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Abdelgadir J, Gelman J, Dutko L, Mehta V, Friedman A, Zomorodi A. Cognitive outcomes following aneurysmal subarachnoid hemorrhage: Rehabilitation strategies. World Neurosurg X 2024; 22:100341. [PMID: 38450248 PMCID: PMC10914592 DOI: 10.1016/j.wnsx.2024.100341] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/13/2022] [Accepted: 02/21/2024] [Indexed: 03/08/2024] Open
Abstract
Despite decreases in mortality rate, the treatment of cognitive deficits following aneurysmal subarachnoid hemorrhage (aSAH) remains a serious challenge for clinicians and survivors alike. Deficits in executive function, language, and memory prevent more than half of survivors from returning to their previous level of work and put a tremendous amount of stress on the individual and their family. New therapies are needed for survivors of aSAH in order to improve cognitive outcomes and quality of life. The aim of this review is to discuss the prevalence and contributing factors of cognitive deficits following aSAH, as well as areas for therapeutic intervention. Due to the limited research on cognitive rehabilitative strategies for aSAH, a literature search of traumatic brain injury (TBI) was used to explore therapies with the potential to improve cognitive outcomes in aSAH. Across cognitive domains, existing rehabilitative and pharmacotherapeutic strategies for TBI show promise to be useful for survivors of aSAH. However, further study of these therapies in addition to consistent assessment of cognitive deficits are required to determine their efficacy in survivors of aSAH.
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Affiliation(s)
- Jihad Abdelgadir
- Department of Neurosurgery, Duke University Medical Center, Durham, NC, USA
| | - Justin Gelman
- Trinity College of Arts and Sciences, Duke University, Durham, NC, USA
| | - Lindsay Dutko
- Duke Speech Pathology, Duke University Medical Center, Durham, NC, USA
| | - Vikram Mehta
- Department of Neurosurgery, Duke University Medical Center, Durham, NC, USA
| | - Allan Friedman
- Department of Neurosurgery, Duke University Medical Center, Durham, NC, USA
| | - Ali Zomorodi
- Department of Neurosurgery, Duke University Medical Center, Durham, NC, USA
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Buunk AM, Spikman JM, Wagemakers M, Jeltema JR, de Vries J, Mazuri A, Uyttenboogaart M, Groen RJM. The vanishing of the ACoA syndrome after aneurysmal subarachnoid haemorrhage: New era, different management, fewer problems? J Neuropsychol 2024; 18 Suppl 1:142-157. [PMID: 37902411 DOI: 10.1111/jnp.12352] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/01/2023] [Revised: 09/25/2023] [Accepted: 09/28/2023] [Indexed: 10/31/2023]
Abstract
Historically, a specific set of symptoms has been related to the rupture and repair of anterior communicating artery (ACoA) aneurysms. These consequences were defined as the 'ACoA syndrome' and included observations of severe memory loss, confabulation and personality or behavioural changes. These observations correspond to neuropsychological impairments in memory, executive functions and social cognition. However, in more recent studies, the existence of such a distinct syndrome has been called into question. We aimed to investigate the existence of the ACoA syndrome, by combining analysis of our own data with a systematic review of the literature. Memory, executive functions and social cognition of subarachnoid haemorrhage patients with ACoA aneurysms (N = 28) were compared to patients with aneurysms in other locations (N = 66). Results showed no significant differences. Subsequently, a systematic review of the existing literature on the ACoA syndrome was performed using Embase and PubMed until October 2022. Studies that investigated cognitive functions after rupture and repair of ACoA aneurysms were included. The search yielded 847 unique entries and after screening titles and abstracts, 648 records were excluded. 199 full-text articles were assessed for eligibility and 55 articles were included. Evidence was found for the ACoA syndrome in studies between 1960 and 2000, with impairments in memory and executive problems in the majority of studies. However, the majority of studies from 2000 did not demonstrate a distinct ACoA syndrome, although neuropsychological measurements improved. This coincides with the changes in the management of ACoA aneurysms over the past decades, such as the emergence of endovascular treatment and improvement of neurointensive care. Therefore, we hypothesize that the management techniques of ACoA aneurysms until around 2000, i.e. mainly conventional clipping, could be related to the presence of symptoms of the ACoA syndrome.
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Affiliation(s)
- A M Buunk
- Department of Neurology, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands
- Department of Neurosurgery, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands
| | - J M Spikman
- Department of Neurology, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands
| | - M Wagemakers
- Department of Neurosurgery, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands
| | - J R Jeltema
- Department of Neurosurgery, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands
| | - J de Vries
- Department of Neurosurgery, Radboud University Medical Center, Nijmegen, The Netherlands
| | - A Mazuri
- Medical Imaging Center, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands
| | - M Uyttenboogaart
- Department of Neurology, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands
- Medical Imaging Center, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands
| | - R J M Groen
- Department of Neurosurgery, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands
- Department of Neurosurgery, Faculty of Medicine Universitas Airlangga, Dr. Soetomo General Academic Hospital, Surabaya, Indonesia
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Khosdelazad S, Jorna LS, Rakers SE, Koffijberg R, Groen RJM, Spikman JM, Buunk AM. Long-term Course of Cognitive Functioning After Aneurysmal and Angiographically Negative Subarachnoid Hemorrhage. Neurosurgery 2023; 93:1235-1243. [PMID: 37272715 DOI: 10.1227/neu.0000000000002559] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/19/2022] [Accepted: 04/17/2023] [Indexed: 06/06/2023] Open
Abstract
BACKGROUND AND OBJECTIVES Cognitive impairment is a common consequence of subarachnoid hemorrhage (SAH), negatively affecting everyday functioning. This study is the first to investigate the long-term course of cognitive functioning after SAH and its associations with long-term well-being (ie, anxiety and depression), cognitive complaints, and return to work, separately for patients with aneurysmal SAH (aSAH) and angiographically negative SAH (anSAH) in a longitudinal design. METHODS Cognitive functioning was measured at 2 time points (T1: 3-6 months post-SAH; T2: 2-4 years post-SAH) in 58 patients with aSAH and 22 patients with anSAH with neuropsychological tests for (working) memory, psychomotor speed, and attention/executive functioning. Questionnaires were used to measure cognitive complaints and well-being at T1 and T2 and return to work at T2. RESULTS At T2, patients with aSAH only showed improvements in memory and on an executive functioning and psychomotor speed subtest, whereas in contrast, patients with anSAH had significantly poorer scores on tests for psychomotor speed. A significant amount of patients with aSAH and anSAH still reported cognitive complaints, anxiety, and depression in the chronic stage. Cognitive functioning was not significantly associated with cognitive complaints in both SAH groups. On the other hand, cognitive complaints were related to well-being at the long-term in both SAH groups. More cognitive complaints were also associated with more difficulties in return to work in patients with aSAH. CONCLUSION Patients with aSAH and anSAH have cognitive impairments at the subacute stage post-SAH, and these impairments persist into the chronic stage. Moreover, both SAH groups still reported decreased well-being in the chronic stage post-SAH, related to cognitive complaints but not to cognitive impairment. For clinical practice, an early neuropsychological assessment will already provide relevant information to estimate long-term cognitive impairment, but in addition, it is important to pay attention to psychological distress at the long-term.
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Affiliation(s)
- Sara Khosdelazad
- Department of Neurology, Unit Neuropsychology, University Medical Center Groningen, University of Groningen, Groningen , The Netherlands
| | - Lieke S Jorna
- Department of Neurology, Unit Neuropsychology, University Medical Center Groningen, University of Groningen, Groningen , The Netherlands
| | - Sandra E Rakers
- Department of Neurology, Unit Neuropsychology, University Medical Center Groningen, University of Groningen, Groningen , The Netherlands
| | - Ralf Koffijberg
- Department of Medical Psychology, Medical Center Leeuwarden, Leeuwarden , The Netherlands
| | - Rob J M Groen
- Department of Neurosurgery, University Medical Center Groningen, University of Groningen, Groningen , The Netherlands
| | - Jacoba M Spikman
- Department of Neurology, Unit Neuropsychology, University Medical Center Groningen, University of Groningen, Groningen , The Netherlands
| | - Anne M Buunk
- Department of Neurology, Unit Neuropsychology, University Medical Center Groningen, University of Groningen, Groningen , The Netherlands
- Department of Neurosurgery, University Medical Center Groningen, University of Groningen, Groningen , The Netherlands
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Stienen MN, Germans MR, Zindel-Geisseler O, Dannecker N, Rothacher Y, Schlosser L, Velz J, Sebök M, Eggenberger N, May A, Haemmerli J, Bijlenga P, Schaller K, Guerra-Lopez U, Maduri R, Beaud V, Al-Taha K, Daniel RT, Chiappini A, Rossi S, Robert T, Bonasia S, Goldberg J, Fung C, Bervini D, Maradan-Gachet ME, Gutbrod K, Maldaner N, Neidert MC, Früh S, Schwind M, Bozinov O, Brugger P, Keller E, Marr A, Roux S, Regli L. Longitudinal neuropsychological assessment after aneurysmal subarachnoid hemorrhage and its relationship with delayed cerebral ischemia: a prospective Swiss multicenter study. J Neurosurg 2022; 137:1742-1750. [PMID: 35535839 DOI: 10.3171/2022.2.jns212595] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/10/2021] [Accepted: 02/07/2022] [Indexed: 11/06/2022]
Abstract
OBJECTIVE While prior retrospective studies have suggested that delayed cerebral ischemia (DCI) is a predictor of neuropsychological deficits after aneurysmal subarachnoid hemorrhage (aSAH), all studies to date have shown a high risk of bias. This study was designed to determine the impact of DCI on the longitudinal neuropsychological outcome after aSAH, and importantly, it includes a baseline examination after aSAH but before DCI onset to reduce the risk of bias. METHODS In a prospective, multicenter study (8 Swiss centers), 112 consecutive alert patients underwent serial neuropsychological assessments (Montreal Cognitive Assessment [MoCA]) before and after the DCI period (first assessment, < 72 hours after aSAH; second, 14 days after aSAH; third, 3 months after aSAH). The authors compared standardized MoCA scores and determined the likelihood for a clinically meaningful decline of ≥ 2 points from baseline in patients with DCI versus those without. RESULTS The authors screened 519 patients, enrolled 128, and obtained complete data in 112 (87.5%; mean [± SD] age 53.9 ± 13.9 years; 66.1% female; 73% World Federation of Neurosurgical Societies [WFNS] grade I, 17% WFNS grade II, 10% WFNS grades III-V), of whom 30 (26.8%) developed DCI. MoCA z-scores were worse in the DCI group at baseline (-2.6 vs -1.4, p = 0.013) and 14 days (-3.4 vs -0.9, p < 0.001), and 3 months (-0.8 vs 0.0, p = 0.037) after aSAH. Patients with DCI were more likely to experience a decline of ≥ 2 points in MoCA score at 14 days after aSAH (adjusted OR [aOR] 3.02, 95% CI 1.07-8.54; p = 0.037), but the likelihood was similar to that in patients without DCI at 3 months after aSAH (aOR 1.58, 95% CI 0.28-8.89; p = 0.606). CONCLUSIONS Aneurysmal SAH patients experiencing DCI have worse neuropsychological function before and until 3 months after the DCI period. DCI itself is responsible for a temporary and clinically meaningful decline in neuropsychological function, but its effect on the MoCA score could not be measured at the time of the 3-month follow-up in patients with low-grade aSAH with little or no impairment of consciousness. Whether these findings can be extrapolated to patients with high-grade aSAH remains unclear. Clinical trial registration no.: NCT03032471 (ClinicalTrials.gov).
