Neurological, neuropsychological, and functional outcome following treatment for unruptured intracranial aneurysms

Neurologic and Neuropsychological Outcomes for Treatment of Unruptured Middle Cerebral Artery Aneurysms: Standard Pterional Versus Minipterional Approach in a Retrospective Single-Center Analysis

BACKGROUND

In accordance with technique advancement and minimal invasiveness surgical approaches, the minipterional has progressively replaced the standard pterional approach for treatment of unruptured middle cerebral artery (MCA) aneurysms. Nowadays, multimodal intraoperative resources including microDoppler and microflow probes, indocyanine green videoangiography, and neurophysiologic monitoring constitute a fundamental prerequisite for increasing the safety of the clipping procedure. Our study investigated and compared in a single-center experience the effect of the evolution of a minimally invasive and multimodal approach in unruptured MCA aneurysm surgery by measuring postoperative complication rate, recovery time, and long-term neuropsychological and functional outcomes.

METHODS

One hundred and thirty-one patients who underwent surgical treatment for unruptured MCA aneurysms at our institution were evaluated retrospectively. Patients' clinical, radiologic, and surgical reports were collected. Cognitive evaluation and quality of life were assessed through validated tests in telephone interviews. Patients who met the inclusion criteria were divided into 2 groups: "PT (pterional)" and "MPT (minipterional)."

RESULTS

Ninety-two patients were included in the analysis. A significant reduction of postoperative complication rates and new-onset postoperative seizures was recorded in the MPT group (P value = 0.006). Severe cognitive deficits were lower in the MPT group, although without a clear statistical correlation.

CONCLUSIONS

Decreased complication rates, faster recovery time, and a trend toward better cognitive and functional performances were documented for the MPT group of patients. In our experience, the minipterional approach with multimodality-assisted microsurgery reduced neurologic complications and recovery time and improved long-term cognitive outcome and quality of life.

Return to Work after Surgical Clipping versus Endovascular Treatment of Unruptured Intracranial Aneurysms: A Nationwide Registry-Based Study

PURPOSE

To assess return to work following the treatment of unruptured intracranial aneurysms (UIAs).

MATERIALS AND METHODS

This retrospective, nationwide registry-based study included all adult patients of working age treated for a UIA in Norway between 2008 and 2018 who had a record of sickness leave on the day of treatment. Data from The Norwegian Patient Registry and The Norwegian Labour and Welfare Administration were linked on an individual level. Daily sickness and recipiency of disability benefits, as an indirect measure of working status, from 1 year before treatment to 1 year after treatment were analyzed. Return to work after endovascular treatment and surgical clipping was compared.

RESULTS

In total, 412 patients were included. Of patients who worked 1 year before treatment, 83% returned to work 1 year after treatment. The number of days from treatment to the first day back at work in a continuous 3-month working period was lower in patients who underwent endovascular treatment than in those treated with surgical clipping (median, 69 days; 95% confidence interval [CI], 51-87; vs 201 days, 95% CI, 163-239; P < .001). Return to work was more likely in patients who underwent endovascular treatment at 3 months after treatment (hazard ratio, 3.53; 95% CI, 2.54-4.93; P < .001). There was no difference in return to work at 6 and 12 months after treatment.

CONCLUSIONS

The treatment of UIAs affects patients' postoperative working status. Patients treated endovascularly return to work earlier than those who undergo open surgery.

Relationship between Deep White Matter Hyperintensities on Magnetic Resonance Imaging and Postoperative Cognitive Function Following Clipping of Unruptured Intracranial Aneurysm

To evaluate the effects on cognitive function of deep white matter hyperintensities (DWMHs) on magnetic resonance imaging (MRI) in patients treated surgically for unruptured intracranial aneurysms (UIAs). The subjects were 106 patients in whom a Wechsler adult intelligence scale-revised (WAIS-R) examination was performed 1 week before and 1 month after clipping surgery for asymptomatic UIAs. DWMH severity was evaluated on preoperative MR images by Fazekas scale, as follows: none (absence), mild (punctate foci), moderate (beginning confluence of foci), or severe (large confluent areas). A decrease of 7 or more points in intelligence quotient (IQ) postoperatively was considered deterioration. Fazekas score was none in 41 (none group), mild in 42 (mild group), moderate in 21, and severe in 2 patients (moderate/severe group). Patient characteristics, surgical factors, IQ change, and abnormal findings on postoperative MRI were compared among the groups. Although there was no statistically significant deterioration in IQ postoperatively in any group, the percentage of deteriorated patients was significantly higher in the moderate/severe group (34.8%) than in the other groups (4.9% in the none group, 7.1% in the mild group; p <0.01, p <0.05, respectively). Brain injury was observed more frequently on postoperative MR images in the moderate/severe group (17.4%) compared with the none group (2.4%; p = 0.052). The presence of moderate/severe DWMHs was an independent prognostic factor for postoperative cognitive dysfunction. In conclusion, the presence of moderate/severe DWMHs was a prognostic factor for postoperative cognitive dysfunction after surgery for UIAs.

