Long-term fatigue after perimesencephalic subarachnoid haemorrhage in relation to cognitive functioning, mood and comorbidity

Re-evaluating patient communication and care in angiographically negative subarachnoid hemorrhage: Balancing realism and optimism

Angiographically negative subarachnoid hemorrhage (anSAH) has traditionally been considered a benign condition, mainly because of favorable outcomes in the acute stage in comparison to the often negative acute outcomes of aneurysmal subarachnoid hemorrhage. However, a growing body of research in recent years shows that anSAH often leads to cognitive impairments, emotional distress, and difficulties in resuming work or other daily life activities. Therefore, in this position paper, we call for a change in neurological care and a shift in patient communication, emphasizing the importance of addressing patient needs and fostering realistic expectations rather than solely focusing on the benign nature of the condition.

Long-term Course of Cognitive Functioning After Aneurysmal and Angiographically Negative Subarachnoid Hemorrhage

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.

Is there evidence for a relationship between cognitive impairment and fatigue after acquired brain injury: a systematic review and meta-analysis

PURPOSE

Fatigue is a major symptom of ABI. Greater fatigue is associated with cognitive impairment. Our aim was to systematically review, describe and analyse the literature on the extent of this relationship.

METHODS

Five databases were searched from inception. Studies were included where: participants had a defined clinical diagnosis of ABI which included TBI, stroke or subarachnoid haemorrhage; a fatigue measure was included; at least one objective cognitive measure was used. Three reviewers individually identified studies and determined quality using the Quality Assessment Tool for Observational Cohort and Cross-sectional Studies.

RESULTS

Sixteen of the 412 identified studies, investigating the relationship between cognitive dysfunction and fatigue, comprising a total of 1,745 participants, were included. Quality ranged from fair to good. Meta-analysis found fatigue was significantly associated with an overall pattern of cognitive slowing on tasks of sustained attention. A narrative synthesis found weak associations with fatigue and information processing, attention, memory and executive function.

CONCLUSION

Analysis found sustained attentional performance had stronger associations with fatigue after ABI. Whereas, weak associations were found between fatigue and information processing, attention and to some extent memory and executive function. More focused research on specific cognitive domains is needed to understand the mechanisms of fatigue.

Daily patterns of fatigue after subarachnoid haemorrhage: an ecological momentary assessment study

OBJECTIVE

To examine the daily course of, and factors associated with, momentary fatigue after subarachnoid haemorrhage, and to explore subgroups of patients with distinct diurnal patterns of fatigue.

DESIGN

Observational study using ecological momentary assessment.

SUBJECTS

A total of 41 participants with subarachnoid haemorrhage.

METHODS

Patients with fatigue were included within one year post-onset. Momentary fatigue (scale 1-7) was assessed with repeated measurements (10-11 times/day) during 7 consecutive days. Multilevel-mixed-model analyses and latent-class trajectory modelling were conducted.

RESULTS

Mean (standard deviation; SD) age of the group was 53.9 (13.0) years, 56% female, and mean (SD) time post-subarachnoid haemorrhage onset was 9.3 (3.2) months. Mean (SD) momentary fatigue over all days was 3.22 (1.47). Fatigue increased significantly (p < 0.001) over the day, and experiencing more burden of fatigue and day type (working day vs weekend day) were significantly (p < 0.05) associated with higher momentary fatigue. Three subgroups could be distinguished based on diurnal patterns of fatigue. The largest group (n = 17, 41.5%) showed an increasing daily pattern of fatigue.

CONCLUSION

Momentary fatigue in patients with subarachnoid haemorrhage increases over the day, and diurnal patterns of fatigue differ between  participants. In addition to conventional measures, momentary measures of fatigue might provide valuable information for physicians to optimize personalized management of fatigue after subarachnoid haemorrhage.

Unraveling the interplay between daily life fatigue and physical activity after subarachnoid hemorrhage: an ecological momentary assessment and accelerometry study

BACKGROUND

Fatigue is one of the most commonly reported symptoms after subarachnoid hemorrhage (SAH) and is indirectly associated with physical activity (PA). Associations between fatigue and PA are primarily examined based on conventional measures (i.e. a single fatigue score or average PA levels), thereby assuming that fatigue and PA do not fluctuate over time. However, levels of fatigue and PA may not be stable and may interrelate dynamically in daily life. Insight in direct relationships between fatigue and PA in daily life, could add to the development of personalized rehabilitation strategies. Therefore we aimed to examine bidirectional relationships between momentary fatigue and PA in people with SAH.