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Affiliation(s)
- Martin N Stienen
- 1Department of Neurosurgery, University Hospital Zurich.,2Clinical Neuroscience Center, University of Zurich.,13Neuropsychology Unit, Department of Neurology, University Hospital Berne
| | - Menno R Germans
- 1Department of Neurosurgery, University Hospital Zurich.,2Clinical Neuroscience Center, University of Zurich
| | | | - Noemi Dannecker
- 3Neuropsychology Unit, Department of Neurology, University Hospital Zurich
| | - Yannick Rothacher
- 3Neuropsychology Unit, Department of Neurology, University Hospital Zurich
| | - Ladina Schlosser
- 3Neuropsychology Unit, Department of Neurology, University Hospital Zurich
| | - Julia Velz
- 1Department of Neurosurgery, University Hospital Zurich.,2Clinical Neuroscience Center, University of Zurich
| | - Martina Sebök
- 1Department of Neurosurgery, University Hospital Zurich.,2Clinical Neuroscience Center, University of Zurich
| | - Noemi Eggenberger
- 3Neuropsychology Unit, Department of Neurology, University Hospital Zurich
| | - Adrien May
- 4Department of Neurosurgery, University Hospital Geneva
| | | | | | - Karl Schaller
- 4Department of Neurosurgery, University Hospital Geneva
| | | | - Rodolfo Maduri
- 6Avaton Surgical Group, Clinique de Genolier, Swiss Medical Network, Genolier
| | - Valérie Beaud
- 7Neuropsychology Unit, Department of Neurology, University Hospital Lausanne
| | - Khalid Al-Taha
- 8Department of Clinical Neurosciences, Service of Neurosurgery, Lausanne University Hospital (CHUV), Lausanne
| | - Roy Thomas Daniel
- 8Department of Clinical Neurosciences, Service of Neurosurgery, Lausanne University Hospital (CHUV), Lausanne
| | | | - Stefania Rossi
- 10Neuropsychology Unit, Department of Neurology, Cantonal Hospital Lugano
| | - Thomas Robert
- 9Department of Neurosurgery, Cantonal Hospital Lugano
| | - Sara Bonasia
- 9Department of Neurosurgery, Cantonal Hospital Lugano
| | - Johannes Goldberg
- 11Department of Neurosurgery, University Hospital Berne, Switzerland
| | - Christian Fung
- 11Department of Neurosurgery, University Hospital Berne, Switzerland.,12Department of Neurosurgery, University Hospital Freiburg, Germany
| | - David Bervini
- 11Department of Neurosurgery, University Hospital Berne, Switzerland
| | | | - Klemens Gutbrod
- 13Neuropsychology Unit, Department of Neurology, University Hospital Berne
| | | | | | - Severin Früh
- 15Neuropsychology Unit, Department of Neurology, Cantonal Hospital St. Gallen
| | - Marc Schwind
- 15Neuropsychology Unit, Department of Neurology, Cantonal Hospital St. Gallen
| | - Oliver Bozinov
- 1Department of Neurosurgery, University Hospital Zurich.,2Clinical Neuroscience Center, University of Zurich.,14Department of Neurosurgery, Cantonal Hospital St. Gallen
| | - Peter Brugger
- 3Neuropsychology Unit, Department of Neurology, University Hospital Zurich.,16Neuropsychology Unit, Rehabilitation Clinic Valens; and
| | - Emanuela Keller
- 1Department of Neurosurgery, University Hospital Zurich.,2Clinical Neuroscience Center, University of Zurich
| | - Angelina Marr
- 17Global Clinical Development, Idorsia Pharmaceuticals Ltd., Allschwil, Switzerland
| | - Sébastien Roux
- 17Global Clinical Development, Idorsia Pharmaceuticals Ltd., Allschwil, Switzerland
| | - Luca Regli
- 1Department of Neurosurgery, University Hospital Zurich.,2Clinical Neuroscience Center, University of Zurich
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Sato Y, Kojima T, Kawahara Y, Koguchi Y, Kobayashi S. Cognitive outcome in patients one month after mild to moderate aneurysmal subarachnoid hemorrhage: Focus on the location of the aneurysm. INTERDISCIPLINARY NEUROSURGERY 2022. [DOI: 10.1016/j.inat.2021.101377] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022] Open
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Le JT, Agrón E, Keenan TDL, Clemons TE, Brenowitz WD, Yaffe K, Chew EY. Assessing bidirectional associations between cognitive impairment and late age-related macular degeneration in the Age-Related Eye Disease Study 2. Alzheimers Dement 2021; 18:1296-1305. [PMID: 34758100 DOI: 10.1002/alz.12473] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/11/2021] [Revised: 07/06/2021] [Accepted: 08/11/2021] [Indexed: 11/10/2022]
Abstract
INTRODUCTION We aimed to investigate bidirectional associations between cognitive impairment and late age-related macular degeneration (AMD). METHODS Participants in the Age-Related Eye Disease Study 2 (AREDS2) received annual eye examinations and cognitive function testing (e.g., Modified Telephone Interview for Cognitive Status [TICS-M]). We examined bidirectional associations between cognitive impairment (e.g., a TICS-M score < 30) and late AMD at 5 and 10 years. RESULTS Five thousand one hundred eighty-nine eyes (3157 participants; mean age 72.7 years) were analyzed and followed for a median of 10.4 years. Eyes of participants with cognitive impairment at baseline were more likely to progress to late AMD at 5 years (hazard ratio [HR], 1.24; 95% confidence interval [CI], 1.08-1.43) and 10 years (HR, 1.20; 95% CI, 1.05-1.37) than eyes of participants without cognitive impairment. Worse baseline AMD severity was not associated with developing cognitive impairment. DISCUSSION Cognitive impairment is associated with late AMD progression in AREDS2. Our finding highlights the importance of eyecare for people with cognitive impairment.
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Affiliation(s)
- Jimmy T Le
- Division of Epidemiology and Clinical Applications & Division of Extramural Research, National Eye Institute, National Institutes of Health, Bethesda, Maryland, USA
| | - Elvira Agrón
- Division of Epidemiology and Clinical Applications, National Eye Institute, National Institutes of Health, Bethesda, Maryland, USA
| | - Tiarnan D L Keenan
- Division of Epidemiology and Clinical Applications, National Eye Institute, National Institutes of Health, Bethesda, Maryland, USA
| | | | - Willa D Brenowitz
- Departments of Psychiatry and Behavioral Science, Neurology, and Epidemiology & Biostatistics, University of California, San Francisco, San Francisco, California, USA
| | - Kristine Yaffe
- Department of Neurology, University of California San Francisco, San Francisco, San Francisco, California, USA.,Departments of Psychiatry and Behavioral Science, Neurology, and Epidemiology & Biostatistics, University of California, San Francisco, San Francisco, California, USA
| | - Emily Y Chew
- Division of Epidemiology and Clinical Applications, National Eye Institute, National Institutes of Health, Bethesda, Maryland, USA
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de Havenon A, Tirschwell DL, Heitsch L, Cramer SC, Braun R, Cole J, Reddy V, Majersik JJ, Lindgren A, Worrall BB. Variability of the Modified Rankin Scale Score Between Day 90 and 1 Year After Ischemic Stroke. Neurol Clin Pract 2021; 11:e239-e244. [PMID: 34484897 DOI: 10.1212/cpj.0000000000000954] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/16/2020] [Accepted: 08/07/2020] [Indexed: 11/15/2022]
Abstract
Objective Studies indicate that the functional outcome evolves in the year after ischemic stroke onset. However, the traditional outcome measure in stroke trials is the modified Rankin Scale (mRS) at 90 days from onset. To determine mRS fluctuations in the first year after stroke, we examined data from 3 major stroke trials. Methods In a secondary analysis, we evaluated intrapatient mRS between 90 days and 1 year from stroke onset, the mRS shift (∆mRS = 1 year-day 90), and the trials' primary outcome at day 90 and 1 year. Results We included 624 patients from the National Institute of Neurological Disorders and Stroke rt-PA Stroke Study, 587 from Albumin Treatment for Acute Ischaemic Stroke, and 611 from Interventional Management of Stroke III, for which the proportion of patients with a ∆mRS change between day 90 and 1 year was 36.5%, 41.7%, and 36.0%. However, the trials' primary outcomes did not differ at 1 year vs 90 days. Similar findings were seen in a second cohort where we pooled the trials and excluded patients with recurrent stroke or death during the follow-up. In those 1,314 patients, 544 (41.4%) had a ∆mRS change, of which 379 (28.9%) had improvement and 165 (12.5%) had worsening, apart from death. Conclusion We describe the patient-level spectrum of mRS change from day 90 to 1 year after ischemic stroke in 3 high-quality randomized trials. The patient-level shifts consisted of a sufficiently counterbalanced number of mRS improvements and declines, which masked clinical evolution occurring in over one-third of patients. These results may have important implications, both for clinical trial design and outcome adjudication in stroke research and duration of rehabilitative therapy.
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Affiliation(s)
- Adam de Havenon
- Departments of Neurology, University of Utah (AdH, JJM, VR); University of Washington (DLT); University of Virginia (BBW); University of Maryland (RB, JC); University of California Los Angeles (SCC); Lund University (AL); and the Department of Emergency Medicine, Washington University (LH)
| | - David L Tirschwell
- Departments of Neurology, University of Utah (AdH, JJM, VR); University of Washington (DLT); University of Virginia (BBW); University of Maryland (RB, JC); University of California Los Angeles (SCC); Lund University (AL); and the Department of Emergency Medicine, Washington University (LH)
| | - Laura Heitsch
- Departments of Neurology, University of Utah (AdH, JJM, VR); University of Washington (DLT); University of Virginia (BBW); University of Maryland (RB, JC); University of California Los Angeles (SCC); Lund University (AL); and the Department of Emergency Medicine, Washington University (LH)
| | - Steven C Cramer
- Departments of Neurology, University of Utah (AdH, JJM, VR); University of Washington (DLT); University of Virginia (BBW); University of Maryland (RB, JC); University of California Los Angeles (SCC); Lund University (AL); and the Department of Emergency Medicine, Washington University (LH)
| | - Robynne Braun
- Departments of Neurology, University of Utah (AdH, JJM, VR); University of Washington (DLT); University of Virginia (BBW); University of Maryland (RB, JC); University of California Los Angeles (SCC); Lund University (AL); and the Department of Emergency Medicine, Washington University (LH)
| | - John Cole
- Departments of Neurology, University of Utah (AdH, JJM, VR); University of Washington (DLT); University of Virginia (BBW); University of Maryland (RB, JC); University of California Los Angeles (SCC); Lund University (AL); and the Department of Emergency Medicine, Washington University (LH)
| | - Vivek Reddy
- Departments of Neurology, University of Utah (AdH, JJM, VR); University of Washington (DLT); University of Virginia (BBW); University of Maryland (RB, JC); University of California Los Angeles (SCC); Lund University (AL); and the Department of Emergency Medicine, Washington University (LH)
| | - Jennifer J Majersik
- Departments of Neurology, University of Utah (AdH, JJM, VR); University of Washington (DLT); University of Virginia (BBW); University of Maryland (RB, JC); University of California Los Angeles (SCC); Lund University (AL); and the Department of Emergency Medicine, Washington University (LH)
| | - Arne Lindgren
- Departments of Neurology, University of Utah (AdH, JJM, VR); University of Washington (DLT); University of Virginia (BBW); University of Maryland (RB, JC); University of California Los Angeles (SCC); Lund University (AL); and the Department of Emergency Medicine, Washington University (LH)
| | - Bradford B Worrall
- Departments of Neurology, University of Utah (AdH, JJM, VR); University of Washington (DLT); University of Virginia (BBW); University of Maryland (RB, JC); University of California Los Angeles (SCC); Lund University (AL); and the Department of Emergency Medicine, Washington University (LH)
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Transcranial Doppler for Early Prediction of Cognitive Impairment after Aneurysmal Subarachnoid Hemorrhage and the Associated Clinical Biomarkers. Stroke Res Treat 2020; 2020:8874605. [PMID: 33299539 PMCID: PMC7704183 DOI: 10.1155/2020/8874605] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/14/2020] [Revised: 10/27/2020] [Accepted: 10/31/2020] [Indexed: 11/17/2022] Open
Abstract
Methods Prospective study included 40 cases with acute aSAH. Initial evaluation by Glasgow Coma Scale (GCS) and the severity of aSAH was detected by both the clinical Hunt and Hess and radiological Fisher's grading scales. TCD was done for all patients five times within 10 days measuring the mean flow velocities (MFVs) of cerebral arteries. At the 3-month follow-up, patients were classified into two groups according to Montreal Cognitive Assessment (MoCA) scale: the first group was 31 cases (77.5%) with intact cognitive functions and the other group was 9 cases (22.5%) with impaired cognition. Results Patients with impaired cognitive functions showed significantly lower mean GCS (p = 0.03), significantly higher mean Hunt and Hess scale grades (p = 0.04), significantly higher mean diabetes mellitus (DM) (p = 0.03), significantly higher mean systolic blood pressure (SBP) and diastolic blood pressure (DBP) (p = 0.02 and p = 0.005, respectively), and significantly higher MFVs measured within the first 10 days. The patients with cognitive impairment were accompanied by a higher incidence of hydrocephalus (p = 0.01) and a higher incidence of delayed cerebral ischemia (DCI) (p < 0.001). Logistic regression analysis detected that MFV ≥ 86 cm/s in the middle cerebral artery (MCA), MFV ≥ 68 cm/s in the anterior cerebral artery (ACA), and MFV ≥ 45 cm/s in the posterior cerebral artery (PCA) were significantly associated with increased risk of cognitive impairment. Conclusion Cognitive impairment after the 3-month follow-up phase in aSAH patients was 22.5%. Acute hydrocephalus and DCI are highly associated with poor cognitive function in aSAH. Increased MFV is a strong predictor for poor cognitive function in aSAH. This trial is registered with NCT04329208.