Functional outcomes and quality of life after microsurgical clipping of unruptured intracranial aneurysms: a prospective cohort study

OBJECTIVE :Few studies have examined patients' ability to drive and quality of life (QOL) after microsurgical repair for unruptured intracranial aneurysms (uIAs). However, without a strong evidentiary basis, jurisdictional road transport authorities have recommended driving restrictions following brain surgery. In the present study, authors examined the outcomes of the microsurgical repair of uIAs by measuring patients' perceived QOL and cognitive abilities related to driving. METHODS: Between January 2011 and January 2016, patients with a new diagnosis of uIA were prospectively enrolled in this study. Assessments were performed at referral, before surgery, and at 6 weeks and 12 months after surgery in those undergoing microsurgical repair and at referral and at 12 months in conservatively managed patients. Assessments included the Physical Component Summary (PCS) and Mental Component Summary (MCS) of the SF-36, the off-road driver-screening instrument DriveSafe (DS), the modified Barthel Index (mBI), and the modified Rankin Scale (mRS). RESULTS: One hundred sixty-nine patients were enrolled in and completed the study, and 112 (66%) of them had microsurgical repair of their aneurysm. In the microsurgical group, there was a trend for improved DS scores: from a mean (± standard deviation) score of 108 ± 10.7 before surgery to 111 ± 9.7 at 6 weeks after surgery to 112 ± 10.2 at 12 months after surgery (p = 0.05). Two percent of the microsurgical repair group and 4% of the conservatively managed group whose initial scores indicated competency to drive according to the DS test subsequently had 12-month scores deemed as not competent to drive; the difference between these 2 groups was not statistically significant (p > 0.99). Factors associated with a decline in the DS score among those who had a license at the time of initial assessment were an increasing age (p < 0.01) and mRS score > 0 at one of the assessments (initial, 6 weeks, or 12 months; p < 0.01). Mean PCS scores in the microsurgical repair group were 52 ± 8.1, 46 ± 6.8, and 52 ± 7.1 at the initial, 6-week, and 12-month assessments, respectively (p < 0.01). These values represented a significant decline in the mean PCS score at 6 weeks that recovered by 12 months (p < 0.01). There were no significant changes in the MCS, mBI, or mRS scores in the surgical group. CONCLUSIONS: Overall, QOL at 12 months for the microsurgical repair group had not decreased and was comparable to that in the conservatively managed group. Furthermore, as assessed by the DS test, the majority of patients were not affected in their ability to drive.

Using reliability of change analysis to evaluate post-acute neuro-rehabilitation

BACKGROUND

It is important to evaluate change in order to re-assure commissioners, staff and patients of the effectiveness of interventions, but also in order to identify areas for improvement.

OBJECTIVE

To consider whether analysis of improvement at the level of the individual, taking into account measurement error, may offer a further valuable way to assess change and inform service development over considering change at the group level in a post-acute neuro-rehabilitation unit.

METHOD

Pre and post intervention Scores on the FIM+FAM Full Scale and Cognitive and Motor subscales were considered for eighteen patients aged between 35 and 81 with mixed diagnoses who attended a post-acute inpatient neuro-rehabilitation unit for treatment.

RESULTS

Statistically significant improvements were achieved on the FIM+FAM Full Scale and Cognitive and Motor subscales in a whole group analysis. Reliable change analyses for each patient within each subscale however identified only half of the sample achieved reliable improvement within the Motor domain and just one person within the Cognitive domain (5.6%).

CONCLUSIONS

Findings are consistent with the emphasis of the rehabilitation unit on physical/motor function, and unsurprising as many of those assessed had multiple sclerosis, an often deteriorative condition. Use of reliable change analysis allowed a more detailed understanding of intervention impact, potentially identifying what services reliably work for whom, thereby informing future planning.

