Relationship of Local Infarctions to Cognitive and Psychosocial Impairments after Aneurysmal Subarachnoid Hemorrhage

Rehabilitation with intensive attention training early after acquired brain injury promotes better long-term status on health-related quality of life, daily activities, work ability and return to work

OBJECTIVE

To describe long-term effects on activity, participation, and quality of life (i) at different post-injury starting time points of attention training and (ii) of two different types of rehabilitation with attention training in patients after stroke or traumatic brain injury; and to describe their functioning level.

DESIGN

2 years after rehabilitation intervention, comparisons were made in one cohort receiving attention training subacute (< 4 months) or post-acute (4-12 months) and in one cohort with two different training methods, a process-based and an activity-based method respectively.

PATIENTS

100 patients were recruited from our earlier RCT study. They had mild to moderate stroke or traumatic brain injury with relatively limited symptomatology, and all had moderate to severe attention impairment.

METHODS

A questionnaire-based interview: EuroQol 5 dimensions, Occupational Gaps Questionnaire, Work Ability Index, self-assessed work status, self-reported employment conditions, sick leave, and experienced cognitive limitations in work performance.

RESULTS

An advantage for patients receiving subacute attention training regarding daily activities, work ability and returning to work.

CONCLUSION

The results indicate that subacute rehabilitation with attention training (< 4 months) is preferable compared to post-acute intervention (4-12 months). There were only minor differences between the training methods.

Validation and Optimization of Barrow Neurological Institute Score in Prediction of Adverse Events and Functional Outcome After Subarachnoid Hemorrhage-Creation of the HATCH (Hemorrhage, Age, Treatment, Clinical State, Hydrocephalus) Score

BACKGROUND

The Barrow Neurological Institute (BNI) score, measuring maximal thickness of aneurysmal subarachnoid hemorrhage (aSAH), has previously shown to predict symptomatic cerebral vasospasms (CVSs), delayed cerebral ischemia (DCI), and functional outcome.

OBJECTIVE

To validate the BNI score for prediction of above-mentioned variables and cerebral infarct and evaluate its improvement by integrating further variables which are available within the first 24 h after hemorrhage.

METHODS

We included patients from a single center. The BNI score for prediction of CVS, DCI, infarct, and functional outcome was validated in our cohort using measurements of calibration and discrimination (area under the curve [AUC]). We improved it by adding additional variables, creating a novel risk score (measure by the dichotomized Glasgow Outcome Scale) and validated it in a small independent cohort.

RESULTS

Of 646 patients, 41.5% developed symptomatic CVS, 22.9% DCI, 23.5% cerebral infarct, and 29% had an unfavorable outcome. The BNI score was associated with all outcome measurements. We improved functional outcome prediction accuracy by including age, BNI score, World Federation of Neurologic Surgeons, rebleeding, clipping, and hydrocephalus (AUC 0.84, 95% CI 0.8-0.87). Based on this model we created a risk score (HATCH-Hemorrhage, Age, Treatment, Clinical State, Hydrocephalus), ranging 0 to 13 points. We validated it in a small independent cohort. The validated score demonstrated very good discriminative ability (AUC 0.84 [95% CI 0.72-0.96]).

CONCLUSION

We developed the HATCH score, which is a moderate predictor of DCI, but excellent predictor of functional outcome at 1 yr after aSAH.

Subarachnoid Hemorrhage is Followed by Pituitary Gland Volume Loss: A Volumetric MRI Observational Study

Background

Subarachnoid hemorrhage (SAH) is a devastating disease associated with high mortality and morbidity. Besides neurological sequelae, neuropsychological deficits largely contribute to patients’ long-term quality of life. Little is known about the pituitary gland volume (PGV) after SAH compared to healthy referents and the association of PGV with long-term outcome including cognitive function.

Methods

Sixty consecutive non-traumatic SAH patients admitted to the neurological intensive care unit between 2010 and 2014 were enrolled. 3-Tesla magnetic resonance imagining was performed at baseline (16 days) and 12 months after SAH to measure PGV semi-automatically using the software iPlan Net 3.5.0. PGV was compared to age and sex matched healthy referents. The difference between baseline and 1-year-PGV was classified as increase (> 20 mm³ PGV increase), stable (± 20 mm³), or decrease (> 20 mm³ PGV decrease). In addition, total intracerebral volume was calculated. Neuropsychological testing was applied in 43 SAH patients at 1-year follow up encompassing several domains (executive, attention, memory) and self-assessment (questionnaire for self-perceived deficits in attention [German: FEDA]) of distractibility in mental processes, fatigue and decrease in motivation. Multivariable regression with multivariable generalized linear models was used for comparison of PGVs and for subgroup analysis to evaluate a potential association between PGV and neuropsychological outcome.

Results

Patients were 53 years old (IQR = 44–63) and presented with a median Hunt&Hess grade of 2 (IQR = 1–3). SAH patients had a significantly lower PGV both at baseline (360 ± 19 mm³, p < 0.001) and 1 year (367 ± 18 mm³p < 0.001) as compared to matched referents (mean 505 ± 18 mm³). PGV decreased by 75 ± 8 mm³ in 28 patients, increased by 120 ± 22 mm³ in 22 patients and remained stable in 10 patients at 1-year follow-up. PGV in patients with PGV increase at 12 months was not different to healthy referents (p = 0.062). Low baseline PGV was associated with impaired executive functions at 1 year (adjOR = 8.81, 95%-CI = 1.46–53.10, p = 0.018) and PGV decrease within 1 year was associated with self-perceived worse motivation (FEDA; Wald-statistic = 6.6, df = 1, p = 0.010).