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9
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Turan N, Heider RA, Nadeem M, Miller BA, Wali B, Yousuf S, Sayeed I, Stein DG, Pradilla G. Neurocognitive Outcomes in a Cisternal Blood Injection Murine Model of Subarachnoid Hemorrhage. J Stroke Cerebrovasc Dis 2020; 29:105249. [PMID: 33066928 DOI: 10.1016/j.jstrokecerebrovasdis.2020.105249] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/21/2020] [Revised: 07/13/2020] [Accepted: 08/10/2020] [Indexed: 11/28/2022] Open
Abstract
BACKGROUND Subarachnoid hemorrhage (SAH) results in neurocognitive dysfunction and anxiety in humans and in animal models. Neurobehavioral tests such as the Morris Water Maze (MWM) and Elevated Plus Maze (EPM) tests are validated in several models of SAH but have not been tested in the murine cisternal blood injection SAH model. METHODS Adult C57BL/6 mice (n=16) were randomized into two groups. Group 1 (n=8) received sham surgery. Group 2 (n=8) underwent SAH with 60 µL of autologous blood injected into the cisterna magna. Mice were then tested using the Modified Garcia Score on post-operative day 2 (POD2), EPM on POD5 & POD16, and MWM on POD6-16.Brain tissues harvested on POD16 were stained with Fluoro-Jade C to identify neurodegeneration in the hippocampus and cortex and Iba-1 immunofluorescence staining for microglial activation in the dentate gyrus and CA1 region of the hippocampus. RESULTS SAH mice showed increased escape latency on POD10. Swim distance was significantly increased on POD9-10 and swim speed was significantly decreased on POD6&POD10 in SAH mice. SAH mice exhibited a trend for lowered proportion of covered arm entries in EPM on POD16. Modified Garcia Score was not significantly different between the groups on POD2. The area of microglial activation in the dentate gyrus and CA1 region of the hippocampus was mildly increased but not significantly different at day 16 after SAH. Similarly, no significant differences were noted in the number of Fluoro-Jade C (+) cells in cortex or hippocampus. CONCLUSIONS Cisternal single blood injection in mice produces mild neurocognitive deficits most pronounced in spatial learning and most evident 10 days after SAH.
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Affiliation(s)
- Nefize Turan
- Emory University School of Medicine, Department of Neurosurgery, Atlanta, GA, USA; Cerebrovascular Research Laboratory, Department of Neurosurgery, Atlanta, GA, USA
| | - Robert A Heider
- Emory University School of Medicine, Department of Neurosurgery, Atlanta, GA, USA
| | - Maheen Nadeem
- Emory University School of Medicine, Department of Neurosurgery, Atlanta, GA, USA
| | - Brandon A Miller
- Emory University School of Medicine, Department of Neurosurgery, Atlanta, GA, USA; Cerebrovascular Research Laboratory, Department of Neurosurgery, Atlanta, GA, USA
| | - Bushra Wali
- Emory University School of Medicine, Department of Emergency Medicine, Atlanta, GA, USA
| | - Seema Yousuf
- Emory University School of Medicine, Department of Emergency Medicine, Atlanta, GA, USA
| | - Iqbal Sayeed
- Emory University School of Medicine, Department of Emergency Medicine, Atlanta, GA, USA
| | - Donald G Stein
- Emory University School of Medicine, Department of Emergency Medicine, Atlanta, GA, USA
| | - Gustavo Pradilla
- Emory University School of Medicine, Department of Neurosurgery, Atlanta, GA, USA; Cerebrovascular Research Laboratory, Department of Neurosurgery, Atlanta, GA, USA.
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10
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Lam J, Rennert RC, Ravina K, Lamorie-Foote K, Rangwala SD, Russin JJ. Bypass and Deconstructive Technique for Hunt and Hess Grade 3-5 Aneurysmal Subarachnoid Hemorrhage Deemed Unfavorable for Endovascular Treatment: Case Series of Outcomes and Comparison with Clipping. World Neurosurg 2020; 138:e251-e259. [PMID: 32105867 DOI: 10.1016/j.wneu.2020.02.088] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/23/2019] [Revised: 02/12/2020] [Accepted: 02/14/2020] [Indexed: 11/18/2022]
Abstract
BACKGROUND Intracranial bypass to treat ruptured aneurysms has been well described in the literature but is largely deferred in patients with higher Hunt and Hess (H & H) grades due to complexity and length of surgery, risk of inducing vasospasm, and poor prognosis. However, there is a paucity of data and no direct comparison with more traditional open surgical techniques. This study investigated outcomes in patients with H & H grade 3-5 aneurysmal subarachnoid hemorrhage (aSAH) unfavorable for stand-alone endovascular treatment managed with bypass compared with direct surgical clipping. METHODS A prospective database of patients treated for aSAH with H & H grade 3-5 between 2013 and 2018 was retrospectively analyzed. Complications and functional status at discharge and latest follow-up were compared between patients who underwent bypass surgery versus direct clipping. RESULTS Twenty-three patients underwent revascularization, and 60 underwent clipping alone. There were no significant differences in all-cause 30-day mortality (15% vs. 16%; P = 0.97) or Glasgow Outcome Scale and modified Rankin Scale at discharge or median 8-month follow-up (P > 0.67). There was a higher overall stroke rate with revascularization (P = 0.004), specifically endovascular treatment-related stroke (P = 0.049), with no difference in surgical (P = 0.47) or vasospasm-related stroke (P = 0.53). There were no differences in overall complications, medical complications, seizures, reruptures, hydrocephalus, or perioperative death (P > 0.05). CONCLUSIONS Bypass is a viable option for patients presenting with higher H & H grade aSAH deemed unfavorable for stand-alone endovascular therapy. Despite obvious differences in aneurysm complexity and a higher risk of stroke, functional outcomes with revascularization can be comparable with clipping in this high-risk patient cohort.
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Affiliation(s)
- Jordan Lam
- Neurorestoration Center, Department of Neurosurgery, Keck School of Medicine of the University of Southern California, Los Angeles, California, USA
| | - Robert C Rennert
- Department of Neurological Surgery, University of California, San Diego, California, USA
| | - Kristine Ravina
- Neurorestoration Center, Department of Neurosurgery, Keck School of Medicine of the University of Southern California, Los Angeles, California, USA
| | - Krista Lamorie-Foote
- Neurorestoration Center, Department of Neurosurgery, Keck School of Medicine of the University of Southern California, Los Angeles, California, USA
| | - Shivani D Rangwala
- Neurorestoration Center, Department of Neurosurgery, Keck School of Medicine of the University of Southern California, Los Angeles, California, USA
| | - Jonathan J Russin
- Neurorestoration Center, Department of Neurosurgery, Keck School of Medicine of the University of Southern California, Los Angeles, California, USA.
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11
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Impact of Hyperoxia and Hypocapnia on Neurological Outcomes in Patients with Aneurysmal Subarachnoid Hemorrhage: A Retrospective Study. Crit Care Res Pract 2019; 2019:7584573. [PMID: 31885915 PMCID: PMC6925754 DOI: 10.1155/2019/7584573] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/11/2019] [Revised: 11/04/2019] [Accepted: 11/11/2019] [Indexed: 01/13/2023] Open
Abstract
In recent decades, there is increasing evidence suggesting that hyperoxia and hypocapnia are associated with poor outcomes in critically ill patients with cardiac arrest or traumatic brain injury. Yet, the impact of hyperoxia and hypocapnia on neurological outcome in patients with subarachnoid hemorrhage (SAH) has not been well studied. In the present study, we evaluated the impact of hyperoxia and hypocapnia on neurological outcomes in patients with aneurysmal SAH (aSAH). Patients with aSAH who were admitted to the intensive care unit (ICU) of a tertiary hospital in Hong Kong between January 2011 and December 2016 were retrospectively recruited. Patients' demographics, comorbidities, radiological findings, clinical grades of SAH, PO2, and PCO2 within 24 hours of ICU admission, and Glasgow Outcome Scale (GOS) at 3 months after admission were recorded. Patients with a GOS score of 3 or less were considered having poor neurological outcomes. Among the 244 patients with aSAH, 122 of them (50%) had poor neurological outcomes at 3 months. Early hyperoxia (PO2 > 200 mmHg) and hypercapnia (PCO2 > 45 mmHg) were more common among patients with poor neurological outcomes. Logistic regression analysis indicated that hyperoxia independently predicted poor neurological outcomes (OR 3.788, 95% CI 1.131-12.690, P=0.031). Classification tree analysis revealed that hypocapnia was associated with poor neurological outcomes in patients who were less critically ill (APACHE < 50) and without concomitant intracranial hemorrhage (ICH) or intraventricular hemorrhage (IVH) (adjusted P=0.006, χ 2 = 7.452). These findings suggested that hyperoxia and hypocapnia may be associated with poor neurological outcomes in patients with aSAH.
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12
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LaBuzetta JN, Rosand J, Vranceanu AM. Review: Post-Intensive Care Syndrome: Unique Challenges in the Neurointensive Care Unit. Neurocrit Care 2019; 31:534-545. [PMID: 31486026 PMCID: PMC7007600 DOI: 10.1007/s12028-019-00826-0] [Citation(s) in RCA: 32] [Impact Index Per Article: 6.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
Within the last couple of decades, advances in critical care medicine have led to increased survival of critically ill patients, as well as the discovery of notable, long-term health challenges in survivors and their loved ones. The terms post-intensive care syndrome (PICS) and PICS-family (PICS-F) have been used in non-neurocritical care populations to characterize the cognitive, psychiatric, and physical sequelae associated with critical care hospitalization in survivors and their informal caregivers (e.g., family and friends who provide unpaid care). In this review, we first summarize the literature on the cognitive, psychiatric, and physical correlates of PICS and PICS-F in non-neurocritical patient populations and draw attention to their long-term negative health consequences. Next, keeping in mind the distinction between disease-related neurocognitive changes and those that are associated directly with the experience of a critical illness, we review the neuropsychological sequelae among patients with common neurocritical illnesses. We acknowledge the clinical factors contributing to the difficulty in studying PICS in the neurocritical care patient population, provide recommendations for future lines of research, and encourage collaboration among critical care physicians in all specialties to facilitate continuity of care and to help elucidate mechanism(s) of PICS and PICS-F in all critical illness survivors. Finally, we discuss the importance of early detection of PICS and PICS-F as an opportunity for multidisciplinary interventions to prevent and treat new neuropsychological deficits in the neurocritical care population.
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Affiliation(s)
- Jamie Nicole LaBuzetta
- Division of Neurocritical Care, Department of Neurosciences, University of California-San Diego, 9444 Medical Center Drive, ECOB 3-028, MC 7740, La Jolla, CA, 92037, USA.
| | - Jonathan Rosand
- Division of Neurocritical Care and Emergency Neurology, Massachusetts General Hospital and Harvard Medical School, Boston, USA
- Henry and Allison McCance Center for Brain Health, Massachusetts General Hospital, Boston, USA
| | - Ana-Maria Vranceanu
- Henry and Allison McCance Center for Brain Health, Massachusetts General Hospital, Boston, USA
- Integrated Brain Health Clinical and Research Program, Department of Psychiatry, Massachusetts General Hospital and Harvard Medical School, Boston, USA
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13
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James RF, Khattar NK, Aljuboori ZS, Page PS, Shao EY, Carter LM, Meyer KS, Daniels MW, Craycroft J, Gaughen JR, Chaudry MI, Rai SN, Everhart DE, Simard JM. Continuous infusion of low-dose unfractionated heparin after aneurysmal subarachnoid hemorrhage: a preliminary study of cognitive outcomes. J Neurosurg 2019; 130:1460-1467. [PMID: 29749915 DOI: 10.3171/2017.11.jns17894] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/10/2017] [Accepted: 11/29/2017] [Indexed: 11/06/2022]
Abstract
OBJECTIVE Cognitive dysfunction occurs in up to 70% of aneurysmal subarachnoid hemorrhage (aSAH) survivors. Low-dose intravenous heparin (LDIVH) infusion using the Maryland protocol was recently shown to reduce clinical vasospasm and vasospasm-related infarction. In this study, the Montreal Cognitive Assessment (MoCA) was used to evaluate cognitive changes in aSAH patients treated with the Maryland LDIVH protocol compared with controls. METHODS A retrospective analysis of all patients treated for aSAH between July 2009 and April 2014 was conducted. Beginning in 2012, aSAH patients were treated with LDIVH in the postprocedural period. The MoCA was administered to all aSAH survivors prospectively during routine follow-up visits, at least 3 months after aSAH, by trained staff blinded to treatment status. Mean MoCA scores were compared between groups, and regression analyses were performed for relevant factors. RESULTS No significant differences in baseline characteristics were observed between groups. The mean MoCA score for the LDIVH group (n = 25) was 26.4 compared with 22.7 in controls (n = 22) (p = 0.013). Serious cognitive impairment (MoCA ≤ 20) was observed in 32% of controls compared with 0% in the LDIVH group (p = 0.008). Linear regression analysis demonstrated that only LDIVH was associated with a positive influence on MoCA scores (β = 3.68, p =0.019), whereas anterior communicating artery aneurysms and fevers were negatively associated with MoCA scores. Multivariable linear regression analysis resulted in all 3 factors maintaining significance. There were no treatment complications. CONCLUSIONS This preliminary study suggests that the Maryland LDIVH protocol may improve cognitive outcomes in aSAH patients. A randomized controlled trial is needed to determine the safety and potential benefit of unfractionated heparin in aSAH patients.
