled continuous performance test (ACCPT), word-color test (WCT) and verbal learning test (VLT) were performed before and after (6 months) preventive surgery. RESULTS ACCPT (attention), WCT (executive function) and VLT (learning and memory) scores did not change significantly between the pre- and postoperative evaluations. The ACCPT, WCT, total VLT scores (verbal learning) and delayed VLT scores (memory) did not differ significantly between patients undergoing microsurgery and those undergoing endovascular surgery. However, ACCPT, WCT and delayed VLT scores decreased postoperatively in patients with leukoaraiosis on preoperative FLAIR images (OR 9.899, p = 0.041; OR 11.421, p = 0.006; OR 2.952, p = 0.024, respectively). CONCLUSIONS Preventive surgery for unruptured intracranial aneurysms did not affect attention, executive function, learning or memory. However, patients with leukoaraiosis on FLAIR images might be prone to deficits in attention, executive function and memory postoperatively, whereas learning might not be affected.
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Affiliation(s)
- Joonho Chung
- Department of Neurosurgery, Gangnam Severance Hospital, Yonsei University College of Medicine, 211, Eonjuro, Gangnam-gu, Seoul, 135-720, Republic of Korea
- Severance Institute for Vascular and Metabolic Research, Yonsei University College of Medicine, Seoul, Republic of Korea
| | - Jeong-Ho Seok
- Department of Psychiatry, Gangnam Severance Hospital, Yonsei University College of Medicine, Seoul, Republic of Korea
| | - Min A Kwon
- Department of Neurosurgery, Gangnam Severance Hospital, Yonsei University College of Medicine, 211, Eonjuro, Gangnam-gu, Seoul, 135-720, Republic of Korea
| | - Yong Bae Kim
- Department of Neurosurgery, Gangnam Severance Hospital, Yonsei University College of Medicine, 211, Eonjuro, Gangnam-gu, Seoul, 135-720, Republic of Korea
| | - Jin-Yang Joo
- Department of Neurosurgery, Gangnam Severance Hospital, Yonsei University College of Medicine, 211, Eonjuro, Gangnam-gu, Seoul, 135-720, Republic of Korea
| | - Chang-Ki Hong
- Department of Neurosurgery, Gangnam Severance Hospital, Yonsei University College of Medicine, 211, Eonjuro, Gangnam-gu, Seoul, 135-720, Republic of Korea.
- Severance Institute for Vascular and Metabolic Research, Yonsei University College of Medicine, Seoul, Republic of Korea.
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Badjatia N, Monahan A, Carpenter A, Zimmerman J, Schmidt JM, Claassen J, Connolly ES, Mayer SA, Karmally W, Seres D. Inflammation, negative nitrogen balance, and outcome after aneurysmal subarachnoid hemorrhage. Neurology 2015; 84:680-7. [PMID: 25596503 DOI: 10.1212/wnl.0000000000001259] [Citation(s) in RCA: 57] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/26/2022] Open
Abstract
OBJECTIVE To analyze the impact of inflammation and negative nitrogen balance (NBAL) on nutritional status and outcomes after subarachnoid hemorrhage (SAH). METHODS This was a prospective observational study of SAH patients admitted between May 2008 and June 2012. Measurements of C-reactive protein (CRP), transthyretin (TTR), resting energy expenditure (REE), and NBAL (g/day) were performed over 4 preset time periods during the first 14 postbleed days (PBD) in addition to daily caloric intake. Factors associated with REE and NBAL were analyzed with multivariable linear regression. Hospital-acquired infections (HAI) were tracked daily for time-to-event analyses. Poor outcome at 3 months was defined as a modified Rankin Scale score ≥ 4 and assessed by multivariable logistic regression. RESULTS There were 229 patients with an average age of 55 ± 15 years. Higher REE was associated with younger age (p = 0.02), male sex (p < 0.001), higher Hunt Hess grade (p = 0.001), and higher modified Fisher score (p = 0.01). Negative NBAL was associated with lower caloric intake (p < 0.001), higher body mass index (p < 0.001), aneurysm clipping (p = 0.03), and higher CRP:TTR ratio (p = 0.03). HAIs developed in 53 (23%) patients on mean PBD 8 ± 3. Older age (p = 0.002), higher Hunt Hess (p < 0.001), lower caloric intake (p = 0.001), and negative NBAL (p = 0.04) predicted time to first HAI. Poor outcome at 3 months was associated with higher Hunt Hess grade (p < 0.001), older age (p < 0.001), negative NBAL (p = 0.01), HAI (p = 0.03), higher CRP:TTR ratio (p = 0.04), higher body mass index (p = 0.03), and delayed cerebral ischemia (p = 0.04). CONCLUSIONS Negative NBAL after SAH is influenced by inflammation and associated with an increased risk of HAI and poor outcome. Underfeeding and systemic inflammation are potential modifiable risk factors for negative NBAL and poor outcome after SAH.