Conclusions

Our data indicate significantly lower PGVs following SAH. The association of sustained PGV decrease with impaired neuropsychological long-term outcome warrants further investigations including neuroendocrine hormone measurements.

A meta-analysis of executive functions among survivors of subarachnoid haemorrhage

Subarachnoid Haemorrhage (SAH) is a type of stroke which is suggested to result in Executive Functioning (EF) deficits. Within the SAH research, EF is typically assessed as a unitary cognitive construct. Therefore, the nature and extent to which the different components of EF are impacted post SAH remain unclear. In this meta-analysis, 10 studies met selection criteria including 248 SAH participants, treated by endovascular coiling. Participants were assessed by EF measures and compared with 230 controls. Searches were conducted in November 2018 including Medline, PsychINFO, Web of Science, Scopus and CINAHL databases. EF measures were assigned to categories including Cognitive Flexibility, Working Memory, Inhibitory Control and Planning/Problem Solving [Diamond, 2013. Executive functions. Annual Review of Psychology, 64(1), 135-168. https://doi.org/10.1146/annurev-psych-113011-143750]. A statistically significant effect was found for overall EF. Cognitive Flexibility (G = -0.76) and Inhibitory Control (G = -0.51) generated moderate effect sizes, while Working Memory and Planning/Problem Solving found a small effect size (G = -0.45 and G = -0.49, respectively). The I² statistic suggested small to moderate heterogeneity between studies, hypothesized to relate to different cognitive tools. Underlying components of EF appear to be differentially impacted post SAH, with Cognitive flexibility demonstrating the largest degree of deficit. Recommendations for a standardized and uniform assessment of EF post SAH are outlined.

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

INTRODUCTION

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

METHODS

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

RESULTS

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

DISCUSSION

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

The relationship between ischaemic brain lesions and cognitive outcome after aneurysmal subarachnoid haemorrhage

Background

Cerebral ischaemia is thought to be an important determinant of cognitive outcome after aneurysmal subarachnoid haemorrhage (aSAH), but the exact relationship is unclear. We studied the effect of ischaemic brain lesions during clinical course on cognitive outcome 2 months after aSAH.

Methods

We studied 74 consecutive patients admitted to the University Medical Center Utrecht who had MRI post-coiling (3–21 days post-aSAH) and neuropsychological examination at 2 months. An ischaemic lesion was defined as hyperintensity on T2-FLAIR and DWI images. We measured both cognitive complaints (subjective) and cognitive functioning (objective). The relationship between ischaemic brain lesions and cognitive outcome was analysed by logistic regression analyses.

Results

In 40 of 74 patients (54%), 152 ischaemic lesions were found. The median number of lesions per patient was 2 (1–37) and the median total lesion volume was 0.2 (0–17.4) mL. No difference was found between the group with and the group without ischaemic lesions with respect to the frequency of cognitive complaints. In the group with ischaemic lesions, significantly more patients (55%) showed poor cognitive functioning compared to the group without ischaemic lesions (26%) (OR 3.4, 95% CI 1.3–9.1). We found no relationship between the number and volume of the ischaemic lesions and cognitive functioning.

Conclusions

Ischaemic brain lesions detected on MRI during clinical course after aSAH is a marker for poor cognitive functioning 2 months after aSAH, irrespective of the number or volume of the ischaemic lesions. Network or connectivity studies are needed to better understand the relationship between location of the ischaemic brain lesions and cognitive functioning.

Patient Outcomes and Cerebral Infarction after Ruptured Anterior Communicating Artery Aneurysm Treatment

BACKGROUND AND PURPOSE

Anterior communicating artery aneurysm rupture and treatment is associated with high rates of dependency, which are more severe after clipping compared with coiling. To determine whether ischemic injury might account for these differences, we characterized cerebral infarction burden, infarction patterns, and patient outcomes after surgical or endovascular treatment of ruptured anterior communicating artery aneurysms.

MATERIALS AND METHODS

We performed a retrospective cohort study of consecutive patients with ruptured anterior communicating artery aneurysms. Patient data and neuroimaging studies were reviewed. A propensity score for outcome measures was calculated to account for the nonrandom assignment to treatment. Primary outcome was the frequency of frontal lobe and striatum ischemic injury. Secondary outcomes were patient mortality and clinical outcome at discharge and at 3 months.

RESULTS

Coiled patients were older (median, 55 versus 50 years; P = .03), presented with a worse clinical status (60% with Hunt and Hess Score >2 versus 34% in clipped patients; P = .02), had a higher modified Fisher grade (P = .01), and were more likely to present with intraventricular hemorrhage (78% versus 56%; P = .03). Ischemic frontal lobe infarction (OR, 2.9; 95% CI, 1.1-8.4; P = .03) and recurrent artery of Heubner infarction (OR, 20.9; 95% CI, 3.5-403.7; P < .001) were more common in clipped patients. Clipped patients were more likely to be functionally dependent at discharge (OR, 3.2; P = .05) compared with coiled patients. Mortality and clinical outcome at 3 months were similar between coiled and clipped patients.

CONCLUSIONS

Frontal lobe and recurrent artery of Heubner infarctions are more common after surgical clipping of ruptured anterior communicating artery aneurysms, and are associated with poorer clinical outcomes at discharge.

Impaired Work Productivity After Aneurysmal Subarachnoid Hemorrhage

BACKGROUND

Aneurysmal subarachnoid hemorrhage (aSAH) is a sudden debilitating condition affecting individuals during the most productive times of their lives. Treatment advances have reduced mortality rates but increased the number of survivors facing deficits in physical and neuropsychological function.

OBJECTIVE

This study examined associations between neuropsychological function and work productivity after aSAH.