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Affiliation(s)
- Robert F James
- 1Department of Neurological Surgery, University of Louisville School of Medicine, Louisville, Kentucky
- 2Department of Surgery, Brody School of Medicine at East Carolina University, Greenville, North Carolina
| | - Nicolas K Khattar
- 1Department of Neurological Surgery, University of Louisville School of Medicine, Louisville, Kentucky
| | - Zaid S Aljuboori
- 1Department of Neurological Surgery, University of Louisville School of Medicine, Louisville, Kentucky
| | - Paul S Page
- 1Department of Neurological Surgery, University of Louisville School of Medicine, Louisville, Kentucky
| | - Elaine Y Shao
- 2Department of Surgery, Brody School of Medicine at East Carolina University, Greenville, North Carolina
| | - Lacey M Carter
- 2Department of Surgery, Brody School of Medicine at East Carolina University, Greenville, North Carolina
| | - Kimberly S Meyer
- 1Department of Neurological Surgery, University of Louisville School of Medicine, Louisville, Kentucky
| | - Michael W Daniels
- 3Department of Bioinformatics and Biostatistics, University of Louisville School of Public Health, Louisville, Kentucky
| | - John Craycroft
- 3Department of Bioinformatics and Biostatistics, University of Louisville School of Public Health, Louisville, Kentucky
| | - John R Gaughen
- 4Sentara Martha Jefferson Hospital, Charlottesville, Virginia
| | - M Imran Chaudry
- 5Comprehensive Stroke and Cerebrovascular Center, Medical University of South Carolina, Charleston, South Carolina
| | - Shesh N Rai
- 3Department of Bioinformatics and Biostatistics, University of Louisville School of Public Health, Louisville, Kentucky
| | - D Erik Everhart
- Departments of6Psychology and
- 7Internal Medicine, East Carolina University, Greenville, North Carolina; and
| | - J Marc Simard
- Departments of8Neurosurgery
- 9Pathology, and
- 10Physiology, University of Maryland School of Medicine, Baltimore, Maryland
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14
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Neuro Intensive Care Unit. PHYSICIAN ASSISTANT CLINICS 2019. [DOI: 10.1016/j.cpha.2018.12.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
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15
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Blood Pressure and End-tidal Carbon Dioxide Ranges during Aneurysm Occlusion and Neurologic Outcome after an Aneurysmal Subarachnoid Hemorrhage. Anesthesiology 2019; 130:92-105. [DOI: 10.1097/aln.0000000000002482] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/28/2022]
Abstract
Abstract
EDITOR’S PERSPECTIVE
What We Already Know about This Topic
It remains unknown what end-tidal carbon dioxide and mean arterial pressure are optimal for surgical management of patients with an aneurysmal subarachnoid hemorrhage
What This Article Tells Us That Is New
The investigators retrospectively evaluated 1,099 patients who had endovascular coiling or surgical clipping for subarachnoid hemorrhages
There were no clinically important or statistical significant associations between either end-tidal carbon dioxide or mean arterial pressure thresholds and Glasgow Outcome Scale at discharge or three months
Other prognostic factors are more important than carbon dioxide and blood pressure, at least within the observed clinical ranges
Background
Hypocapnia, hypotension, and hypertension during aneurysm occlusion in patients with an aneurysmal subarachnoid hemorrhage may lead to a poor prognosis, but evidence for end-tidal carbon dioxide (ETco2) and mean arterial pressure (MAP) targets is lacking. Within the ranges of standardized treatment, the authors aimed to study the association between hypocapnia (Paco2 < 35 mmHg), hypotension (MAP < 80 mmHg), and hypertension (MAP >100 mmHg) during general anesthesia for aneurysm occlusion and neurologic outcome.
Methods
This retrospective observational study included patients who underwent early aneurysm occlusion after an aneurysmal subarachnoid hemorrhage under general anesthesia. ETco2 and MAP were summarized per patient as the mean and time-weighted average area under the curve for various absolute (ETco2 < 30, < 35, < 40, < 45 mmHg; and MAP < 60, < 70, < 80, > 90, > 100 mmHg) and relative thresholds (MAP < 70%, < 60%, < 50%). Clinical outcome was assessed with the Glasgow Outcome Scale at discharge and at three months, as primary and secondary outcome measure, respectively.
Results
Endovascular coiling was performed in 578 patients, and 521 underwent neurosurgical clipping. Of these 1,099 patients, 447 (41%) had a poor neurologic outcome at discharge. None of the ETco2 and MAP ranges found within the current clinical setting were associated with a poor neurologic outcome at discharge, with an adjusted risk ratio for any ETco2 value less than 30 mmHg of 0.95 (95% CI, 0.81 to 1.10; P < 0.496) and an adjusted risk ratio for any MAP less than 60 mmHg of 0.94 (95% CI, 0.78 to 1.14; P < 0.530). These results were not influenced by preoperative neurologic condition, treatment modality and timing of the intervention. Comparable results were obtained for neurologic outcome at three months.
Conclusions
Within a standardized intraoperative treatment strategy in accordance with current clinical consensus, hypocapnia, hypotension, and hypertension during aneurysm occlusion were not found to be associated with a poor neurologic outcome at discharge in patients with an aneurysmal subarachnoid hemorrhage.
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16
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Haug Nordenmark T, Karic T, Sorteberg W, Sorteberg A. Predictors of cognitive function in the acute phase after aneurysmal subarachnoid hemorrhage. Acta Neurochir (Wien) 2019; 161:177-184. [PMID: 30535853 DOI: 10.1007/s00701-018-3760-0] [Citation(s) in RCA: 21] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/30/2018] [Accepted: 11/30/2018] [Indexed: 10/27/2022]
Abstract
BACKGROUND Cognitive dysfunction is the most common form of neurological impairment after aneurysmal subarachnoid hemorrhage (aSAH) in the chronic phase. Cognitive deficits in the acute phase after aSAH, however, remain scarcely investigated. The aim of the present study was to test cognitive function and to identify medical predictors of cognitive deficits in the acute phase of aSAH. METHODS Prospective study including 51 patients treated for aSAH. Patients were treated in accordance with a standardized institutional protocol and subjected to neuropsychological evaluation around discharge from neurosurgical care. The neuropsychological test results were transformed into a global cognitive impairment index where an index value of 0.00 is considered normal and 1.00 is considered maximally pathological. Patients with an index score of less than 0.75 were considered having good global cognitive function while those with an index score equal to or above 0.75 were considered having poor global cognitive function. Univariate and multiple regression analysis were used to identify medical predictors of cognitive function. RESULTS Fifty-seven percent of the patients had poor cognitive function. They showed severe cognitive deficits, with most tests falling well below two standard deviations from the expected normal mean. Poor cognitive function was not reflected in a poor modified Rankin score in almost half of the cases. Patients with good cognitive function showed only mild cognitive deficits with most tests falling only slightly below the normal mean. Delayed memory was the most affected function in both groups. Univariate analysis identified acute hydrocephalus and aSAH-acquired cerebral infarction to be predictors of poor cognitive function. Cerebrospinal fluid drainage in excess of 2000 ml six-folded the risk of poor cognitive function, whereas a new cerebral infarction 11-folded the respective risk of poor cognitive function. CONCLUSION More than half of aSAH patients have severe cognitive deficits in the acute phase. The modified Rankin Score should be combined with neuropsychological screening in the acute phase after aSAH to get a more accurate description of the patients' disabilities. Acute hydrocephalus and aSAH-acquired cerebral infarction are the strongest predictors of poor cognitive function in the acute phase.
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17
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Ali A, Bitir B, Abdullah T, Sabanci PA, Aras Y, Aydoseli A, Tanirgan G, Sencer S, Akinci IO. Gray-to-white matter ratio predicts long-term recovery potential of patients with aneurysmal subarachnoid hemorrhage. Neurosurg Rev 2018; 43:195-202. [PMID: 30244413 DOI: 10.1007/s10143-018-1029-y] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/23/2018] [Revised: 07/23/2018] [Accepted: 08/28/2018] [Indexed: 11/30/2022]
Abstract
Predicting recovery potential of patients with aneurysmal subarachnoid hemorrhage (aSAH) is challenging. We investigated whether the gray-to-white matter ratio (GWR) predicts recovery of cognitive function (CF) and quality of life (QOL) of these patients. We analyzed data of 69 patients with aSAH. Patients' demographics, comorbidities, and neurological status were recorded. One year after aSAH, Montreal Cognitive Assessment (MoCA) and Short Form-36 (SF-36) tests were administered to the patients, and brain volumes of patients were examined using MRI. Three years after aSAH, MoCA and SF-36 tests were conducted again. Differences between the test scores 1 and 3 years after aSAH were evaluated (ΔMoCA and ΔSF-36). Patients with ΔMoCA ≥ 4 points and those with ΔSF-36 ≥ 8 points were referred to as good MoCA and SF-36 recovery, respectively. ΔMoCA correlated with GWR in male and female patients (females: p < 0.001, R2 = 0.581; males: p < 0.001, R2 = 0.481). In female patients, GWR > 1.34 predicted good MoCA recovery with 82.3% sensitivity and 80% specificity, and in male patients, GWR > 1.36 predicted good MoCA recovery with 80% sensitivity and 95% specificity. ΔSF-36 correlated with GWR in male and female patients (females: p < 0.001, R2 = 0.479; males: p < 0.001, R2 = 0.627). In female patients, GWR > 1.35 predicted good SF-36 recovery with 74% sensitivity and 84% specificity, and in male patients, GWR > 1.38 predicted good SF-36 recovery with 72% sensitivity and 92% specificity. GWR is a good predictor of the recovery of CF and QOL in patients with aSAH and, thus, can help physicians to better organize rehabilitation of patients.
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Affiliation(s)
- Achmet Ali
- Istanbul Medical Faculty, Department of Anesthesiology and Reanimation, Istanbul University, Istanbul, Turkey. .,İ.Ü. İstanbul Tıp Fakültesi Anesteziyoloj ABD, Turgut Ozal cad. Fatih, Istanbul, Turkey.
| | - Burcu Bitir
- Istanbul Medical Faculty, Department of Anesthesiology and Reanimation, Istanbul University, Istanbul, Turkey
| | - Taner Abdullah
- Istanbul Medical Faculty, Department of Anesthesiology and Reanimation, Istanbul University, Istanbul, Turkey
| | - Pulat Akin Sabanci
- Istanbul Medical Faculty, Department of Neurosurgery, Istanbul University, Istanbul, Turkey
| | - Yavuz Aras
- Istanbul Medical Faculty, Department of Neurosurgery, Istanbul University, Istanbul, Turkey
| | - Aydin Aydoseli
- Istanbul Medical Faculty, Department of Neurosurgery, Istanbul University, Istanbul, Turkey
| | - Gamze Tanirgan
- Istanbul Medical Faculty, Department of Anesthesiology and Reanimation, Istanbul University, Istanbul, Turkey
| | - Serra Sencer
- Istanbul Medical Faculty, Department of Neuroradiology, Istanbul University, Istanbul, Turkey
| | - Ibrahim Ozkan Akinci
- Istanbul Medical Faculty, Department of Anesthesiology and Reanimation, Istanbul University, Istanbul, Turkey
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18
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Re-evaluating the Weekend Effect on SAH: A Nationwide Analysis of the Association Between Mortality and Weekend Admission. Neurocrit Care 2018; 30:293-300. [DOI: 10.1007/s12028-018-0609-6] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/28/2022]
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19
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Risk Factors for Mild Cognitive Impairment in Patients with Aneurysmal Subarachnoid Hemorrhage Treated with Endovascular Coiling. World Neurosurg 2018; 119:e527-e533. [PMID: 30075259 DOI: 10.1016/j.wneu.2018.07.196] [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: 05/04/2018] [Revised: 07/21/2018] [Accepted: 07/23/2018] [Indexed: 01/31/2023]
Abstract
OBJECTIVE To assess the potential early risk factors of mild cognitive impairment after aneurysmal subarachnoid hemorrhage. METHODS We prospectively enrolled patients with aneurysmal subarachnoid hemorrhage treated with endovascular coiling during a 5-year period. The demographic characteristics and radiologic and laboratory data were collected. Cognitive assessments were carried out using the Montreal Cognitive Assessment at 6 months after ictus. Multivariate logistic regression was used to determine the risk factors associated with the development of mild cognitive impairment. RESULTS Of 152 patients, 59 patients (39%) developed cognitive impairment 6 months later. Univariate analysis showed that the patients with anterior communicating artery or anterior cerebral artery aneurysms (P < 0.001) with Glasgow Outcome Scale score of 7 or less at ictus (P = 0.002), Hunt and Hess grade of 3 or higher (P = 0.002), and Fisher grade of 3 or higher (P = 0.032) were more likely to develop mild cognitive impairment. The risk of mild cognitive impairment was increased for patients who had delayed cerebral ischemia (P = 0.040) and hydrocephalus (P = 0.002). In multivariate logistic regression analysis, mild cognitive impairment was independently associated with anterior communicating artery or anterior cerebral aneurysms (odds ratio [OR], 11.046; 95% confidence interval [CI], 3.371-36.198; P < 0.001), delayed cerebral ischemia (OR, 6.153; 95% CI, 1.587-23.855; P = 0.009), and hydrocephalus (OR, 8.768; 95% CI, 2.115-36.345; P = 0.003). CONCLUSIONS The location of the aneurysm, delayed cerebral ischemia, and hydrocephalus were independently associated with the occurrence of mild cognitive impairment after aneurysmal subarachnoid hemorrhage and can contribute to improved identification of patients at high risk for mild cognitive impairment.