METHODS

People (n = 38) with SAH who suffer from chronic fatigue were included in an observational study using Ecological Momentary Assessment (EMA) and accelerometry. Momentary fatigue was assessed on a scale from 1 to 7 (no to extreme fatigue), assessed with 10-11 prompts per day for 7 consecutive days using EMA with a mobile phone. PA was continuously measured during this 7-day period with a thigh-worn Activ8 accelerometer and expressed as total minutes of standing, walking, running and cycling in a period of 45 min before and after a momentary fatigue prompt. Multilevel mixed model analyses including random effects were conducted.

RESULTS

Mean age was 53.2 years (SD = 13.4), 58% female, and mean time post SAH onset was 9.5 months (SD = 2.1). Multilevel analyses with only time effects to predict fatigue and PA revealed that fatigue significantly (p < 0.001) increased over the day and PA significantly (p < 0.001) decreased. In addition, more PA was significantly associated with higher subsequent fatigue (β = 0.004, p < 0.05) and higher fatigue was significantly associated with less subsequent PA (β=-0.736, p < 0.05). Moreover, these associations significantly differed between participants (p < 0.001).

CONCLUSIONS

By combining EMA measures of fatigue with accelerometer-based PA we found that fatigue and PA are bidirectionally associated. In addition, these associations differ among participants. Given these different bidirectional associations, rehabilitation aimed at reducing fatigue should comprise personalized strategies to improve both fatigue and PA simultaneously, for example by combining exercise therapy with cognitive behavioral and/or energy management therapy.

Incidence and Prediction of Chronic Depression Following Aneurysmal Subarachnoid Hemorrhage: A Single-Center 17-Year Experience

OBJECTIVE

The incidence and risk factors for chronic depression after aneurysmal subarachnoid hemorrhage (aSAH) are described.

METHODS

Patients with aSAH treated at a single institution (January 1, 2003-December 31, 2019) and a modified Rankin Scale score ≤3 at follow-up who were evaluated for chronic depression were analyzed. Chronic depression was defined using a depression screening questionnaire as ≥5 positive answers for symptoms lasting >2 weeks. A predictive model was designed for the primary outcome of depression.

RESULTS

Among 1419 patients with aSAH, 460 patients were analyzed; 130 (28%) had major depressive disorder. Mean follow-up was >6 years. Higher depression rates were associated with tobacco smoking (odds ratio [OR] = 2.64, P < 0.001), illicit drug use (OR = 2.35, P = 0.007), alcohol use disorder (1.92, P = 0.04), chronic obstructive pulmonary disease (COPD) (OR=2.68, P = 0.03), and vasospasm requiring angioplasty (OR=2.09, P = 0.048). The predictive model included tobacco smoking, illicit drug use, liver disease, COPD, diabetes, nonsaccular aneurysm type, anterior communicating artery or anterior cerebral artery aneurysm location, refractory spasm requiring angioplasty, and a modified Rankin Scale score at discharge of >1 (P ≤ 0.03). The model performed with appropriate goodness of fit and an area under the receiver operator curve of 0.70 for depression. Individual independent predictors of depression were tobacco smoking, COPD, diabetes, and nonsaccular aneurysm.

CONCLUSIONS

A substantial percentage of patients had symptoms of depression on follow-up. The proposed predictive model for depression may be a useful clinical tool to identify patients at high risk for developing depression who warrant early screening and evaluation.

Subarachnoid Hemorrhage

PURPOSE OF REVIEW

Subarachnoid hemorrhage (SAH) remains an important cause of mortality and long-term morbidity. This article uses a case-based approach to guide readers through the fundamental epidemiology and pathogenesis of SAH, the approach to diagnosis and management, the results of clinical trials and evidence to date, prognostic considerations, controversies, recent developments, and future directions in SAH.

RECENT FINDINGS

Historically, management of SAH focused on prevention and treatment of subsequent cerebral vasospasm, which was thought to be the primary cause of delayed cerebral ischemia. Clinical and translational studies over the past decade, including several therapeutic phase 3 randomized clinical trials, suggest that the pathophysiology of SAH-associated brain injury is multiphasic and multifactorial beyond large vessel cerebral vasospasm. The quest to reduce SAH-associated brain injury and improve outcomes is shifting away from large vessel cerebral vasospasm to a new paradigm targeting multiple brain injury mechanisms, including early brain injury, delayed cerebral ischemia, microcirculatory dysfunction, spreading cortical depolarization, inflammation, and the brain-body interaction in vascular brain injury with critical illness.Despite multiple negative randomized clinical trials in search of potential therapeutic agents ameliorating the downstream effects after SAH, the overall outcome of SAH has improved over recent decades, likely related to improvements in interventional options for ruptured cerebral aneurysms and in critical care management. Emerging clinical evidence also suggests potential harmful impact of historic empiric treatments for SAH-associated vasospasm, such as prophylactic induction of hypertension, hypervolemia, and hemodilution (triple H therapy).With decreasing mortality, long-term SAH survivorship and efforts to reduce chronic morbidity and to improve quality of life and patient-centered outcome are growing areas of unmet need. Despite existing guidelines, significant variabilities in local and regional practices and in scientific terminologies have historically limited advancement in SAH care and therapeutic development. Large global collaborative efforts developed harmonized SAH common data elements in 2019, and studies are under way to examine how existing variabilities in SAH care impact long-term SAH outcomes.