METHODS

Fifty-two patients with aSAH, employed before hemorrhage, were recruited from an ongoing National Institutes of Health study. Work Limitations Questionnaire (WLQ), neuropsychological tests (executive function, psychomotor speed, attention and mental flexibility, memory), and Patient Assessment of Own Function were completed at 3 and 12 months after aSAH.

RESULTS

Subjects in this analysis reported some level of difficulty in work productivity at 3 and 12 months (35% and 30%, respectively) after hemorrhage. Lower WLQ scores in time management and mental/interpersonal subscales were associated with poorer performance in psychomotor function (r = .5, p = .04 and r = .42, p = .09). Poorer mental flexibility and working memory correlated with time management difficulty at 3 months (r = -.4, p = .09 and r = .54, p = .02). Patients performing poorly on story recall tests were more likely to report difficulty with job physical performance (r = -.42, p = .09) and completing work effectively (r = .61, p = .009). Poorer working memory performance was associated with lower scores on mental/interpersonal WLQ subscales (r = .45, p = .05) and overall health-related work productivity loss (r = .47, p = .04). WLQ areas also correlated with participants' perception of their neuropsychological function after aSAH.

CONCLUSIONS

These results suggest that neuropsychological deficits impact work quality after hemorrhage and provide strong impetus for future studies so that domain-specific interventions can be implemented to improve outcomes that affect quality of life including work productivity.

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

OBJECTIVE

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

DESIGN/METHODS

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

RESULTS

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

CONCLUSIONS

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

Course of Participation after Subarachnoid Hemorrhage

OBJECTIVES

The study aimed to investigate participation problems in patients with subarachnoid hemorrhage (SAH), and the course of participation between 3 and 12 months post-SAH, and to identify determinants of this course.

DESIGN

This is a prospective cohort study.

SETTING

The study was done in the SAH outpatient clinic at the University Medical Center Utrecht.

SUBJECTS

Subjects included patients independent in activities of daily living who visited the SAH outpatient clinic for a routine follow-up visit 3 months after the event.

MAIN MEASURES

Participation was assessed using the restrictions scale of the Utrecht Scale for Evaluation of Rehabilitation-Participation at 3, 6, and 12 months post-SAH. Repeated measures analysis of variance was conducted to identify possible determinants of participation (demographic and SAH characteristics, mood, and cognition).

RESULTS

One hundred patients were included. Three months after SAH, the most commonly reported restrictions concerned work/unpaid work/education (70.5%), housekeeping (50.0%), and going out (45.2%). Twelve months post-SAH, patients felt most restricted in work/unpaid work/education (24.5%), housekeeping (23.5%), and chores in and around the house (16.3%). Participation scores increased significantly between 3 and 6 months, and between 3 and 12 months, post-SAH. The course of participation was associated with mood, cognition, and gender, but was in the multivariate analysis only determined by mood (F [1, 74] = 18.31, P = .000, partial eta squared: .20), showing lower participation scores at each time point for patients with mood disturbance.

CONCLUSIONS

Participation in functionally independent SAH patients improved over time. However, 1 out of 3 patients (34.9%) still reported one or more participation restrictions 12 months post-SAH. Mood disturbance was negatively associated with the course of participation after SAH.

Workplace Outcomes in Work-Disability Prevention Research: A Review with Recommendations for Future Research

Introduction Outcome assessment is a central issue in work disability prevention research. The goal of this paper was to (1) ascertain the most salient workplace outcomes; (2) evaluate the congruence between business and science perspectives; (3) illustrate new perspectives on assessing longitudinal outcomes; and (4) provide recommendations for advancing outcome evaluation in this area of research. Methods The authors participated in a year-long collaboration that culminated in a sponsored 3-day conference, "Improving Research of Employer Practices to Prevent Disability", held October 14-16, 2015, in Hopkinton, MA, USA. The collaboration included a topical review of the literature, group conference calls to identify key areas and challenges, drafting of initial documents, review of industry publications, and a conference presentation that included feedback from peer researchers and a question/answer session with a special panel of knowledge experts with direct employer experience. Results Numerous workplace work-disability prevention outcome measures were identified. Analysis indicated that their applicability varied depending on the type of work disability the worker was experiencing. For those who were working, but with health-related work limitations (Type 1), predominant outcomes were measures of productivity, presenteeism, and work-related limitations. For those who were off work due to a health condition (Type 2), predominant outcomes were measures of time off work, supervisor/employee interactions, and return-to-work (RTW) preparation. For those who had returned to work (Type 3), predominant outcomes were measures of presenteeism, time until RTW, percentage of work resumption, employment characteristics, stigma, work engagement, co-worker interactions, and sustained or durable RTW. For those who had withdrawn from the labor force (Type 4), predominant outcomes were cost and vocational status. Discussion Currently available measures provide a good basis to use more consistent outcomes in disability prevention in the future. The research area would also benefit from more involvement of employers as stakeholders, and multilevel conceptualizations of disability outcomes.

Dissociation of Early and Delayed Cerebral Infarction After Aneurysmal Subarachnoid Hemorrhage

Background and Purpose—

Cerebral infarction after aneurysmal subarachnoid hemorrhage is a significant cause of substantial morbidity and mortality. Because early and delayed cerebral infarction after aneurysmal subarachnoid hemorrhage may be mediated by different processes, we evaluated whether aneurysm-securing methods contributed to infarcts and whether long-term outcomes differ between early and delayed infarcts.

Methods—

A post hoc analysis of the CONSCIOUS-1 study (Clazosentan to Overcome Neurological Ischemia and Infarction Occurring After Subarachnoid Hemorrhage) was performed. Using multivariate logistic regression analysis and propensity matching, independent clinical risk factors associated with infarctions were identified, and the contribution of cerebral infarcts to long-term outcomes was evaluated.