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20
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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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21
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da Costa L, Shah-Basak PP, Dunkley BT, Robertson AD, Pang EW. Visual Working Memory Encoding and Recognition in Good Outcome Aneurysmal Subarachnoid Patients. Front Neurol 2018; 9:494. [PMID: 29997567 PMCID: PMC6028596 DOI: 10.3389/fneur.2018.00494] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/21/2018] [Accepted: 06/06/2018] [Indexed: 11/13/2022] Open
Abstract
Objectives: Aneurysmal subarachnoid hemorrhage (aSAH) accounts for less than 5% of strokes but is associated with significant morbidity and mortality. Amongst survivors, neurocognitive complaints are common, often despite normal imaging. We used magnetoencephalography (MEG) to investigate neurophysiological function during a visual working memory task in aSAH survivors with good recovery and normal structural imaging. Methods: Patients with aSAH treated with coiling and exhibiting good outcome measured by Glasgow Outcome Scale (GOS) and without related parenchymal structural lesions in post-treatment MRI, were recruited and compared to age- and sex-matched controls. All participants underwent intelligence and cognitive screening, structural MRI, and MEG testing in conjunction with a 1-back visual working memory task. Sensor-level global field power and virtual electrode source analysis of neuronal activity and connectivity in aSAH were assessed. Results: Thirteen patients and 13 matched controls were enrolled (age: 56 ± 11 years, 19 female). The 1-back task was completed with similar accuracy despite a trend for a longer reaction time in aSAH patients (p = 0.054). During encoding and recognition phases, aSAH patients showed significantly increased neuronal activation and hyperconnectivity in periventricular areas, specifically the anterior and posterior cingulate gyri. Conclusions: Increased posterior and anterior cingulate gyri neuronal activity is demonstrated in aSAH patients during visual working memory tasks, in the absence of structural lesions. These areas work mainly as a hub to “organize” memory storage and retrieval. Increased activity in these areas might be compensatory due to injury and consequently loss of neuronal response in connected areas in the working memory networks.
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Affiliation(s)
- Leodante da Costa
- Division of Neurosurgery, Department of Surgery, Sunnybrook Health Sciences Centre, University of Toronto, Toronto, ON, Canada
| | - Priyanka P Shah-Basak
- Department of Diagnostic Imaging, The Hospital for Sick Children, Toronto, ON, Canada.,Rotman Research Institute, Baycrest Health Centre, Toronto, ON, Canada
| | - Benjamin T Dunkley
- Department of Diagnostic Imaging, The Hospital for Sick Children, Toronto, ON, Canada.,Neurosciences and Mental Health, Sick Kids Research Institute, Toronto, ON, Canada
| | - Andrew D Robertson
- Canadian Partnership for Stroke Recovery, Sunnybrook Research Institute, University of Toronto, Toronto, ON, Canada
| | - Elizabeth W Pang
- Neurosciences and Mental Health, Sick Kids Research Institute, Toronto, ON, Canada.,Division of Neurology, The Hospital for Sick Children, University of Toronto, Toronto, ON, Canada
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22
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Mohanty M, Dhandapani S, Gupta SK, Shahid AH, Patra DP, Sharma A, Mathuriya SN. Cognitive Impairments After Clipping of Ruptured Anterior Circulation Aneurysms. World Neurosurg 2018; 117:e430-e437. [PMID: 29920394 DOI: 10.1016/j.wneu.2018.06.048] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/28/2017] [Revised: 06/06/2018] [Accepted: 06/08/2018] [Indexed: 11/29/2022]
Abstract
BACKGROUND The cognitive impairments after treatment of ruptured aneurysms have often been underestimated. This study sought to assess their prevalence and analyze various associated factors. METHODS Patients who were operated on for ruptured anterior circulation aneurysms and discharged with a Glasgow Outcome Scale score of 4-5 were studied at 3 months for various cognitive impairments. Continuous scales of memory (recent, remote, verbal, visual, and overall memory), verbal fluency (phonemic and category fluency), and others were studied in relation to various factors. Univariate and multivariate analyses were performed using SPSS version 21. RESULTS A total of 87 patients were included in our study. Phonemic fluency was the most affected, noted in 66% of patients. Although 56% had some memory-related impairments, 13 (15%) and 6 (7%) had moderate and severe deficits in recent memory and 19 (22%) and 12 (14%) had moderate and severe deficits in remote memory, respectively. Patients operated on for anterior cerebral artery (ACA) aneurysms had significantly greater impairments in recent (34% vs. 8%) and remote memory (43% vs. 28%) compared with the rest, both in univariate (P = 0.01 and 0.002, respectively) and multivariate analyses (P = 0.01 and 0.03, respectively). ACA-related aneurysms also had significantly greater independent impairments in phonemic fluency (P = 0.04), compared with others. The clinical grade had a significant independent impact only on remote memory (P = 0.01). CONCLUSIONS Cognitive impairments are frequent after treatment of ruptured anterior circulation aneurysms. Impairments in recent memory, remote memory, and phonemic fluency are significantly greater after treatment of ACA-related aneurysms, compared with others, independent of other factors.
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Affiliation(s)
- Manju Mohanty
- Department of Neurosurgery, Postgraduate Institute of Medical Education and Research, Chandigarh, India.
| | - Sivashanmugam Dhandapani
- Department of Neurosurgery, Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | - Sunil Kumar Gupta
- Department of Neurosurgery, Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | - Adnan Hussain Shahid
- Department of Neurosurgery, Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | - Devi Prasad Patra
- Department of Neurosurgery, Louisiana State University HSC, Shreveport, Louisiana, USA
| | - Anchal Sharma
- Department of Radiodiagnosis, Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | - Suresh N Mathuriya
- Department of Neurosurgery, Postgraduate Institute of Medical Education and Research, Chandigarh, India
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Caveney AF, Langenecker SA, Pandey AS, Farah LB, Ortiz JA, Huq N, Bhaumik R, Thompson BG, Giordani BJ, Auer D, Morgenstern LB. Neuropsychological Changes in Patients Undergoing Treatment of Unruptured Intracranial Aneurysms. Neurosurgery 2018; 84:581-587. [DOI: 10.1093/neuros/nyy077] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/07/2017] [Accepted: 02/15/2018] [Indexed: 11/12/2022] Open
Affiliation(s)
- Angela F Caveney
- Department of Psychiatry, University of Michigan, Ann Arbor, Michigan
| | | | - Aditya S Pandey
- Department of Neurosurgery, University of Michigan, Ann Arbor, Michigan
| | - Laura B Farah
- Department of Psychiatry, University of Illinois, Chicago, Illinois
| | - J Alexis Ortiz
- Center for Health Policy, University of New Mexico, Albuquerque, New Mexico
| | - Nadia Huq
- Department of Psychology, University of North Carolina, Greensboro, North Carolina
| | - Runa Bhaumik
- Department of Psychiatry, University of Illinois, Chicago, Illinois
| | | | - Bruno J Giordani
- Department of Psychiatry, University of Michigan, Ann Arbor, Michigan
| | - Donna Auer
- Department of Neurology, University of Michigan, Ann Arbor, Michigan
| | - Lewis B Morgenstern
- Department of Neurosurgery, University of Michigan, Ann Arbor, Michigan
- Department of Neurology, University of Michigan, Ann Arbor, Michigan
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Kumar MA, Levine J, Faerber J, Elliott JP, Winn HR, Doerfler S, Le Roux P. The Effects of Red Blood Cell Transfusion on Functional Outcome after Aneurysmal Subarachnoid Hemorrhage. World Neurosurg 2017; 108:807-816. [PMID: 29038077 DOI: 10.1016/j.wneu.2017.09.038] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/22/2016] [Revised: 09/06/2017] [Accepted: 09/07/2017] [Indexed: 11/25/2022]
Abstract
BACKGROUND The optimal red blood cell transfusion (RBCT) trigger for patients with aneurysmal subarachnoid hemorrhage (SAH) is unknown. In patients with cerebral vasospasm, anemia may increase susceptibility to ischemic injury; conversely, RBCT may worsen outcome given known deleterious effects. OBJECTIVE To examine the association between RBCT, delayed cerebral ischemia (DCI), vasospasm, and outcome after SAH. METHODS A total of 421 consecutive patients with SAH, admitted to a neurocritical care unit at a university-affiliated hospital and who underwent surgical occlusion of their ruptured aneurysm were retrospectively identified from a prospective observational database. Propensity score methods were used to reduce the bias associated with treatment selection. RESULTS Two hundred and sixty-one patients (62.0%) received an RBCT. Angiographic vasospasm (odds ratio [OR] 1.6; 95% confidence interval [CI], 1.1-2.3; P = 0.025) but not severe angiographic spasm, DCI, or delayed infarction was associated with RBCT. A total of 283 patients (67.2%) experienced a favorable outcome, defined as good or moderately disabled on the Glasgow Outcome Scale; 47 (11.2%) were severely disabled or vegetative and 91 patients (21.6%) were dead at 6-month follow-up. Among patients who survived ≥2 days, RBCT was associated with unfavorable outcome (OR, 2.6; 95% CI, 1.6-4.1). Transfusion of ≥3 units of blood was associated with an increased incidence of unfavorable outcome. Propensity analysis to control for the probability of exposure to RBCT conditional on observed covariates measured before RBCT indicates that RBCT is associated with unfavorable outcome in the absence of DCI (OR, 2.17; 95% CI, 1.56-3.01; P < 0.0001) but not when DCI is present (OR, 0.82; 95% CI, 0.35-1.92; P = 0.65). CONCLUSIONS Blood transfusions are associated with unfavorable outcome after SAH particularly when DCI is absent. Propensity analysis suggests that RBCT may be associated with poor outcome rather than being a marker of disease severity. However, when DCI is present, RBCT may help improve outcome.
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Affiliation(s)
- Monisha A Kumar
- Department of Neurosurgery, University of Pennsylvania, Philadelphia, Pennsylvania, USA; Department of Neurology, University of Pennsylvania, Philadelphia, Pennsylvania, USA; Department of Anesthesiology and Critical Care, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Joshua Levine
- Department of Neurosurgery, University of Pennsylvania, Philadelphia, Pennsylvania, USA; Department of Neurology, University of Pennsylvania, Philadelphia, Pennsylvania, USA; Department of Anesthesiology and Critical Care, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Jennifer Faerber
- Center for Clinical Epidemiology and Biostatistics, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - J Paul Elliott
- Colorado Neurological Institute, Englewood, Colorado, USA
| | - H Richard Winn
- Department of Neurosurgery, Mount Sinai Hospital, New York, New York, USA
| | - Sean Doerfler
- Department of Neurosurgery, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Peter Le Roux
- Brain and Spine Center and Lankenau Institute of Medical Research Lankenau Medical Center, Wynnewood, Pennsylvania, USA.
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Stabel HH, Pedersen AR, Johnsen SP, Nielsen JF. Rupture of a non-traumatic anterior communicating artery aneurysm: Does location of aneurysm associate with functional independence following post-acute in-patient neurorehabilitation? Top Stroke Rehabil 2017; 24:585-591. [PMID: 28920549 DOI: 10.1080/10749357.2017.1373973] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
Abstract
OBJECTIVE Patients with non-traumatic rupture of an aneurysm located at the anterior communicating artery (ACoA) often experience cognitive disabilities. It is unknown whether location of aneurysm also affects the possibility for improvement in functional independence compared to patients with an aneurysmal subarachnoid hemorrhage (a-SAH) located elsewhere. The aim was to explore the association between location of aneurysm (ACoA versus other) and level of functional independence, measured by Functional Independence Measure (FIM), at discharge from rehabilitation. Additionally, age and FIM at admission were explored. METHOD Historical cohort study among 107 patients with a-SAH based on data from a clinical database and a population-based register. Data were analyzed using multivariable logistic regression. RESULTS Patients with ACoA were admitted with poorer cognitive FIM (median 6 (IQR 5-14) compared to patients with aneurysms located elsewhere (median 12 (IQR 6-23) (p = 0.0129); no difference at discharge. No association between aneurysm location and functional independence was observed. Higher age was associated with poorer outcome in bowel management OR 0.54 (95% CI 0.31-0.92), bladder management OR 0.59 (95% CI 0.35-0.98), comprehension OR 0.53 (95% CI 0.30-0.94), and memory OR 0.48 (95% CI 0.25-0.93). Overall, FIM at admission was associated with functional independence at discharge with the exception of stair walking and bladder management which did not reach statistical significance. CONCLUSION ACoA was not associated with poorer level of functional independence compared to patients with a-SAH located elsewhere. Higher age was associated with poorer outcome in continence, comprehension, and memory, whereas higher FIM was associated with better functional independence across items at discharge.