SUMMARY

Although the overall incidence and mortality of SAH is decreasing with advances in preventive and acute care, SAH remains a major cause of long-term morbidity in survivors. Significant variabilities in care settings and empiric treatment protocols and inconsistent scientific terminologies have limited advancement in patient care and therapeutic clinical studies. Large consensus efforts are under way to introduce clinical guidelines and common data elements to advance therapeutic approaches and improve patient outcome.

Psychological distress after subarachnoid haemorrhage: A systematic review and meta-analysis

OBJECTIVE

Psychological distress is a common complication in patients after Subarachnoid haemorrhage (SAH) which often has significant impact on the prognosis. The objective of this study was to determine the pooled prevalence of anxiety symptoms and depressive symptoms in patients after SAH and identify relevant risk factors.

METHODS

The study adopted a systematic review and meta-analysis protocol. Multiple databases including EMBASE, Medline, PsychInfo, and Web of Science were searched for publications before 1st January 2020. Screening, data extraction, and quality assessment were undertaken following the PRISMA guidelines for preferred reporting of systematic reviews and meta-analysis. The random-effects model was used to calculate pooled prevalence rates. Meta-analysis was conducted using Comprehensive Meta-analysis software. The review protocol was registered on PROSPERO (CRD42020182594).

RESULTS

42 studies reporting anxiety symptoms and 64 studies reporting depressive symptoms were included. The pooled short term(<3 years) and long term(≥3 years) prevalence rates of anxiety symptoms were 31.4%(95% CI: 23.6%, 40.4%) and 40.4%(95% CI: 31.6%, 49.8%), respectively, whereas the pooled short term and long term prevalence rates of depressive symptoms were 25.2%(95%CI: 17.8%, 34.5%) and 35.8%(95%CI: 28.6%, 43.6%), respectively. Gender and pre-existing psychiatric conditions were identified as potential risk factors.

CONCLUSIONS

The high prevalence of anxiety symptoms and depressive symptoms after SAH highlights the need for appropriate assessment and management of psychological stress in patients after SAH. Further research is warranted to explore potential underlying mechanisms and to develop holistic interventions that incorporate understanding of both the biological and psychological impact of SAH.

Depression after Subarachnoid Hemorrhage: A Systematic Review

Background and Purpose

Depression is common and debilitating illness accompanying many neurological disorders including non-traumatic subarachnoid hemorrhage (SAH). The aim of this systematic review was to identify and critically appraise all published studies that have reported the frequency, severity and time course of depression after SAH, the factors associated with its development and the impact of depression on patients’ quality of life after SAH.

Methods

The PubMed database was searched for studies published in English that recruited at least 40 patients (>18 years old) after SAH who were also diagnosed with depression.

Results

Altogether 55 studies covering 6,327 patients met study entry criteria. The frequency of depression ranged from 0% to 61.7%, with a weighted proportion of 28.1%. Depression remained common even several years after the index SAH. Depression after SAH was associated with female sex, premorbid depression, anxiety, substance use disorders or any psychiatric disorders, and coping styles. Comorbid cognitive impairment, fatigue, and physical disability also increased the risk of depression. Aneurysmal SAH and infarction may be related to depression as well. Depression reduces the quality of life and life satisfaction in patients after SAH.

Conclusions

Depression is common after SAH and seems to persist. Further research is needed to clarify its time course and identify the neuroendocrine and neurochemical factors and brain circuits associated with the development of post-SAH depression. Randomized controlled treatment trials targeting SAH-related depression are warranted.

Review: Post-Intensive Care Syndrome: Unique Challenges in the Neurointensive Care Unit

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.

Systematic review of subjective memory measures to inform assessing memory limitations after stroke and stroke-related aphasia

AIM

Primary aims of this systematic review were to: (1) identify the range of subjective memory measures used in the stroke and stroke-related aphasia literature and (2) critically appraise their psychometric properties as well as (3) the methodological qualities of studies that included them, (4) investigate whether such measures provide an accurate reflection of memory impairments (i.e., in comparison to norms from age-matched, neurotypical participants), (5) document the representation of individuals with stroke-related aphasia, and (6) examine the extent to which subjective memory measures correlate with objective memory measures.