Results—

Within the cohort of 413 subjects, early infarcts were present in 76 subjects (18%), whereas delayed infarcts occurred in 79 subjects (19%), and 36 subjects (9%) had new infarctions that were present on both early and delayed imaging. Propensity score matching revealed a significantly higher proportion of early infarcts after clipping (odds ratio, 4.62; 95% confidence interval, 1.99–11.57; P =0.00012). Multivariate logistic regressions identified clipping as an independent risk factor for early cerebral infarction (odds ratio, 0.26; 95% confidence interval, 0.15–0.48; P <0.001), and angiographic vasospasm was an independent risk factor for delayed cerebral infarction (odds ratio, 1.79; 95% confidence interval, 1.03–3.13; P =0.039). Early infarcts were a significant independent risk factor for poor long-term outcomes at 3 months (odds ratio, 2.34; 95% confidence interval, 1.18–4.67; P =0.015).

Conclusions—

Clipping is an independent risk factor for the development of early cerebral infarcts, whereas delayed cerebral infarcts are associated with angiographic vasospasm. Early cerebral infarcts are stronger predictors of worse outcome than delayed infarction.

Clinical Trial Registration—

URL: http://www.clinicaltrials.gov . Unique identifier: NCT00111085.

Early Cerebral Infarction after Aneurysmal Subarachnoid Hemorrhage

Aneurysmal subarachnoid hemorrhage (SAH) is a serious disease with high case fatality and morbidity. Early cerebral infarction has been suggested as a risk factor for poor outcome. We aimed to assess the pattern of early and delayed cerebral infarction after aneurysmal subarachnoid hemorrhage. We prospectively enrolled consecutive aneurysmal subarachnoid hemorrhage (SAH) patients presenting to an academic neurosurgical referral center (Prince of Wales Hospital, the Chinese University of Hong Kong) in Hong Kong. Cerebral infarction occurred in 24 (48 %) patients, in which 14 (28 %) had early cerebral infarction and 14 (28 %) had delayed cerebral infarction. Early anterior cerebral infarction occurred in a similar proportion of anterior and posterior circulation aneurysms (24 % vs. 21 %), whereas posterior circulation aneurysm patients had a higher proportion of early posterior cerebral infarction compared with anterior circulation aneurysm patients (18 % vs. 2 %). In conclusion, early cerebral infarction was common and different from delayed cerebral infarction.

Call for uniform neuropsychological assessment after aneurysmal subarachnoid hemorrhage: Swiss recommendations

BACKGROUND

In a high proportion of patients with favorable outcome after aneurysmal subarachnoid hemorrhage (aSAH), neuropsychological deficits, depression, anxiety, and fatigue are responsible for the inability to return to their regular premorbid life and pursue their professional careers. These problems often remain unrecognized, as no recommendations concerning a standardized comprehensive assessment have yet found entry into clinical routines.

METHODS

To establish a nationwide standard concerning a comprehensive assessment after aSAH, representatives of all neuropsychological and neurosurgical departments of those eight Swiss centers treating acute aSAH have agreed on a common protocol. In addition, a battery of questionnaires and neuropsychological tests was selected, optimally suited to the deficits found most prevalent in aSAH patients that was available in different languages and standardized.

RESULTS

We propose a baseline inpatient neuropsychological screening using the Montreal Cognitive Assessment (MoCA) between days 14 and 28 after aSAH. In an outpatient setting at 3 and 12 months after bleeding, we recommend a neuropsychological examination, testing all relevant domains including attention, speed of information processing, executive functions, verbal and visual learning/memory, language, visuo-perceptual abilities, and premorbid intelligence. In addition, a detailed assessment capturing anxiety, depression, fatigue, symptoms of frontal lobe affection, and quality of life should be performed.

CONCLUSIONS

This standardized neuropsychological assessment will lead to a more comprehensive assessment of the patient, facilitate the detection and subsequent treatment of previously unrecognized but relevant impairments, and help to determine the incidence, characteristics, modifiable risk factors, and the clinical course of these impairments after aSAH.

Fisher Grading Scale Associated with Language Disorders in Patients with Anterior Circulation Aneurysmal Subarachnoid Hemorrhage

OBJECTIVE

To associate the presence of language deficits with varying scores of the Fisher grading scale in patients with subarachnoid hemorrhage in the period preceding the treatment of aneurysm in the anterior circulation, as well as to compare the scores of this scale, identifying the grades more associated with the decline of language.

METHODS

Database analysis of 185 preoperative evaluations of language, through the Montreal Toulouse Protocol Alpha version and verbal fluency through CERAD battery, of patients from "Hospital da Restauração" with aneurysmal subarachnoid hemorrhage, divided according to the Fisher grading scale (Fisher I, II, III, or IV) and compared with a control group of individuals considered normal.

RESULTS

The various scores of the Fisher grading scale have different levels of language deficits, more pronounced as the amount of blood increases. Fisher III and IV scores are most associated with the decline of language.

CONCLUSIONS

Our study made it possible to obtain information not yet available in the literature, by correlating the various scores of the Fisher grading scale with language yet in the period preceding treatment.