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Affiliation(s)
- Henriette Holm Stabel
- a Hammel Neurorehabilitation Centre and University Research Clinic , Aarhus University , Hammel , Denmark
| | - Asger Roer Pedersen
- a Hammel Neurorehabilitation Centre and University Research Clinic , Aarhus University , Hammel , Denmark
| | - Søren Paaske Johnsen
- b Department of Clinical Epidemiology , Aarhus University Hospital , Aarhus , Denmark
| | - Jørgen Feldbæk Nielsen
- a Hammel Neurorehabilitation Centre and University Research Clinic , Aarhus University , Hammel , Denmark
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Functional Independence: A Comparison of the Changes During Neurorehabilitation Between Patients With Nontraumatic Subarachnoid Hemorrhage and Patients With Intracerebral Hemorrhage or Acute Ischemic Stroke. Arch Phys Med Rehabil 2017; 98:759-765. [DOI: 10.1016/j.apmr.2016.11.010] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/18/2016] [Revised: 11/07/2016] [Accepted: 11/12/2016] [Indexed: 11/21/2022]
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da Costa L, Dunkley BT, Bethune A, Robertson A, Keller A, Pang EW. Increased Frontal Lobe Activation After Aneurysmal Subarachnoid Hemorrhage. Stroke 2016; 47:2503-10. [PMID: 27531345 DOI: 10.1161/strokeaha.116.013786] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/14/2016] [Accepted: 07/11/2016] [Indexed: 11/16/2022]
Abstract
BACKGROUND AND PURPOSE Neurocognitive deficits are common among survivors of aneurysmal subarachnoid hemorrhage, even among those with good outcomes and no structural lesions. This study aims to probe the neurophysiological underpinnings of cognitive dysfunction among patients with ruptured intracranial aneurysms using magnetoencephalography (MEG). METHODS Thirteen patients who had undergone uncomplicated coiling for aneurysmal subarachnoid hemorrhage and 13 matched controls were enrolled. Neuropsychological tests were done before magnetoencephalography scans. Magnetoencephalography data were acquired in a 151-channel, whole-head magnetoencephalography system for resting state and 2 cognitive tasks (go-no-go and set-shifting). Mean time from treatment to test was 18.8 months. RESULTS Cognitive tasks of inhibition (go-no-go) indicated greater activation in the right anterior cingulate and inferior frontal gyrus, and cognitive set-shifting tasks (mental flexibility) indicated greater activity in the bilateral anterior cingulate cortex and right medial frontal gyrus among aneurysmal subarachnoid hemorrhage patients, with significantly different timing of activation between groups. Resting-state, beta-band connectivity of the anterior cingulate correlated negatively with Montreal Cognitive Assessment scores (left: r=-0.56; P<0.01 and right: r=-0.55; P<0.01): higher connectivity of this region was linked to poorer cognitive test performance. CONCLUSIONS We have shown increased activation in areas of the anterior cingulate gyrus and frontobasal regions during the execution of more demanding tasks in good grade. The degree of activation in the anterior cingulate gyrus has a negative correlation with cognitive (Montreal Cognitive Assessment) scores. These subtle differences may be related to the common neurocognitive and behavioral complaints seen in this patient population.
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Affiliation(s)
- Leodante da Costa
- From the Department of Surgery, Division of Neurosurgery, Sunnybrook Health Sciences Centre (L.d.C., A.B.), Department of Medical Imaging, Sunnybrook Health Sciences Centre (L.d.C.), Department of Diagnostic Imaging, The Hospital for Sick Children (B.T.D., A.R.), and Division of Neurology, The Hospital for Sick Children (A.K., E.W.P.), University of Toronto, Ontario, Canada.
| | - Benjamin T Dunkley
- From the Department of Surgery, Division of Neurosurgery, Sunnybrook Health Sciences Centre (L.d.C., A.B.), Department of Medical Imaging, Sunnybrook Health Sciences Centre (L.d.C.), Department of Diagnostic Imaging, The Hospital for Sick Children (B.T.D., A.R.), and Division of Neurology, The Hospital for Sick Children (A.K., E.W.P.), University of Toronto, Ontario, Canada
| | - Allison Bethune
- From the Department of Surgery, Division of Neurosurgery, Sunnybrook Health Sciences Centre (L.d.C., A.B.), Department of Medical Imaging, Sunnybrook Health Sciences Centre (L.d.C.), Department of Diagnostic Imaging, The Hospital for Sick Children (B.T.D., A.R.), and Division of Neurology, The Hospital for Sick Children (A.K., E.W.P.), University of Toronto, Ontario, Canada
| | - Amanda Robertson
- From the Department of Surgery, Division of Neurosurgery, Sunnybrook Health Sciences Centre (L.d.C., A.B.), Department of Medical Imaging, Sunnybrook Health Sciences Centre (L.d.C.), Department of Diagnostic Imaging, The Hospital for Sick Children (B.T.D., A.R.), and Division of Neurology, The Hospital for Sick Children (A.K., E.W.P.), University of Toronto, Ontario, Canada
| | - Anne Keller
- From the Department of Surgery, Division of Neurosurgery, Sunnybrook Health Sciences Centre (L.d.C., A.B.), Department of Medical Imaging, Sunnybrook Health Sciences Centre (L.d.C.), Department of Diagnostic Imaging, The Hospital for Sick Children (B.T.D., A.R.), and Division of Neurology, The Hospital for Sick Children (A.K., E.W.P.), University of Toronto, Ontario, Canada
| | - Elizabeth W Pang
- From the Department of Surgery, Division of Neurosurgery, Sunnybrook Health Sciences Centre (L.d.C., A.B.), Department of Medical Imaging, Sunnybrook Health Sciences Centre (L.d.C.), Department of Diagnostic Imaging, The Hospital for Sick Children (B.T.D., A.R.), and Division of Neurology, The Hospital for Sick Children (A.K., E.W.P.), University of Toronto, Ontario, Canada
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Sasaki T, Hoffmann U, Kobayashi M, Sheng H, Ennaceur A, Lombard FW, Warner DS. Long-Term Cognitive Deficits After Subarachnoid Hemorrhage in Rats. Neurocrit Care 2016; 25:293-305. [DOI: 10.1007/s12028-016-0250-1] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
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Koso M, Dizdarevic K. Attention and executive functions in microsurgically treated patients after subarachnoid hemorrhage. Asian J Neurosurg 2015; 10:260-5. [PMID: 26425152 PMCID: PMC4558799 DOI: 10.4103/1793-5482.162683] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/01/2022] Open
Abstract
OBJECTIVES This research aimed to assess attention and executive functions in subarachnoid hemorrhage (SAH) patients. METHODS The prospective, controlled, longitudinal study was conducted. There were two groups of patients (SAH and lumbar microdiscectomy groups), and all of them were operated on by a single neurosurgeon (KD) in the same institution. Preoperatively, SAH patients were in the Hunt-Hess Grade I and II. They did not develop any focal neurological deficit or hydrocephalus postoperatively. The patients were tested in 2-time points: 15 and 45 days after microsurgery with a battery of tests and questioners consisting of the Trail Making Test, the Sustained Attention to Response Task, the Hayling Sentence Completion Test, The Attention/Concentration test of Attention, the Wechsler Adult Intelligence Scale (verbal part). Results between groups were compared (sex, age; years of education and verbal IQ). RESULTS It was found the presence of lower attention and executive function test scores in the SAH group of patients with a trend of improving during the time. CONCLUSION The detailed neuropsychological assessment of operated patients who sustained SAH and were without the focal neurological deficit postoperatively, showed declination in their attention and executive function with a trend of cognitive recovery as time passes by.
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Affiliation(s)
- Maida Koso
- Department of Psychology, University of Sarajevo, Bosnia and Herzegovina
| | - Kemal Dizdarevic
- Department of Neurosurgery, Clinical Centre and Medical School, University of Sarajevo, Bosnia and Herzegovina
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Chew EY, Clemons TE, Agrón E, Launer LJ, Grodstein F, Bernstein PS. Effect of Omega-3 Fatty Acids, Lutein/Zeaxanthin, or Other Nutrient Supplementation on Cognitive Function: The AREDS2 Randomized Clinical Trial. JAMA 2015; 314:791-801. [PMID: 26305649 PMCID: PMC5369607 DOI: 10.1001/jama.2015.9677] [Citation(s) in RCA: 139] [Impact Index Per Article: 15.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Abstract
IMPORTANCE Observational data have suggested that high dietary intake of saturated fat and low intake of vegetables may be associated with increased risk of Alzheimer disease. OBJECTIVE To test the effects of oral supplementation with nutrients on cognitive function. DESIGN, SETTING, AND PARTICIPANTS In a double-masked randomized clinical trial (the Age-Related Eye Disease Study 2 [AREDS2]), retinal specialists in 82 US academic and community medical centers enrolled and observed participants who were at risk for developing late age-related macular degeneration (AMD) from October 2006 to December 2012. In addition to annual eye examinations, several validated cognitive function tests were administered via telephone by trained personnel at baseline and every 2 years during the 5-year study. INTERVENTIONS Long-chain polyunsaturated fatty acids (LCPUFAs) (1 g) and/or lutein (10 mg)/zeaxanthin (2 mg) vs placebo were tested in a factorial design. All participants were also given varying combinations of vitamins C, E, beta carotene, and zinc. MAIN OUTCOMES AND MEASURES The main outcome was the yearly change in composite scores determined from a battery of cognitive function tests from baseline. The analyses, which were adjusted for baseline age, sex, race, history of hypertension, education, cognitive score, and depression score, evaluated the differences in the composite score between the treated vs untreated groups. The composite score provided an overall score for the battery, ranging from -22 to 17, with higher scores representing better function. RESULTS A total of 89% (3741/4203) of AREDS2 participants consented to the ancillary cognitive function study and 93.6% (3501/3741) underwent cognitive function testing. The mean (SD) age of the participants was 72.7 (7.7) years and 57.5% were women. There were no statistically significant differences in change of scores for participants randomized to receive supplements vs those who were not. The yearly change in the composite cognitive function score was -0.19 (99% CI, -0.25 to -0.13) for participants randomized to receive LCPUFAs vs -0.18 (99% CI, -0.24 to -0.12) for those randomized to no LCPUFAs (difference in yearly change, -0.03 [99% CI, -0.20 to 0.13]; P = .63). Similarly, the yearly change in the composite cognitive function score was -0.18 (99% CI, -0.24 to -0.11) for participants randomized to receive lutein/zeaxanthin vs -0.19 (99% CI, -0.25 to -0.13) for those randomized to not receive lutein/zeaxanthin (difference in yearly change, 0.03 [99% CI, -0.14 to 0.19]; P = .66). Analyses were also conducted to assess for potential interactions between LCPUFAs and lutein/zeaxanthin and none were found to be significant. CONCLUSIONS AND RELEVANCE Among older persons with AMD, oral supplementation with LCPUFAs or lutein/zeaxanthin had no statistically significant effect on cognitive function. TRIAL REGISTRATION clinicaltrials.gov Identifier: NCT00345176.
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Affiliation(s)
| | - Emily Y. Chew
- Division of Epidemiology and Clinical Applications, Clinical Trials Branch, National Eye Institute/National Institutes of Health, Bethesda, MD
| | | | - Elvira Agrón
- Division of Epidemiology and Clinical Applications, Clinical Trials Branch, National Eye Institute/National Institutes of Health, Bethesda, MD
| | - Lenore J. Launer
- Neuroepidemiology Section, National Institute on Aging/National Institutes of Health, Bethesda, MD
| | - Francine Grodstein
- Department of Medicine, Brigham and Women’s Hospital, Harvard Medical School, and Department of Epidemiology, Harvard School of Public Health, Boston, MA
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Hasan DM, Hindman BJ, Todd MM. Pressure Changes Within the Sac of Human Cerebral Aneurysms in Response to Artificially Induced Transient Increases in Systemic Blood Pressure. Hypertension 2015; 66:324-31. [DOI: 10.1161/hypertensionaha.115.05500] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/18/2015] [Accepted: 05/19/2015] [Indexed: 12/26/2022]
Abstract
Formation and rupture of cerebral aneurysms have been associated with chronic hypertension. The effect of transient increase in blood pressure and its effect on intra-aneurysmal hemodynamics have not been studied. We examined the effects of controlled increases in blood pressure on different pressure parameters inside the sac of human cerebral aneurysms and corresponding parent arteries using invasive technology. Twelve patients (10 female, 2 male, age 54±15 years) with unruptured cerebral aneurysms undergoing endovascular coiling were recruited. Dual-sensor microwires with the capacity to simultaneously measure flow velocity and pressure were used to measure systolic, diastolic, and mean pressure inside the aneurysm sac and to measure both pressures and flow velocities in the feeder vessel just outside the aneurysm. These pressures were recorded simultaneously with pressures from a radial arterial catheter. Measurements were taken at baseline and then during a gradual increase in systemic systolic blood pressure to a target value of ≈25 mm Hg above baseline, using a phenylephrine infusion. The dose needed to achieve the required increase in radial arterial systolic blood pressure was 0.8±0.2 μg/kg/min. There was a clear linear relationship between changes in radial and aneurysmal pressures with substantial patient-by-patient variation in the slopes of those relationships. The overall increases in systolic and mean pressures in both radial artery and in the aneurysms were similar. Pressures in the aneurysm and in the parent vessels were similar. Peak and mean flow velocities in the parent arteries did not change significantly with phenylephrine infusion, nor did vessel diameters as measured angiographically.