METHODS

Systematic review of the literature from 1970 to June 2019 using a comprehensive range of relevant search terms in EMBASE, Medline, PsychINFO, SCOPUS, and Web of Science. Eligibility criteria were for studies to include adults who had suffered of clinical stroke, to report a subjective memory measure that was completed by the stroke survivors, to be reported in a peer-reviewed journal, and to be published in English or Dutch. Quality appraisal was carried out for the included studies as well as the subjective memory measures they employed.

RESULTS

A total of 7,077 titles or abstracts were screened, with 41 studies included in the quantitative and qualitative synthesis. Twenty-six subjective memory measures were used in the included studies. The critical appraisal of their psychometric properties and the methodological quality of the included studies revealed significant shortcomings; for example, neurotypical participants were included in only 14 of the 41 studies. When statistical comparisons were made, different outcomes arose. Only eight studies statistically compared subjective with objective memory measures.

CONCLUSIONS

This literature domain currently provides an unclear picture as to how memory limitations affect participation in stroke and stroke-related aphasia.IMPLICATIONS FOR REHABILITATIONA broad range of subjective memory measures have been used to determine stroke survivors' perceptions of their everyday memory issues.Because of psychometric weaknesses such as inadequate reliability and cross-cultural validity among subjective memory measures, there remains a need to carefully review a given measure's properties to determine if it is appropriate for use with a given stroke survivor.Stroke survivors with aphasia have been infrequently included or inadequately described in studies of subjective memory measures, and thus how these individuals perceive their everyday memory abilities requires further investigation.Although the relationship between subjective and objective memory measures has been infrequently investigated by stroke researchers, both types of measures should be considered as they likely offer complementary rather than redundant information about stroke survivors' memory abilities.

Mental versus physical fatigue after subarachnoid hemorrhage: differential associations with outcome

Background and purpose

Fatigue is a major consequence of subarachnoid hemorrhage (SAH), but the specific characteristics are unclear. Our objective was to investigate the nature of post‐SAH fatigue (mental or physical) and to determine the relationship with functional outcome in the chronic stage. Also, the possible influence of mood disorders and acute SAH‐related factors [SAH type and external cerebrospinal fluid (CSF) drainage] on the presence of fatigue was investigated.

Methods

Patients with an aneurysmal SAH (aSAH) or angiographically negative SAH (anSAH) were assessed 3–10 years post‐SAH (N = 221). Questionnaires were used to investigate mental and physical fatigue and mood. Functional outcome was examined with the Glasgow Outcome Scale Extended. Between‐group comparisons and binary logistic regression analysis were performed.

Results

Frequencies of mental and physical fatigue were 48.4% and 38.5%, respectively, with prevalence of mental fatigue being significantly higher. A two‐way anova with SAH type and external CSF drainage as independent variables and mental fatigue as dependent variable showed a significant main effect of CSF drainage only (P < 0.001). Only mental fatigue explained a significant part of the variance in long‐term functional outcome (model χ² = 52.99, P < 0.001; Nagelkerke R² = 0.32).

Conclusions

Mental fatigue after SAH is a serious burden to the patient and is associated with impaired long‐term functional outcome. Distinguishing different aspects of fatigue is relevant as mental post‐SAH fatigue might be a target for treatment aimed to improve long‐term outcome.

Consequences and coping strategies six years after a subarachnoid hemorrhage - A qualitative study

Background

After a subarachnoid haemorrhage (SAH), continuing impairment is common and may impact the person’s life. There is a lack of knowledge regarding long-term consequences experienced.

Purpose

To explore experiences of the care and rehabilitation as well as the consequences and strategies used to cope with everyday life six years post SAH.

Methods

An explorative interview study with a qualitative design. Individual interviews, with open ended questions, using an interview guide were performed with sixteen participants (mean age 63, 8 men, 8 women) six years post SAH. Data was analyzed according to a descriptive thematic analysis, and themes were discovered inductively.

Results

Two major themes from the analysis, both including four sub-themes, were identified; these themes were consequences of the SAH and coping strategies. Participants were grateful to have survived the SAH and most were satisfied with their acute medical care. If discharged directly from the neurosurgical unit participants can feel abandoned. In contrast, participants who were referred to a rehabilitation clinic felt supported and informed. Cognitive problems, such as impaired memory and mental fatigue, were reported as still present six years post SAH. Coping strategies were; receiving support from family, society, employers, or technical equipment. At work, talking to colleagues and to taking breaks were common. Participants described hiding their symptoms from employers and friends, as well as trying to continue doing tasks in the same manner as prior to the SAH. If this was not possible, some refrained from doing these tasks. They went through a mourning process, fear, and worries.

Conclusions

Participants reported several long-term consequences which impacted on their daily lives post SAH, and different coping strategies were used to cope with these problems. Participants reported lack of awareness regarding the consequences of SAH and stressed the importance of structured multidisciplinary follow-ups, which mostly is missing.