Comparison of two models of hemispheric specialization with unilaterally lesioned patients: material-specific impairment vs response-bias distortion

Validity of two models of hemispheric specialization was compared. The "material-specific impairment" model was radicalized as postulating that left hemisphere (LH) lesions impair processing of verbal material and that right hemisphere (RH) lesions impair processing of visuospatial material, independently of response-bias distortions. The "response-bias distortion" model was radicalized as postulating that LH lesions distort response style toward omissiveness and that RH lesions distort response style toward commissiveness, regardless of material-specific impairments. Participants had comparable left (N=27) or right (N=24) hemisphere cortical lesions having occurred between birth and early adolescence. Four cognitive neuropsychological tests were adjusted to optimize applicability and comparability of the two theoretical models: Rey Complex Figure, Kimura's Recurring Figures, the Story Recall subtest of the Children's Memory Scale, and the California Verbal Learning Test. Both models significantly, independently, and equally distinguished the LH from the RH patients. Both these forms of hemispheric specialization seemed to be implemented very early in life and very rigidly. Intrahemispheric lesion sites, e.g., frontal vs nonfrontal, held no significant relation to the effects described above.

Functional and occupational characteristics predictive of a return to work within 18 months after stroke in Japan: implications for rehabilitation

Objective

This study examined clinical, functional, and occupational factors associated with return to work within 18 months after stroke, specifically focusing on the impact of higher cortical dysfunction on return to work in the chronic phase.

Methods

This prospective cohort study in 21 hospitals specializing in clinical and occupational health recruited consecutive working-age inpatients receiving acute care for their first stroke (n = 351). A unified database was used to extract patient information from hospital records at the time of admission, discharge, and follow-up at 18 months post-stroke. Cox proportional hazard regression analysis was conducted to determine clinical, functional, and occupational factors influencing return to work within 18 months.

Results

Of 351 registered stroke patients (280 males, 71 females, mean age ± SD, 55.3 ± 7.2 years) who met inclusion criteria, 250 responded to the follow-up survey and 101 were lost to follow-up. Half (51 %) succeeded in returning to work during the 18-month follow-up after stroke onset. After adjusting for age, gender, and Barthel index at initial rehabilitation, the following factors were identified as significant predictors of a return to work: white-collar versus blue-collar occupation (hazard ratio (HR) 1.5; 95 % confidence interval (CI) 1.1–2.2), no aphasia (HR 3.0; 95 % CI 1.5–5.9), no attention dysfunction (HR 2.0; 95 % CI 1.0–4.0), and walking ability (HR 3.1; 95 % CI 1.3–7.1).

Conclusions

This study indicated the importance of tailored rehabilitation to alleviate the impact of higher cortical dysfunction and to support return to work by stroke survivors.

Predictors of work status and quality of life 9-13 years after aneurysmal subarachnoid hemorrahage

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.

C-reactive protein as predictor for poor outcome after aneurysmal subarachnoid haemorrhage

BACKGROUND

Aneurysmal subarachnoid haemorrhage (SAH) is a severe disease with high case-fatality and morbidity rates. After SAH, the value of C-reactive protein (CRP)--an acute phase sensitive inflammatory marker--as a prognostic factor has been poorly studied, with conflicting results. In this prospective study, we tested whether increased CRP levels increase independently the risk for cerebral infarct and poor outcome.

METHODS

Previous diseases as well as clinical, laboratory and radiological variables were recorded for 178 patients with SAH admitted within 48 h and with aneurysms occluded within 60 h after bleeding. Plasma CRP was measured, as well as computed tomography (CT) scans routinely obtained on admission, in the morning after aneurysm occlusion, and at discharge during second week after SAH. Factors predicting occurrence of cerebral infarct and poor outcome at 3 months after SAH were tested with multiple logistic regression.

RESULTS

CRP levels increased significantly (p < 0.001) between hospital admission (mean ± SD, 11.4 ± 21.3 mg/l) and the postoperative morning (27.0 ± 31.0 mg/l) and then decreased (p < 0.001) during the the second week (19.8 ± 25.0 mg/l). Admission (18.0 ± 35.7 vs 8.5 ± 8.4 mg/l) and postoperative (41.0 ± 40.2 vs 21.1 ± 24.1 mg/l) CRP levels were higher (p < 0.001) in those with a poor outcome than in those with a favourable outcome, but CRP values did not predict delayed cerebral ischaemia or cerebral infarction. CRP levels did not independently predict outcome, since these correlated with admission clinical grade and occurrence of intraventricular haemorrhage. Higher increase in CRP level between admission and postoperative morning, however, independently predicted poor outcome (p = 0.004). Part of this increased risk was likely due to an appearance of early postoperative cerebral infarction.

CONCLUSIONS

CRP levels correlate with outcome but do not seem to predict delayed cerebral ischaemia or infarction after SAH.

Barriers and facilitators of return to work for individuals with strokes: perspectives of the stroke survivor, vocational specialist, and employer

The purpose of this study was to identify factors that facilitated or acted as a barrier to return to work (RTW) for stroke survivors. We applied 3 approaches to identify the factors. First, we conducted qualitative interviews with 10 stroke survivors about their RTW experience post stroke. Second, we surveyed 21 vocational specialists about barriers and facilitators of RTW based on their clinical practice. Last, we interviewed 7 employers who had experience in interviewing individuals with disabilities or had the authority to make hiring decisions. Descriptions of barriers and facilitators to RTW from these 3 perspectives were illustrated. Identified components were mapped based on the ICF framework. From stroke survivors' perspectives, factors affecting employment after stroke include neurological (motor, cognition, communication), social, personal, and environmental factors. Vocational specialists described similar barriers and facilitators of RTW as the stroke survivors but emphasized personal factors such as flexibility and being realistic in vocational goals. The employers explained that the candidate's disability plays no role in the hiring process and indicated that all applicants must meet the essential job requirements. Some employers described the benefits of having the support of vocational rehabilitation staff and being able to interact with the vocational rehabilitation specialists during the hiring process. The interaction allows the employer to gather initial information (consented to by the job applicant) about the applicants from the vocational rehabilitation service and to be educated about any specific needs related to the applicant's medical issues.

