Cognitive performance following spontaneous subarachnoid haemorrhage versus other forms of intracranial haemorrhage

Effect of RehaCom cognitive rehabilitation software on working memory and processing speed in chronic ischemic stroke patients

Stroke survivors need assistance to overcome cognitive impairments. Working memory (WM) and processing speed (PS) as two critical cognitive functions are disrupted by stroke. The goal of this study was to investigate the effect of RehaCom rehabilitation software on WM and PS in participants with chronic ischemic stroke with hemiplegia (right/left side). Participants were selected among stroke patients who were referred to our special rehabilitation clinic. Fifty participants were assigned to control (n = 25) and experimental (n = 25) groups. The results of the experimental group were compared with the control group before and after the treatment with RehaCom (ten 45-min sessions across five weeks, two sessions per week). The results showed a significant improvement in WM and PS in the experimental group in comparison with the control group after a 5-week training with RehaCom. In conclusion, our findings indicate that treatment with RehaCom software improves WM and PS in chronic ischemic stroke participants with hemiplegia. The exact mechanism of RehaCom is largely unknown and further studies are needed, but its effects on the function of brain regions involved in modulating cognitive functions such as the prefrontal cortex, cingulate cortex, and parietal cortex may be mechanisms of interest.

Cognitive Impairment, Functional Outcome, and Delayed Cerebral Ischemia After Aneurysmal Subarachnoid Hemorrhage

BACKGROUND

Measures such as modified Rankin Scale (mRS) may not reflect cognitive outcome following aneurysmal subarachnoid hemorrhage. The aim of this study was to assess the relationship between functional outcome, measured by mRS, and cognition, measured by mini-mental state examination (MMSE), after aSAH. A secondary analysis evaluated the impact of delayed cerebral ischemia (DCI) on the proportion of patients who had cognitive impairment.

METHODS

We performed a post hoc analysis of the Clazosentan to Overcome Neurological Ischemia and Infarction Occurring After Subarachnoid Hemorrhage (CONSCIOUS-1) trial data. MMSE and mRS scores were compared using Kruskal-Wallis equality-of-populations rank test with pairwise comparison post hoc analysis. Cognitive impairment was defined as MMSE score <27. A stepwise logistic regression model evaluated whether DCI was a predictor of cognitive impairment.

RESULTS

CONSCIOUS-1 comprised 413 patients. Of these, 337 took an MMSE at their 12-week follow-up. Mean MMSE score was 27 with a median of 29 (range, 0-30; SD 5.4). There were no significant differences between MMSE scores of patients who had 12-week mRS scores of 0-2. On multivariate analysis, DCI was independently associated with cognitive impairment after aSAH.

CONCLUSIONS

Patients considered to have a good outcome on mRS had varying degrees of cognitive function on MMSE, whereas development of DCI was an independent predictor of cognitive impairment after aSAH. MMSE may not be sensitive enough to discern subtle defects in cognition, as the median score was 29 out of 30.

Association of Seizure Occurrence with Aneurysm Treatment Modality in Aneurysmal Subarachnoid Hemorrhage Patients

BACKGROUND

Data on new-onset seizures after treatment of aneurysmal subarachnoid hemorrhage (aSAH) patients are limited and variable. We examined the association between new-onset seizures after aSAH and aneurysm treatment modality, as well their relationship with initial clinical severity of aSAH and outcomes.

METHODS

This is a retrospective cohort study of all aSAH patients admitted to our institution over a 6-year period. 'Seizures' were defined as any observed clinical seizure or electrographic seizure on continuous electroencephalogram (cEEG) recordings, as determined by the reviewing neurophysiologist. Subgroup analyses were performed in low-grade (Hunt-Hess 1-3) and high-grade (Hunt-Hess 4-5) patients. Outcomes measures were Glasgow Coma Score (GCS) at intensive care unit (ICU) discharge and modified Rankin Scale (mRS) at outpatient follow-up.