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Affiliation(s)
- Neeraj Badjatia
- From the Section of Neurocritical Care and Emergency Neurology, Program in Trauma, Department of Neurology (N.B.), University of Maryland School of Medicine, Baltimore; and the Neurological Institute of New York (A.M., A.C., J.Z., J.M.S., J.C., E.S.C., S.A.M.), Institute of Human Nutrition (W.K.), and Division of Preventive Medicine and Nutrition, Department of Internal Medicine (D.S.), Columbia University College of Physicians and Surgeons, New York, NY.
| | - Aimee Monahan
- From the Section of Neurocritical Care and Emergency Neurology, Program in Trauma, Department of Neurology (N.B.), University of Maryland School of Medicine, Baltimore; and the Neurological Institute of New York (A.M., A.C., J.Z., J.M.S., J.C., E.S.C., S.A.M.), Institute of Human Nutrition (W.K.), and Division of Preventive Medicine and Nutrition, Department of Internal Medicine (D.S.), Columbia University College of Physicians and Surgeons, New York, NY
| | - Amanda Carpenter
- From the Section of Neurocritical Care and Emergency Neurology, Program in Trauma, Department of Neurology (N.B.), University of Maryland School of Medicine, Baltimore; and the Neurological Institute of New York (A.M., A.C., J.Z., J.M.S., J.C., E.S.C., S.A.M.), Institute of Human Nutrition (W.K.), and Division of Preventive Medicine and Nutrition, Department of Internal Medicine (D.S.), Columbia University College of Physicians and Surgeons, New York, NY
| | - Jacqueline Zimmerman
- From the Section of Neurocritical Care and Emergency Neurology, Program in Trauma, Department of Neurology (N.B.), University of Maryland School of Medicine, Baltimore; and the Neurological Institute of New York (A.M., A.C., J.Z., J.M.S., J.C., E.S.C., S.A.M.), Institute of Human Nutrition (W.K.), and Division of Preventive Medicine and Nutrition, Department of Internal Medicine (D.S.), Columbia University College of Physicians and Surgeons, New York, NY
| | - J Michael Schmidt
- From the Section of Neurocritical Care and Emergency Neurology, Program in Trauma, Department of Neurology (N.B.), University of Maryland School of Medicine, Baltimore; and the Neurological Institute of New York (A.M., A.C., J.Z., J.M.S., J.C., E.S.C., S.A.M.), Institute of Human Nutrition (W.K.), and Division of Preventive Medicine and Nutrition, Department of Internal Medicine (D.S.), Columbia University College of Physicians and Surgeons, New York, NY
| | - Jan Claassen
- From the Section of Neurocritical Care and Emergency Neurology, Program in Trauma, Department of Neurology (N.B.), University of Maryland School of Medicine, Baltimore; and the Neurological Institute of New York (A.M., A.C., J.Z., J.M.S., J.C., E.S.C., S.A.M.), Institute of Human Nutrition (W.K.), and Division of Preventive Medicine and Nutrition, Department of Internal Medicine (D.S.), Columbia University College of Physicians and Surgeons, New York, NY
| | - E Sander Connolly
- From the Section of Neurocritical Care and Emergency Neurology, Program in Trauma, Department of Neurology (N.B.), University of Maryland School of Medicine, Baltimore; and the Neurological Institute of New York (A.M., A.C., J.Z., J.M.S., J.C., E.S.C., S.A.M.), Institute of Human Nutrition (W.K.), and Division of Preventive Medicine and Nutrition, Department of Internal Medicine (D.S.), Columbia University College of Physicians and Surgeons, New York, NY
| | - Stephan A Mayer
- From the Section of Neurocritical Care and Emergency Neurology, Program in Trauma, Department of Neurology (N.B.), University of Maryland School of Medicine, Baltimore; and the Neurological Institute of New York (A.M., A.C., J.Z., J.M.S., J.C., E.S.C., S.A.M.), Institute of Human Nutrition (W.K.), and Division of Preventive Medicine and Nutrition, Department of Internal Medicine (D.S.), Columbia University College of Physicians and Surgeons, New York, NY
| | - Wahida Karmally
- From the Section of Neurocritical Care and Emergency Neurology, Program in Trauma, Department of Neurology (N.B.), University of Maryland School of Medicine, Baltimore; and the Neurological Institute of New York (A.M., A.C., J.Z., J.M.S., J.C., E.S.C., S.A.M.), Institute of Human Nutrition (W.K.), and Division of Preventive Medicine and Nutrition, Department of Internal Medicine (D.S.), Columbia University College of Physicians and Surgeons, New York, NY
| | - David Seres
- From the Section of Neurocritical Care and Emergency Neurology, Program in Trauma, Department of Neurology (N.B.), University of Maryland School of Medicine, Baltimore; and the Neurological Institute of New York (A.M., A.C., J.Z., J.M.S., J.C., E.S.C., S.A.M.), Institute of Human Nutrition (W.K.), and Division of Preventive Medicine and Nutrition, Department of Internal Medicine (D.S.), Columbia University College of Physicians and Surgeons, New York, NY
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