A Retrospective Study of Survivors of Endovascular Coiling for Posterior and Anterior Aneurysms: Medical and Patient Perspectives

This article documents the longer-term medical and psychosocial outcomes of patients referred for endovascular coiling.There is limited research investigating outcome following endovascular coiling for posterior compared to anterior circulation aneurysms, and minimal understanding of how medical outcomes relate to patient experiences of treatment and quality of life.We studied a consecutive cohort of 80 patients referred Australia wide for endovascular coiling between 1995 and 2003 (49% posterior; 76% ruptured; 69% women, mean age 51.5 years). We used a mixed methods approach, assessing medical outcome with the Modified Rankin Scale (MRS) in 61 patients (76%), and health-related quality of life and psychosocial functioning using the EuroQol questionnaire and a qualitative semistructured interview in 49 patients (61%).Despite the high proportion of posterior aneurysms, the majority of patients (80%) showed good medical outcomes as indicated by regained independence of activities of daily living (MRS score ≤3). Patients with unruptured aneurysms were significantly more likely to show good outcomes (P < 0.04), whereas aneurysm location (posterior, anterior, or mixed) showed no significant effect. In patients with good medical outcomes, greater functional disability was associated with neurological complications surrounding treatment (P < 0.05). Good outcomes correlated with higher EuroQol ratings (P < 0.001) and the experience of less change after treatment (P < 0.001), although psychosocial adjustment issues were reported by most of the patients, including those with no medical symptoms.These results support the long-term efficacy of endovascular coiling, particularly for posterior circulation aneurysms. They have implications for guiding clinicians and patients in their choice of treatment, as well as the provision of psychological counseling for patient adjustment issues posttreatment.

Does a craniotomy for treatment of unruptured aneurysm affect cognitive function?

The surgical procedure used to treat an unruptured intracranial aneurysm (UIA) has controversial effects on cognitive function. From January 2010 through December 2012, we enrolled patients who underwent surgical clipping for a UIA. Patients were tested within one week prior to surgery and again postoperatively (6.8 ± 2.3 days) using a neuropsychological battery comprising the Mini-Mental State Examination, the Trail Making Test (TMT), the Frontal Assessment Battery (FAB), and Raven's colored progressive matrices (RCPM). Differences between preoperative and postoperative test scores for each examination were analyzed across individuals. In an additional subgroup analysis, patients were grouped according to age (< 65 or ≥ 65 years), the largest dimension of the aneurysm, the location of the aneurysm (i.e., anterior communicating artery, internal carotid artery, or middle cerebral artery) and operation duration. Paired student's t-tests were used to examine potential differences between groups. Two-tailed P-values < 0.05 were considered significant. Seventy-one patients were included in the analysis. The surgical procedure used to correct a UIA resulted in significant changes in neuropsychological scores. After the procedure, the TMT-A score declined significantly, whereas the FAB and RCPM scores were significantly improved. In the subgroup analysis, a significant deterioration in TMT-A score was observed in older patients and those with larger aneurysms, anterior communicating artery aneurysms and longer surgeries. Our findings, therefore, indicate that the surgical procedure to correct a UIA affects cognitive function. Older patients and those with large aneurysms, anterior communicating aneurysms, and long operations represent the high-risk groups.

Behavioral profile of unruptured intracranial aneurysms: a systematic review

Objectives

To systematically review the literature on the neuropsychological, psychosocial, and functional profiles of patients with unruptured intracranial aneurysms.

Methods

This review was limited to peer-reviewed research articles that reported cognitive, psychosocial, and/or functional profiles of patients with unruptured intracranial aneurysms. Studies were identified through Medline and PsychINFO by searching “(unruptured [intracranial OR cerebral] aneurysm) AND (cogniti* OR neuropsycholog* OR anxiety OR depression OR [quality of life] OR work OR employment OR [activities of daily living] OR [instrumental activities of daily living]).” Only articles that were published since January 1997 were considered. Reference lists of included articles were inspected for additional studies. Only articles in English were included. Case studies were excluded. Twenty-two articles were included in this review.

Results

The literature demonstrates that although treatment for unruptured intracranial aneurysms allays anxiety, it also results in an observable, though transient decline in cognition and daily functioning. Even before treatment, preliminary evidence hints that these patients are not free of such impairments.

Conclusions

The algorithm that underlies the decision to treat an unruptured intracranial aneurysm ought to add more weight to the neuropsychological, psychosocial, and functional profiles of these patients. The clinical relevance of these patients does not begin and end with their risk of rupture.

Surgical treatment of unruptured intracranial aneurysms in a low-volume hospital--outcome and review of literature

BACKGROUND

The aim of this study was to evaluate surgical outcome of unruptured intracranial aneurysms (UIAs) in a low-volume hospital and compare the results with the recent literature.

METHODS

A retrospective review of all consecutive craniotomies for UIA from July 1999 through June 2009 was performed. Morbidity was defined as modified Rankin Scale (mRS) ≥ 3 and evaluated six weeks after surgery. Cognitive function was evaluated at rehabilitation-to-home discharge. A PubMed database search (2001-2011) seeking retrospective, single-center studies reporting on surgical outcome of UIAs was performed.