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Affiliation(s)
- David M. Hasan
- From the Department of Neurosurgery (D.M.H) and Department of Anesthesia (B.J.H., M.M.T.), University of Iowa Carver College of Medicine, Iowa City
| | - Bradley J. Hindman
- From the Department of Neurosurgery (D.M.H) and Department of Anesthesia (B.J.H., M.M.T.), University of Iowa Carver College of Medicine, Iowa City
| | - Michael M. Todd
- From the Department of Neurosurgery (D.M.H) and Department of Anesthesia (B.J.H., M.M.T.), University of Iowa Carver College of Medicine, Iowa City
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Koso M, Dizdarevic K, Sose-Selimotic J. Everyday memory in microsurgically treated patients after subarachnoid hemorrhage. J Clin Med Res 2015; 7:225-31. [PMID: 25699118 PMCID: PMC4330014 DOI: 10.14740/jocmr2073w] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/06/2015] [Indexed: 11/20/2022] Open
Abstract
Background Memory declines measured by traditional tests in patients after subarachnoid hemorrhage (SAH) are well documented. Classic examinations of memory problems sometimes do not significantly correlate with memory functions in everyday life. The objective of the study was to assess the specific type of everyday memory loss in patients after microsurgical treatment of ruptured intracranial aneurysm causing SAH. Methods The prospective controlled, randomized study was conducted using the specific tests for everyday memory measure with high ecological validity. All patients were operated on by the same neurosurgeon (KD). Preoperatively, patients were in a good grade (Hunt-Hess I or II), with no neurological deficit and no hydrocephalus postoperatively. Patients were tested at two phases: 15 and 45 days after microsurgery with the Rivermead behavioral memory test (RBMT) and the cognitive failure questionnaire (CFQ). Results We compared the results of the tests administered in subjects that underwent microdiscectomy surgery for SAH to a control group that underwent surgery for lumbar disc herniation (DH). Conclusion Neuropsychological assessment of operated patients who sustained SAH showed a decline, compared to the DH group, in everyday memory function. Also, we found failures in perception and motor function in operated SAH patients with a trend of cognitive recovery as time progresses.
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Affiliation(s)
- Maida Koso
- Department of Psychology, University of Sarajevo, Bosnia and Herzegovina
| | - Kemal Dizdarevic
- Department of Neurosurgery, Clinical Centre and Medical School, University of Sarajevo, Bosnia and Herzegovina
| | - Jasmina Sose-Selimotic
- Faculty of Arts and Science, Department of Psychology, New York University, New York, USA
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Daniel C. Subarachnoid haemorrhage disease and the anaesthetist. SOUTHERN AFRICAN JOURNAL OF ANAESTHESIA AND ANALGESIA 2014. [DOI: 10.1080/22201173.2010.10872639] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
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Sheng H, Chaparro RE, Sasaki T, Izutsu M, Pearlstein RD, Tovmasyan A, Warner DS. Metalloporphyrins as therapeutic catalytic oxidoreductants in central nervous system disorders. Antioxid Redox Signal 2014; 20:2437-64. [PMID: 23706004 DOI: 10.1089/ars.2013.5413] [Citation(s) in RCA: 34] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Abstract
SIGNIFICANCE Metalloporphyrins, characterized by a redox-active transitional metal (Mn or Fe) coordinated to a cyclic porphyrin core ligand, mitigate oxidative/nitrosative stress in biological systems. Side-chain substitutions tune redox properties of metalloporphyrins to act as potent superoxide dismutase mimics, peroxynitrite decomposition catalysts, and redox regulators of transcription factor function. With oxidative/nitrosative stress central to pathogenesis of CNS injury, metalloporphyrins offer unique pharmacologic activity to improve the course of disease. RECENT ADVANCES Metalloporphyrins are efficacious in models of amyotrophic lateral sclerosis, Alzheimer's disease, epilepsy, neuropathic pain, opioid tolerance, Parkinson's disease, spinal cord injury, and stroke and have proved to be useful tools in defining roles of superoxide, nitric oxide, and peroxynitrite in disease progression. The most substantive recent advance has been the synthesis of lipophilic metalloporphyrins offering improved blood-brain barrier penetration to allow intravenous, subcutaneous, or oral treatment. CRITICAL ISSUES Insufficient preclinical data have accumulated to enable clinical development of metalloporphyrins for any single indication. An improved definition of mechanisms of action will facilitate preclinical modeling to define and validate optimal dosing strategies to enable appropriate clinical trial design. Due to previous failures of "antioxidants" in clinical trials, with most having markedly less biologic activity and bioavailability than current-generation metalloporphyrins, a stigma against antioxidants has discouraged the development of metalloporphyrins as CNS therapeutics, despite the consistent definition of efficacy in a wide array of CNS disorders. FUTURE DIRECTIONS Further definition of the metalloporphyrin mechanism of action, side-by-side comparison with "failed" antioxidants, and intense effort to optimize therapeutic dosing strategies are required to inform and encourage clinical trial design.
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Affiliation(s)
- Huaxin Sheng
- 1 Department of Anesthesiology, Duke University Medical Center (DUMC) , Durham, North Carolina
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Mark RE, Klarenbeek PL, Rutten GJM, Sitskoorn MM. Why Don’t Neurosurgery Patients Return for Neuropsychological Follow-Up? Predictors for Voluntary Appointment Keeping and Reasons for Cancellation. Clin Neuropsychol 2013; 28:49-64. [DOI: 10.1080/13854046.2013.854837] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
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36
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Affiliation(s)
- Kevin Meier
- Clinical Neurosciences Center; University of Utah Health Care; 175 N. Medical Drive East; SLC; UT; 84132; USA
| | - Robert Hoesch
- Clinical Neurosciences Center; University of Utah Health Care; 175 N. Medical Drive East; SLC; UT; 84132; USA
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Uchikawa K, Inaba M, Kagami H, Ichimura S, Fujiwara T, Tsuji T, Otaka Y, Liu M. Executive dysfunction is related with decreased frontal lobe blood flow in patients with subarachnoid haemorrhage. Brain Inj 2013; 28:15-9. [DOI: 10.3109/02699052.2013.847209] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
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Brand C, Alber B, Fladung AK, Knauer K, König R, Oechsner A, Schneider IL, Tumani H, Widder B, Wirtz CR, Woischneck D, Kapapa T. Cognitive performance following spontaneous subarachnoid haemorrhage versus other forms of intracranial haemorrhage. Br J Neurosurg 2013; 28:68-80. [DOI: 10.3109/02688697.2013.815314] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
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Gupta N, Pandia MP, Dash HH. Research studies that have influenced practice of neuroanesthesiology in recent years: A literature review. Indian J Anaesth 2013; 57:117-26. [PMID: 23825809 PMCID: PMC3696257 DOI: 10.4103/0019-5049.111834] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
Through evolving research, recent years have witnessed remarkable achievements in neuromonitoring and neuroanesthetic techniques, with a huge body of literature consisting of excellent studies in neuroanaesthesiology. However, little of this work appears to be directly important to clinical practice. Many controversies still exist in care of patients with neurologic injury. This review discusses studies of great clinical importance carried out in the last five years, which have the potential of influencing our current clinical practice and also attempts to define areas in need of further research. Relevant literature was obtained through multiple sources that included professional websites, medical journals and textbooks using key words “neuroanaesthesiology,” “traumatic brain injury,” “aneurysmal subarachnoid haemorrhage,” “carotid artery disease,” “brain protection,” “glycemic management” and “neurocritical care.” In head injured patients, administration of colloid and pre-hospital hypertonic saline resuscitation have not been found beneficial while use of multimodality monitoring, individualized optimal cerebral perfusion pressure therapy, tranexamic acid and decompressive craniectomy needs further evaluation. Studies are underway for establishing cerebroprotective potential of therapeutic hypothermia. Local anaesthesia provides better neurocognitive outcome in patients undergoing carotid endarterectomy compared with general anaesthesia. In patients with aneurysmal subarachnoid haemorrhage, induced hypertension alone is currently recommended for treating suspected cerebral vasospasm in place of triple H therapy. Till date, nimodipine is the only drug with proven efficacy in preventing cerebral vasospasm. In neurocritically ill patients, intensive insulin therapy results in substantial increase in hypoglycemic episodes and mortality rate, with current emphasis on minimizing glucose variability. Results of ongoing multicentric trials are likely to further improvise our practice.
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Affiliation(s)
- Nidhi Gupta
- Department of Neuroanaesthesiology, All India Institute of Medical Sciences, New Delhi, India
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Brain temperature: physiology and pathophysiology after brain injury. Anesthesiol Res Pract 2012; 2012:989487. [PMID: 23326261 PMCID: PMC3541556 DOI: 10.1155/2012/989487] [Citation(s) in RCA: 73] [Impact Index Per Article: 6.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/01/2012] [Revised: 11/09/2012] [Accepted: 12/12/2012] [Indexed: 12/02/2022] Open
Abstract
The regulation of brain temperature is largely dependent on the metabolic activity of brain tissue and remains complex. In intensive care clinical practice, the continuous monitoring of core temperature in patients with brain injury is currently highly recommended. After major brain injury, brain temperature is often higher than and can vary independently of systemic temperature. It has been shown that in cases of brain injury, the brain is extremely sensitive and vulnerable to small variations in temperature. The prevention of fever has been proposed as a therapeutic tool to limit neuronal injury. However, temperature control after traumatic brain injury, subarachnoid hemorrhage, or stroke can be challenging. Furthermore, fever may also have beneficial effects, especially in cases involving infections. While therapeutic hypothermia has shown beneficial effects in animal models, its use is still debated in clinical practice. This paper aims to describe the physiology and pathophysiology of changes in brain temperature after brain injury and to study the effects of controlling brain temperature after such injury.
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Predictors of work status and quality of life 9-13 years after aneurysmal subarachnoid hemorrahage. Acta Neurochir (Wien) 2012; 154:1437-46. [PMID: 22736050 DOI: 10.1007/s00701-012-1417-y] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/23/2012] [Accepted: 06/05/2012] [Indexed: 10/28/2022]
Abstract
BACKGROUND Aneurysmal subarachnoid hemorrhage (SAH) causes long-term psychosocial impairments even in patients who regain functional independence. Little is known about predictors of these impairments. We studied how early clinical data and neuropsychological results predict work status and health-related quality of life (HRQoL) 9-13 years after SAH. METHODS One hundred one patients performed a neuropsychological test battery and returned their self-rating and partner's rating of a psychosocial impairment questionnaire approximately 1 year after SAH. These data were analyzed for association to the patients' work status and self-rated HRQoL approximately 10 years later. RESULTS Age inversely, lower levels of self-rated impairments, employment and higher levels of education at the first follow-up independently predicted employment at the long-term follow-up. Although most cognitive test results were significantly associated with employment status at the long-term follow-up, they were of limited additional value as predictors of work status. The best predictor combination for long-term high HRQoL was good performance in a face recognition test and lower levels of self-rated impairments at the first follow-up as well as male sex. Problems in usual activities at the long-term follow-up were predicted by poor results in the face recognition and in a word list-learning task. CONCLUSION Questionnaire ratings of patients' psychosocial impairments 1 year after SAH give important information for the long-term prediction of their work status and HRQoL. In the long run, patients' unemployment becomes strongly associated with higher age, while their performance of usual activities can be predicted with learning and memory results.
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Connolly ES, Rabinstein AA, Carhuapoma JR, Derdeyn CP, Dion J, Higashida RT, Hoh BL, Kirkness CJ, Naidech AM, Ogilvy CS, Patel AB, Thompson BG, Vespa P. Guidelines for the management of aneurysmal subarachnoid hemorrhage: a guideline for healthcare professionals from the American Heart Association/american Stroke Association. Stroke 2012; 43:1711-37. [PMID: 22556195 DOI: 10.1161/str.0b013e3182587839] [Citation(s) in RCA: 2252] [Impact Index Per Article: 187.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
PURPOSE The aim of this guideline is to present current and comprehensive recommendations for the diagnosis and treatment of aneurysmal subarachnoid hemorrhage (aSAH). METHODS A formal literature search of MEDLINE (November 1, 2006, through May 1, 2010) was performed. Data were synthesized with the use of evidence tables. Writing group members met by teleconference to discuss data-derived recommendations. The American Heart Association Stroke Council's Levels of Evidence grading algorithm was used to grade each recommendation. The guideline draft was reviewed by 7 expert peer reviewers and by the members of the Stroke Council Leadership and Manuscript Oversight Committees. It is intended that this guideline be fully updated every 3 years. RESULTS Evidence-based guidelines are presented for the care of patients presenting with aSAH. The focus of the guideline was subdivided into incidence, risk factors, prevention, natural history and outcome, diagnosis, prevention of rebleeding, surgical and endovascular repair of ruptured aneurysms, systems of care, anesthetic management during repair, management of vasospasm and delayed cerebral ischemia, management of hydrocephalus, management of seizures, and management of medical complications. CONCLUSIONS aSAH is a serious medical condition in which outcome can be dramatically impacted by early, aggressive, expert care. The guidelines offer a framework for goal-directed treatment of the patient with aSAH.