Early cerebral infarction as a risk factor for poor outcome after aneurysmal subarachnoid haemorrhage

BACKGROUND AND PURPOSE

After aneurysmal subarachnoid haemorrhage, severity of bleeding, and occurrence of rebleeding and cerebral infarcts are the main factors predicting outcome. We investigated predictive risk factors for both early and late cerebral infarcts, and whether time of appearance of infarct is associated with outcome.

METHODS

Previous diseases as well as clinical, laboratory and radiological variables including serial CT scans were recorded for 173 patients admitted within 48 h after bleeding and with ruptured aneurysm occlusion by open surgery within 60 h. Factors predicting occurrence of cerebral infarct and poor outcome at 3 months according to the Glasgow Outcome Scale were tested using multiple logistic regression.

RESULTS

Of several potential predictors, poor outcome was independently predicted by patient age, rebleeding, intraventricular haemorrhage, intracerebral haematoma, delayed cerebral ischaemia with fixed symptoms and early new ischaemic lesion on CT scan appearing on the 1st post-operative morning (P<0.01 for each factor). After adjustment for confounding factors, occurrence of early infarct (odds ratio 12.5; 95% confidence interval 3.2-48.7; P<0.01), both early and late infarct (6.6; 1.1-40.4; P<0.05), and late infarct only (2.4; 0.6-9.1) increased risk for poor outcome. Adjusted independent significant risk factors for early infarction were duration of artery occlusion during surgery (1.4/min; 1.1-1.7, P<0.01) and admission plasma glucose level (1.3 per mM; 1.0-1.6, P<0.05) and for late infarction amount of subarachnoid blood (4.5; 1.3-14.9, P<0.05).

CONCLUSION

Early infarction after surgical aneurysm occlusion seems to have different risk factors and worse prognosis than late infarct which is mostly associated with delayed cerebral ischaemia.

Which variables help explain the poor health-related quality of life after subarachnoid hemorrhage? A meta-analysis

OBJECTIVE

Patients with subarachnoid hemorrhage (SAH) are younger than typical stroke patients. Poor psychosocial outcome after SAH therefore leads to a disproportionately high impact on patients, relatives, and society. Addressing this problem requires an understanding of what causes poor psychosocial outcome. Numerous studies have examined potential predictors but produced conflicting results. We aim to resolve this uncertainty about the potential value of individual predictors by conducting a meta-analysis. This approach allows us to quantitatively combine the findings from all relevant studies to identify promising predictors of psychosocial outcome and determine the strength with which those predictors are associated with measures of psychosocial health.

METHODS

Psychosocial health was measured by health-related quality of life (HRQOL). We included in our analysis those predictors that were most frequently examined in this context, namely patient age, sex, neurologic state at the time of hospital admission, bleed severity, physical disability, cognitive impairment, and time between ictus and psychosocial assessment.

RESULTS

Only 1 of the traditional variables, physical disability, had any notable affect on HRQOL. Therefore, the cause of most HRQOL impairment after SAH remains unknown. The situation is even worse for mental HRQOL, an area that is often significantly affected in SAH patients. Here, 90% of the variance remains unexplained by traditional predictors.

CONCLUSION

Studies need to turn to new factors to account for poor patient outcome.

A sequencing-based survey of functional APAF1 alleles in a large sample of individuals with affective illness and population controls

Rare apoptosis-promoting functional variants in the apoptosis protease activating factor 1 (APAF1) gene were recently reported to co-segregate with major depression in male members of families from Utah. In order to estimate the impact of these variants on risk for major depressive disorder (MDD) in the general population, we surveyed the frequency of the APAF1 putative MDD risk alleles using re-sequencing in a large sample of northern European and European-American subjects, including a large number of males with MDD. The E777K and N782T APAF1 variants previously described by Harlan et al. [Harlan et al. (2006) Mol Psychiatry 11(1):76-85] were found at low frequencies in affected individuals and population controls. The C450W and Q465R variants were not detected in any of the 632 subjects sequenced. These results show that the APAF1 variants associated with risk for MDD in the Utah pedigrees are very rare in Northern European and European-American populations. In addition, the E777K and N782T variants were found at low frequencies both in patients and population controls, suggesting that these variants have limited impact on risk for MDD.

Clinical study on cognitive dysfunction after spontaneous subarachnoid haemorrhage: patient profiles and relationship to cholinergic dysfunction

PURPOSE

We aimed to explore the cognitive profiles of subarachnoid haemorrhage patients who returned to the community, along with the associated risk factors.

METHODS

We recruited 40 Chinese patients with spontaneous subarachnoid haemorrhage 7-27 months after the initial presentation. They had all been discharged to their homes or to care homes for the elderly. For cognitive assessment, we employed the Cognitive Subscale of the Alzheimer Disease Assessment Scale (ADAS-cog) for global cognitive function, the Frontal Assessment Battery (FAB) for frontal lobe function, and the Rivermead Behavioural Memory Test (RBMT) for everyday memory function.

RESULTS

An ADAS-cog of more than 21/85 (poor global cognitive function) was noted in 14 (35%) patients. A FAB of less than 12/18 (poor frontal lobe function) was noted in 13 (27.5%) patients. An RBMT score of less than 15/26 (poor everyday memory function) was noted in 17 (43.6%) patients. Poor cognitive function was found to be associated with chronic hydrocephalus (in terms of FAB), with clinical vasospasm (in terms of RBMT), and with cerebral infarction (in terms of RBMT).

CONCLUSIONS

Poor cognitive function was common and occurred in up to 43.6% of the patients, with the verbal and behavioural memory aspects predominantly affected. We did not find a significant association between cholinergic dysfunction and cognitive dysfunction. Organization of future drug trials and cognitive rehabilitation should take into account the association between frontal lobe dysfunction and chronic hydrocephalus.