RESULTS

There were 282 patients with aSAH; 203 (72.0%) suffered low-grade and 79 (28%) high-grade aSAH. Patients were treated with endovascular coiling (N = 194, 68.8%) or surgical clipping (N = 66, 23.4%). Eighteen (6.4%) patients had seizures, of whom 10 (5.5%) had aneurysm coiling and 7 (10.6%) underwent clipping (p = 0.15). In low-grade patients, seizures occurred less frequently (p = 0.016) and were more common after surgical clipping (p = 0.0089). Seizures correlated with lower GCS upon ICU discharge (p < 0.001), in clipped (p = 0.011) and coiled (p < 0.001) patients and in low-grade aSAH (p < 0.001). Seizures correlated with higher mRS on follow-up (p < 0.001), in clipped (p = 0.032) and coiled (p = 0.004) patients and in low-grade aSAH (p = 0.003).

CONCLUSIONS

New-onset seizures after aSAH occurred infrequently, and their incidence after aneurysm clipping versus coiling was not significantly different. However, in low-grade patients, new seizures were more frequently associated with clipping than coiling. Additionally, non-convulsive seizures did not occur in low-grade patients treated with coiling. These findings may explain, in part, previous work suggesting better outcomes in coiled patients and encourage physicians to have a lower threshold for cEEG utilization in low-grade patients suspected to have acute seizures after surgical clipping.

Responsiveness and predictive validity of the Tablet-based Symbol Digit Modalities Test in patients with stroke

BACKGROUND

The responsiveness and predictive validity of the Tablet-based Symbol Digit Modalities Test (T-SDMT) are unknown, which limits the utility of the T-SDMT in both clinical and research settings.

AIM

The purpose of this study was to examine the responsiveness and predictive validity of the T-SDMT in inpatients with stroke.

DESIGN

A follow-up, repeated-assessments design.

SETTING

One rehabilitation unit at a local medical center.

POPULATION

A total of 50 inpatients receiving rehabilitation completed T-SDMT assessments at admission to and discharge from a rehabilitation ward.

METHODS

The median follow-up period was 14 days. The Barthel index (BI) was assessed at discharge and was used as the criterion of the predictive validity.

RESULTS

The mean changes in the T-SDMT scores between admission and discharge were statistically significant (paired t-test = 3.46, P=0.001). The T-SDMT scores showed a nearly moderate standardized response mean (0.49). A moderate association (Pearson's r =0.47) was found between the scores of the T-SDMT at admission and those of the BI at discharge, indicating good predictive validity of the T-SDMT.

CONCLUSIONS

Our results support the responsiveness and predictive validity of the T-SDMT in patients with stroke receiving rehabilitation in hospitals.

CLINICAL REHABILITATION IMPACT

This study provides empirical evidence supporting the use of the T-SDMT as an outcome measure for assessing processing speed in inpatients with stroke. The scores of the T-SDMT could be used to predict basic activities of daily living function in inpatients with stroke.

Changes in motor function, cognition, and emotion-related behavior after right hemispheric intracerebral hemorrhage in various brain regions of mouse

Intracerebral hemorrhage (ICH) is a detrimental type of stroke. Mouse models of ICH, induced by collagenase or blood infusion, commonly target striatum, but not other brain sites such as ventricular system, cortex, and hippocampus. Few studies have systemically investigated brain damage and neurobehavioral deficits that develop in animal models of ICH in these areas of the right hemisphere. Therefore, we evaluated the brain damage and neurobehavioral dysfunction associated with right hemispheric ICH in ventricle, cortex, hippocampus, and striatum. The ICH model was induced by autologous whole blood or collagenase VII-S (0.075 units in 0.5 µl saline) injection. At different time points after ICH induction, mice were assessed for brain tissue damage and neurobehavioral deficits. Sham control mice were used for comparison. We found that ICH location influenced features of brain damage, microglia/macrophage activation, and behavioral deficits. Furthermore, the 24-point neurologic deficit scoring system was most sensitive for evaluating locomotor abnormalities in all four models, especially on days 1, 3, and 7 post-ICH. The wire-hanging test was useful for evaluating locomotor abnormalities in models of striatal, intraventricular, and cortical ICH. The cylinder test identified locomotor abnormalities only in the striatal ICH model. The novel object recognition test was effective for evaluating recognition memory dysfunction in all models except for striatal ICH. The tail suspension test, forced swim test, and sucrose preference test were effective for evaluating emotional abnormality in all four models but did not correlate with severity of brain damage. These results will help to inform future preclinical studies of ICH outcomes.