RESULTS

There were 47 procedures performed in 42 patients to treat 50 UIAs (mean of 5 annual craniotomies). The mean age was 54.7 ± 12.1 years and mean aneurysm size was 7.6 ± 4.0mm. Favorable outcome (mRS 0-2) at six weeks after surgery was achieved in 45 of 47 procedures (95.7%). Aneurysm size ≥ 12 mm was statistically significant related to adverse outcome defined as mRS change ≥ 1 (71% vs. 29%; p = 0.018). Five patients (10.6%) with favorable neurological outcome (mRS 2) presented with cognitive impairment at rehabilitation-to-home discharge. There was no significant difference in overall morbidity and mortality comparing low- and high-volume hospitals (4.0% vs. 4.8%; p = 0.85).

CONCLUSIONS

Low-volume hospitals may achieve good results for surgical treatment of UIAs. The results indicate that defining numeric operative volume thresholds is not feasible to guide centralization of aneurysm treatment.

Neurological and neurobehavioral assessment of experimental subarachnoid hemorrhage

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

Psychosocial and neurocognitive performance after spontaneous nonaneurysmal subarachnoid hemorrhage related to the APOE-ε4 genotype: a prospective 5-year follow-up study

Object

In this study, the authors prospectively evaluated long-term psychosocial and neurocognitive performance in patients suffering from nonaneurysmal, nontraumatic subarachnoid hemorrhage (SAH) and investigated the association between the APOE-ε4 genotype and outcome in these patients.

Methods

All patients admitted to the authors' institution between January 2001 and January 2003 with spontaneous nonaneurysmal SAH were prospectively examined (mean follow-up 59.8 months). The APOE genotype was determined in all patients by polymerase chain reaction from a blood sample. Of the 30 patients included in this study, 11 were carriers of the ε4 allele.

Results

All patients showed a good recovery and regained full independence with no persisting neurological deficits. The patients with the ε4 allele, however, scored significantly higher on the Beck Depression Inventory (22.1 ± 6.3 vs 14.1 ± 5.1). At follow-up, depression was more persistent in the group with the ε4 allele compared with the group that lacked the allele. This finding reached statistical significance (p < 0.05). Selective attention was impaired in all patients during the first year of follow-up, with an earlier recovery noted in the patients without the ε4 allele. Moreover, there was a tendency toward a linear relationship between the Beck Depression Inventory and the d2 Test of Attention. Two patients who carried the ε4 allele did not return to their employment even after 5 years.

Conclusions

The findings in this study suggest that the APOE genotypes may be associated with the psychosocial and neurocognitive performance after spontaneous nonaneurysmal SAH, even in the absence of neurological impairment. Physicians should consider patient genotype in assessing the long-term consequences of nonaneurysmal SAH.

Current Options in Clipping Versus Coiling of Intracranial Aneurysms: to Clip, to Coil, to Wait and Watch

Treatment of intracranial aneurysms involves many factors: patient preference and demographics; aneurysm size, site, geometry, access, and intrinsics; practitioner experience and availability; facility; technology; and ancillaries. Volume counts, teamwork enhancement, and management should be individualized.

Psychosocial Effects of Harboring an Untreated Unruptured Intracranial Aneurysm

OBJECTIVE:

The primary purpose of the study was to investigate the psychosocial effects of harboring a known but untreated unruptured intracranial aneurysm (UIA), information considered important to the decision of whether to treat or not treat an unruptured aneurysm.

METHODS:

Over a 24–month period, 70 Auckland Hospital patients with UIAs were identified. Of these, 30 completed treatment, 2 patients died before treatment, and 38 were either not treated or treatment was unable to be completed during the time frame of the study. Of this group of 38 untreated UIA patients, 23 were enrolled in the study and were assessed on a brief cognitive screen and a battery of psychosocial measures. Their performance was compared with a group of 26 treated UIA patients.

RESULTS:

Poorer functioning was reported by the untreated UIA group on most psychosocial measures when compared with the treated UIA group 6 months posttreatment, and 36% of untreated UIA patients presented with a pattern of significant psychosocial impairment when compared with the treated UIA group. Qualitative data from the current study suggested that a factor contributing to the poorer reported psychosocial functioning in the untreated group was past or current fear about their untreated UIA.

CONCLUSION:

A decrease in overall quality of life was found to be associated with harboring an identified but untreated UIA. Findings from the current study suggest that further investigation of psychosocial outcome in other groups of untreated UIA patients is warranted. Results also suggest that some untreated UIA patients might benefit from psychological intervention.