Return to work in stroke patients

PURPOSE

To present the current state of knowledge regarding return to work (RTW) following stroke.

METHOD

A comprehensive review of the current stroke rehabilitation literature pertaining to prognostic and treatment factors for RTW following stroke.

RESULTS

Stroke is a major healthcare problem and one of the most expensive diseases in modern society. Stroke results not only in impairment and limitation in basic daily activities; it also impacts on participation in community activities, such as returning to work. Return to work in post-stroke patients has been reported to range between 19% and 73%. Various studies report on return to work in diverse populations, using different follow-up periods, while utilizing variable definitions of stroke and successful work outcomes. The factors positively related to RTW in stroke patients, as found in the literature, are age less then 65 years, high education level and white-collar employment. The significant negative predictor is the severity of stroke. This is indicated by neurological parameters including functional measures of the presence and extent of motor and cognitive impairment. Significantly, the side of the brain damaged and stroke location were not found to be correlated with RTW. Social and financial factors also significantly influence RTW.

CONCLUSIONS

RTW in stroke patients should be considered one of the indicators of a successful rehabilitation as it influences self-image, well-being and life satisfaction. There is still a considerable lack of knowledge regarding effective assessments and interventions in vocational rehabilitation in stroke patients.

Characterization of functional outcome and quality of life following subarachnoid hemorrhage in patients treated with and without nicardipine prolonged-release implants

Object

The use of nicardipine prolonged-release implants (NPRIs) is associated with a significant improvement in the therapy of patients suffering from aneurysmal subarachnoid hemorrhage (aSAH) regarding the occurrence and severity of cerebral vasospasm, new infarcts, and functional outcome (FO). Because quality of life (QOL) measurements more reliably seem to describe the patient's true condition, the present study was conducted to assess FO and QOL 1 year after aneurysm rupture in patients with and without NPRIs.

Methods

From the initial series of 32 patients, 18 were assessed 1 year after aSAH (7 of the control and 11 of the NPRI group). The patients underwent neurological investigation, a structured interview followed by a measurement of QOL (Mini-Mental State Examination [MMSE]; 36-Item Short Form Health Survey [SF-36]; and the Hamilton Depression Rating Scale). There were no intergroup differences in the patient characteristics (that is, localization of aneurysm, initial Hunt and Hess grade, or age).

Results

In addition to the previously reported improvement of the National Institutes of Health Stroke Scale and modified Rankin Scale scores, the NPRI group's Karnofsky Performance Scale and the MMSE scores were markedly to significantly improved (p < 0.05 [Karnofsky Performance Scale] and p = 0.053 [MMSE]). In contrast, anxiety, oblivion, and mild symptoms of depression were equally present in both study groups (p = 0.607 [anxiety]; p = 0.732 [oblivion]; and p = 0.509 [Hamilton Depression Rating Scale]). Furthermore, no intergroup differences were observed in any of the SF-36 domains. The scores in the SF-36 domains of Role-Physical, Vitality, and Role-Emotional were significantly reduced in the NRPI group compared with those observed in an age-matched control population (p < 0.001 [Role-Physical]; p = 0.001 [vitality]; and p = 0.01 [Role-Emotional]). Considering consequent costs, no difference was detectable regarding the duration of in- and outpatient rehabilitation (p = 0.135 and 0.171, respectively) or the Prolo score (p = 0.094).

Conclusions

Despite FO improvement in terms of a lower incidence of cerebral vasospasm, new infarcts, morbidity in the treatment of aSAH in patients with NPRIs, a patient's QOL seems to be related to the severity of the aSAH itself.

Relationship of the Met allele of the brain-derived neurotrophic factor Val66Met polymorphism to memory after aneurysmal subarachnoid hemorrhage

OBJECTIVE

The brain-derived neurotrophic factor (BDNF) Val66Met polymorphism has been shown to be related to variability in episodic memory. We studied whether the Met allele is associated with poor learning and memory in survivors of aneurysmal subarachnoid hemorrhage (SAH).

METHODS

Ninety-six patients were examined with a neuropsychological test battery approximately 1 year after SAH. Their deoxyribonucleic acid samples were genotyped for the BDNF Val66Met polymorphism. The Met carriers were compared to the Val/Val homozygous patients on the test performances.

RESULTS

In the total sample, there was no difference between the genotype groups. However, among the patients with no cerebral infarction, the Met carriers had inferior learning and memory performance than the Val/Val homozygotes, but the groups did not differ on the nonmemory test performances. The patients with left and bilateral infarctions had deficits in verbal memory, which may have concealed the effect of the BDNF Val66Met polymorphism on memory in the total sample.

CONCLUSION

As a whole, the BDNF Val66Met polymorphism was not associated with learning and memory performance in patients recovering from SAH. However, the Met allele might predict poor memory function among patients with SAH not complicated by a cerebral infarction. These findings support earlier reports of an association between the Met allele and low memory performance. Longitudinal studies comparing functional recovery from SAH between Met and Val/Val patients without cerebral infarctions are warranted.

Measuring return to work

BACKGROUND

It is argued that one of the factors limiting the understanding of return to work (RTW) following work disability is the use of measurement tools that do not capture a complete picture of workers' RTW experiences. To facilitate the investigation of RTW, the current authors proposed a developmental conceptualization of RTW, which argues for an expanded awareness that encompasses four phases: off work, work reintegration, work maintenance and advancement. This paper reports on work undertaken with the aim of operationalizing the conceptualization.