Rupture of a non-traumatic anterior communicating artery aneurysm: Does location of aneurysm associate with functional independence following post-acute in-patient neurorehabilitation?

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.

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.

A rat model of chronic subdural hematoma: Insight into mechanisms of revascularization and inflammation

Chronic subdural hematoma (CSDH) is a common neurological occurrence in the elderly population with significant impact on the quality of life and work. Studies have attempted to determine the risk factors and pathophysiological mechanisms of CSDH using models in numerous mammalian species. To date, these animal models have only been able to reproduce limited durations of hematoma which does not accurately reflect the chronic state of CSDH. To address some of these challenges we modified a rat model of CSDH using two consecutive injections of autologous blood resulting in a hematoma of more than three weeks. We observed inflammatory and angiogenic changes related to the development and recovery of CSDH. In this study the technique for producing a CSDH in a small animal model had a success rate of 78.13%. The hematoma was sustainable up to 24 days. Hematoma resolution was associated with a gradual decrease in local pro-inflammatory factors and gradual increase in anti-inflammatory factors as well as proliferation and subsequent maturation of newly formed vessels. These events were also associated with improved behavioral outcome. Expression of anti-inflammatory cytokines also paralleled reabsorption of the hematoma. Reduction in hematoma size was also associated with neurological recovery. These data suggest that vessel maturation and anti-inflammatory pathways may contribute to the resolution of CSDH and neurological recovery. The regulation of the two mechanisms is a potential target for the treatment of CSDH. The modified model of rat CSDH demonstrated a high level of reproducibility in our hands and may be useful in future CSDH studies.

The role of processing speed in post-stroke cognitive dysfunction

The association between speed of information processing and cognition has been extensively validated in normal aging and other neurocognitive disorders. Our aim was to determine whether such a relationship exists in stroke. Thirty patients and 30 age- and education-matched healthy individuals were administered a comprehensive battery of neuropsychological tests divided into the following six cognitive domains: processing speed (PS), verbal memory, visual memory, visuoperceptual function, language, and cognitive flexibility. The results demonstrate that stroke patients were characterized by cognitive deficits in almost all of these domains, but have the most pronounced deficits in PS. After adjusting for symbol digit modalities test score, all significant group differences in cognitive functioning disappeared. However, group differences remained significant after controlling for the influence of other cognitive factors. These findings suggest that decreased PS appears to underlie post-stroke cognitive dysfunction and may serve as a potential target for intervention.

Chronic subdural haematoma: modern management and emerging therapies

Chronic subdural haematoma (CSDH) is one of the most common neurological disorders, and is especially prevalent among elderly individuals. Surgical evacuation is the mainstay of management for symptomatic patients or haematomas exerting significant mass effect. Although burr hole craniostomy is the most widely practised technique worldwide, approximately 10-20% of surgically treated patients experience postoperative recurrence necessitating reoperation. Given the increasing incidence of CSDH in a growing elderly population, a need exists for refined techniques that combine a minimally invasive approach with clinical efficacy and cost-effectiveness. In addition, nonsurgical treatment modalities, such as steroids, are attracting considerable interest, as they have the potential to reduce postoperative recurrence or even replace the need for surgery in selected patients. This Review provides an overview of the contemporary management of CSDH and presents considerations regarding future approaches that could further optimize patient care and outcomes.