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Derrey S, Curey S, Hannequin P, Castel H, Langlois O, Tollard E, Fréger P, Proust F. Elderly patients with aneurysmal subarachnoid hemorrhage: Coils but also clips. Neurochirurgie 2012; 58:140-5. [PMID: 22464899 DOI: 10.1016/j.neuchi.2012.02.014] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/05/2012] [Accepted: 02/08/2012] [Indexed: 11/19/2022]
Abstract
The ageing of the population in good health or without severe morbidity expose them to the occurrence of a subarachnoid hemorrhage (SAH) and requires effective management. Currently, the pertinence of cerebral aneurysm treatment by clipping or coiling is accepted for patients in the 8th or 9th decade of life, and the risk of postoperative morbidity induced by our therapeutic alternative must be carefully assessed. In these decades, the female/male sex ratio for aneurysmal SAH was greater in female who had a 1.6 times higher ratio than in male. The initial clinical status did not appear worse with age despite the frequent severity of bleeding observed on CT scan probably due to the large subarachnoid space. The aneurysm distribution and size were similar to those classically reported in the global population. The endovascular (EV) coiling appears as the first option with a favorable outcome rate estimated at 48% to 63%. Nevertheless, the benefit of EV coiling compared to microsurgical clipping for treatment of ruptured aneurysm in the elderly has not been demonstrated in a large randomized study. This is the reason why the vascular section of the French Society of Neurosurgery developed a prospective and randomized study of the aneurysmal SAH (PHRC 2007-042/HP) on the elderly patients.
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Affiliation(s)
- S Derrey
- Department of Neurosurgery, Rouen University Hospital, 1, rue de Germont, 76031 Rouen cedex, France
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Wallin MT, Pretell EJ, Bustos JA, Caballero M, Alfaro M, Kane R, Wilken J, Sullivan C, Fratto T, Garcia HH. Cognitive changes and quality of life in neurocysticercosis: a longitudinal study. PLoS Negl Trop Dis 2012; 6:e1493. [PMID: 22303492 PMCID: PMC3269427 DOI: 10.1371/journal.pntd.0001493] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/22/2011] [Accepted: 12/09/2011] [Indexed: 11/26/2022] Open
Abstract
BACKGROUND Few studies have focused on the cognitive morbidity of neurocysticercosis (NCC), one of the most common parasitic infections of the central nervous system. We longitudinally assessed the cognitive status and quality of life (QoL) of patients with incident symptomatic NCC cases and matched controls. METHODOLOGY/PRINCIPAL FINDINGS The setting of the study was the Sabogal Hospital and Cysticercosis Unit, Department of Transmissible Diseases, National Institute of Neurological Sciences, Lima, Peru. The design was a longitudinal study of new onset NCC cases and controls. Participants included a total of 14 patients with recently diagnosed NCC along with 14 healthy neighborhood controls and 7 recently diagnosed epilepsy controls. A standardized neuropsychological battery was performed at baseline and at 6 months on NCC cases and controls. A brain MRI was performed in patients with NCC at baseline and 6 months. Neuropsychological results were compared between NCC cases and controls at both time points. At baseline, patients with NCC had lower scores on attention tasks (p<0.04) compared with epilepsy controls but no significant differences compared to healthy controls. Six months after receiving anti-parasitic treatment, the NCC group significantly improved on tasks involving psychomotor speed (p<0.02). QoL at baseline suggested impaired mental function and social function in both the NCC and epilepsy group compared with healthy controls. QoL gains in social function (p=0.006) were noted at 6 months in patients with NCC. CONCLUSIONS/SIGNIFICANCE Newly diagnosed patients with NCC in this sample had mild cognitive deficits and more marked decreases in quality of life at baseline compared with controls. Improvements were found in both cognitive status and quality of life in patients with NCC after treatment.
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Affiliation(s)
- Mitchell T Wallin
- Neurology Service, Department of Veterans Affairs Medical Center, Washington, D.C., USA.
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Rinkel GJE, Algra A. Long-term outcomes of patients with aneurysmal subarachnoid haemorrhage. Lancet Neurol 2011; 10:349-56. [DOI: 10.1016/s1474-4422(11)70017-5] [Citation(s) in RCA: 237] [Impact Index Per Article: 18.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
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Santiago-Ramajo S, Katati MJ, Pérez-García M, Arjona-Moron V. Evaluating the Recovery of Cognitive Impairment in Subarachnoid Hemorrhage Taking Into Consideration the Practice Effects. Neurosurgery 2010; 67:1497-504; discussion 1504. [DOI: 10.1227/neu.0b013e3181fa2152] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022] Open
Abstract
Abstract
BACKGROUND:
It is not completely clear whether there are differences in the evolution of the neuropsychological outcomes between the 2 intervention procedures (surgery and endovascular coiling) used in subarachnoid aneurysmatic hemorrhage. Some studies have investigated this topic but without completely controlling the effect of learning the tests.
OBJECTIVE:
To analyze our data using 2 different statistical procedures that attempt to solve this problem.
METHODS:
The sample consists of 70 patients who have suffered a subarachnoid hemorrhage: 40 treated by means of surgery and 30 by means of endovascular coiling. Two cognitive evaluations were performed at 4 and 12 months after the invention. Twenty-seven healthy subjects were also evaluated twice with a delay of 8 months. The data were analyzed using 2 different statistical procedures: one by Samra et al (2007) using z scores and the other by Crawford and Garthwaite (2007) using the regbuild.exe program.
RESULTS:
The results indicate there are no important differences between the 2 treatment groups in the evolution of the cognitive alterations. Despite an improvement in cognitive scores on repeat testing at 12 months, neither of the 2 treatment groups showed the same level of test-retest learning as healthy control subjects.
CONCLUSION:
The recovery of neuropsychological functions after a subarachnoid hemorrhage is similar with the 2 interventions. It is important to control the learning effect produced by the repeated administration of tests.
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Affiliation(s)
- Sandra Santiago-Ramajo
- Neurosurgery Service, Hospital Virgen de las Nieves; and Department of Personality, Evaluation, and Psychological Treatment, School of Psychology, University de Granada, Granada, Spain
| | - Majed J Katati
- Neurosurgery Service, Hospital Virgen de las Nieves, Granada, Spain
| | - Miguel Pérez-García
- Department of Personality, Evaluation, and Psychological Treatment, School of Psychology; and Institute of Neurosciences, University of Granada, Granada, Spain
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Changes in the acute functional and cognitive disability states of severe hemorrhagic stroke patients. J Neurosci Nurs 2010; 42:245-54. [PMID: 20968220 DOI: 10.1097/jnn.0b013e3181ecaf81] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
The purpose of this study was to characterize temporal patterns of functional and cognitive disability changes during the acute period in hemorrhagic stroke patients. The study subjects were 62 hemorrhagic stroke patients admitted to a surgical intensive care unit at a university hospital located in Incheon, South Korea. As outcome variables, functional disability, cognitive ability, and employment status were evaluated directly at 1, 3, and 6 months after admission. The results showed that significant improvements in functional and cognitive ability were observed between 1 and 6 months after admission. In terms of functional disability, subjects considered their overall functional ability (dependence on others) to be less recovered than the specific functional abilities (feeding, grooming, or toileting): 75% of the subjects stated that they were completely independent on others, whereas 92.9%, 83.9%, and 83.9% of subjects indicated that they were completely independent for feeding, grooming, and toileting at the 6-month assessments, respectively. In terms of cognitive ability, attention, communication, and memory recovery rates were found to be relatively good. However, the proportion of subjects that achieved complete problem solving and safety and social behavior recovery were lower than those that achieved attention, communication, and memory recovery. Our findings can provide the empirical evidences when neuroscience nurses use educational and supportive strategies for rehabilitation of hemorrhagic stroke patients.
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Abstract
Despite advances in aneurysm ablation and the initial management of patients presenting with aneurysmal subarachnoid hemorrhage, delayed cerebral ischemia remains a significant source of morbidity. Traditionally, delayed cerebral ischemia was thought to be a result of vasospasm of the proximal intracranial vessels, and clinical trials have relied largely on radiographic evidence of vasospasm as a surrogate for functional outcome. However, a number of trials have demonstrated a dissociation between angiographic vasospasm and outcome, and more recent data suggest that other mechanisms of injury, such as microvascular dysfunction and complex neuronal-glial interactions, may influence the development of delayed ischemic deficit after aneurysmal subarachnoid hemorrhage. Our evolving understanding of the pathophysiology of delayed cerebral ischemia may offer the opportunity to test new therapeutic strategies in this area and improve clinical trial design.
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Affiliation(s)
- Daniel T Laskowitz
- Departments of Medicine Neurology, Duke University, Durham NC 27710, USA.
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Natural history and medical treatment of cognitive dysfunction after spontaneous subarachnoid haemorrhage: review of current literature with respect to aneurysm treatment. J Neurol Sci 2010; 299:5-8. [PMID: 20850796 DOI: 10.1016/j.jns.2010.08.059] [Citation(s) in RCA: 24] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/04/2010] [Revised: 08/21/2010] [Accepted: 08/24/2010] [Indexed: 11/20/2022]
Abstract
Aneurysmal subarachnoid haemorrhage (aSAH) has the highest mortality and morbidity among all types of stroke. Unfortunately, cognitive dysfunction remains a major problem to those who survive the acute crisis. Most studies focused on patients after microsurgical clipping, which turned out to be different from the modern patient cohorts. With the widespread introduction of endovascular surgery as the first choice of treatment, there was a hope that post-aSAH cognitive dysfunction could be markedly reduced. However, data showed that post-aSAH cognitive dysfunction remained a major burden to the survivors of our modern patient cohort that returned to the community more than nine months after the initial haemorrhage. There is, therefore, a need to further understand its pathophysiology and natural history, and to develop effective treatment strategy. The results are encouraging and further clinical studies are indicated. Collaborations between cognitive scientists, neurologists and neurosurgeons are essential to advance the understanding of the problem.
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Al-Khindi T, Macdonald RL, Schweizer TA. Cognitive and Functional Outcome After Aneurysmal Subarachnoid Hemorrhage. Stroke 2010; 41:e519-36. [DOI: 10.1161/strokeaha.110.581975] [Citation(s) in RCA: 455] [Impact Index Per Article: 32.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Affiliation(s)
- Timour Al-Khindi
- From the University of Toronto (T.A.-K.), Toronto, Ontario, Canada; the Division of Neurosurgery (R.L.M., T.A.S.), St Michael’s Hospital, Toronto, Ontario, Canada; the Division of Neurosurgery (R.L.M., T.A.S.), Department of Surgery, University of Toronto, Toronto, Ontario, Canada; the Keenan Research Centre of the Li Ka Shing Knowledge Institute at St Michael’s Hospital (R.L.M., T.A.S.), Toronto, Ontario, Canada; and the Heart and Stroke Foundation–Centre for Stroke Recovery (T.A.S.), Ontario, Canada
| | - R. Loch Macdonald
- From the University of Toronto (T.A.-K.), Toronto, Ontario, Canada; the Division of Neurosurgery (R.L.M., T.A.S.), St Michael’s Hospital, Toronto, Ontario, Canada; the Division of Neurosurgery (R.L.M., T.A.S.), Department of Surgery, University of Toronto, Toronto, Ontario, Canada; the Keenan Research Centre of the Li Ka Shing Knowledge Institute at St Michael’s Hospital (R.L.M., T.A.S.), Toronto, Ontario, Canada; and the Heart and Stroke Foundation–Centre for Stroke Recovery (T.A.S.), Ontario, Canada
| | - Tom A. Schweizer
- From the University of Toronto (T.A.-K.), Toronto, Ontario, Canada; the Division of Neurosurgery (R.L.M., T.A.S.), St Michael’s Hospital, Toronto, Ontario, Canada; the Division of Neurosurgery (R.L.M., T.A.S.), Department of Surgery, University of Toronto, Toronto, Ontario, Canada; the Keenan Research Centre of the Li Ka Shing Knowledge Institute at St Michael’s Hospital (R.L.M., T.A.S.), Toronto, Ontario, Canada; and the Heart and Stroke Foundation–Centre for Stroke Recovery (T.A.S.), Ontario, Canada
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