METHODS

A review of the RTW and related literature, with databases searched including PubMed, EconLit, and PsycInfo. We began by extracting details of RTW instruments used by previous researchers. We then interpreted these within the context of the phases of RTW. Using the International Classification of Functioning, Disability, and Health (ICF) to inform our thinking and coding structure, we conceptualized phase-based RTW outcomes and categorized them as 'tasks and actions', 'contextual' or 'process driven'. Iteratively, we reviewed existing instruments for their use as measures of RTW. Where gaps in instrumentation were found, the wider vocational and career assessment literature was searched for instruments that could be adapted for use in RTW research.

RESULTS

Results indicate that, although numerous research instruments have been used to assess RTW, within the scientific literature some important dimensions of RTW lack instrumentation. In particular, we found that outcomes such as goal setting, motivation, expectation, job seeking, work maintenance, and career advancement require operationalization. Amongst the outcomes had been operationalized, we found considerable variation in conceptual development and application.

CONCLUSIONS

The lack of consistency and comprehensiveness of RTW measurement is one of the factors compromising the advancement of the field of RTW research. It is suggested that a more complete and psychometrically sound array of research instruments, grounded within a commonly adopted paradigm, would further the understanding of RTW and the factors affecting it.

ApoE genotype and cognition after subarachnoid haemorrhage: a longitudinal study

OBJECTIVES

To investigate the effect of the apolipoprotein epsilon4 allele on cognitive functions after aneurysmal subarachnoid haemorrhage (SAH) in a longitudinal study.

MATERIALS AND METHODS

Performances of 19 patients with and 27 patients without the epsilon4 allele were compared on eight cognitive test variables measured 1-4.5 years and 12-15 years after SAH.

RESULTS

In the baseline examination, epsilon4 patients scored worse than non-epsilon4 patients on verbal fluency (P < 0.05). In the follow-up, a visual memory task and interference in colour naming showed more pronounced impairments from baseline in epsilon4 carriers than in non-carriers.

CONCLUSION

Presence of the epsilon4 allele poses a minor risk for late cognitive impairment after the subacute phase of aneurysmal SAH.

Effects of intraoperative hypothermia on neuropsychological outcomes after intracranial aneurysm surgery

OBJECTIVE

Subarachnoid hemorrhage and surgical obliteration of ruptured intracranial aneurysms are frequently associated with neurological and neuropsychological abnormalities. We reported that intraoperative cooling did not improve neurological outcome in good-grade surgical subarachnoid hemorrhage patients, as assessed by the Glasgow Outcome Scale score or other neurological and functional measures (National Institutes of Health Stroke Scale, Rankin Disability Scale, Barthel Activities of Daily Living). We now report the results of neuropsychological testing in these patients.

METHODS

A total of 1,001 patients who bled < or = 14 days before surgery were randomly assigned to intraoperative hypothermia (t = 33 degrees C) or normothermia (37 degrees C). Outcome was assessed approximately 3 months after surgery. Patients underwent the Benton Visual Retention, Controlled Oral Word Association, Rey-Osterrieth Complex Figure, Grooved Pegboard, and the Trail Making tests. T-scores for each test were calculated from normative data. T-scores were averaged to calculate a Composite Score. A test result (or the Composite Score) was considered "impaired" if the T-score was two or more standard deviations below the norm. A Mini-Mental State Examination was also performed.

RESULTS

Neurological outcome data were available in 1,000 patients. Sixty-one patients died. Of the 939 survivors, 873 completed 3 or more tests (exclusive of the Mini-Mental State Examination). Patients with poor neurological outcomes were less likely to complete testing; only 3.9% of Good Outcome (Glasgow Outcome Scale score = 1) patients were untested, compared with 38.6% of patients with Glasgow Outcome Scale scores of 3 and 4. There were no prerandomization demographic differences between the two treatment groups. For hypothermic patients, 16.8% were impaired from their Composite Score versus 20.0% of patients in the normothermic group (p = 0.317). For patients in the hypothermic group, 54.5% were impaired on at least one test, compared with 55.5% of patients in the normothermic group (p = 0.865). Similar results were seen in patients with baseline WFNS scores = I. Mini-Mental State Examination scores in the hypothermic and normothermic groups were 27.4 +/- 3.8 and 26.8 +/- 4.5, respectively.

INTERPRETATION

This is the largest prospective evaluation of neuropsychological function after subarachnoid hemorrhage to date. Testing was completed in a high fraction of patients, demonstrating the feasibility of such testing in a large trial. However, the frequent inability to complete testing in poor-outcome patients suggests that testing may be best used to refine outcome assessments in good-grade patients. Many patients showed impairment on at least one test, with global impairment present in 17 to 20% of patients (18-21% of survivors). This was true even among the patients with the best preoperative condition (WFNS = 1). There was no difference in the incidence of impairment between hypothermic and normothermic groups.

Mechanisms of early brain injury after subarachnoid hemorrhage

Apoptosis is the term given to programmed cell death, which has been widely connected to a number of intracranial pathologies including stroke, Alzheimer's disease, and more recently subarachnoid hemorrhage (SAH). Subarachnoid hemorrhage is a disease, without any form of effective treatment, that affects mainly the young and middle aged and as a result is responsible for severe disability in otherwise healthy and productive individuals. Despite intense research efforts in the field, we currently possess a very limited understanding of the underlying mechanisms that result in injury after SAH. However, a number of studies have recently indicated that apoptosis may be a major player in the pathogenesis of secondary brain injury after SAH. As a result, the apoptotic cascades present a number of potential therapeutic opportunities that may ameliorate secondary brain injury after SAH. Experimental data suggest that these cascades occur very early after the initial insult and may be related directly to physiologic sequela commonly associated with SAH. It is imperative, therefore, to obtain a thorough understanding of the early events that occur after SAH, which will enable future therapies to be developed.