A prospective study of impairment of cognition and memory and recovery after subarachnoid hemorrhage

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.

Validation of an aneurysmal subarachnoid hemorrhage grading scale in 1532 consecutive patients

OBJECTIVE

The two most commonly used aneurysmal subarachnoid hemorrhage grading scales are the Hunt and Hess and World Federation of Neurological Societies scales. Neither has achieved universal acceptance, however, owing to concerns regarding either subjectivity or lack of correlation with outcomes, respectively. A grading scale based entirely on the Glasgow Coma Scale (GCS) was recently proposed. We have prospectively evaluated the GCS grading system and compared it with the Hunt and Hess and World Federation of Neurological Societies scales for predictive accuracy.

METHODS

Data from 1532 consecutive patients with intracranial aneurysms admitted to our institution between January 1991 and June 2005 were analyzed. The Glasgow Outcome Scale was the primary outcome measure. Mortality and length of stay were secondary measures. The scales were evaluated using simple and multivariable logistic and linear regression. Receiver operating characteristic curves were used to assess predictive accuracy for the Glasgow Outcome Scale. Prognostic factors were assessed with ordinal multivariable logistic regression.

RESULTS

The GCS grading system was most strongly associated with all outcome measures and was the strongest predictor of mortality and persistent vegetative state. Age, vasospasm, hydrocephalus, and intracranial hematoma were found to be significant prognostic elements.

CONCLUSION

The GCS grading system is more strongly associated with outcomes than either the Hunt and Hess or World Federation of Neurological Societies scales, and it is an equivalent to a slightly better predictor of Glasgow Outcome Scale outcomes. Its simplicity, proven inter-rater reliability, and wide level of familiarity among health care personnel render the GCS grading system a superior grading scale for aneurysmal subarachnoid hemorrhage severity, warranting its consideration for universal use.

Posttraumatic stress disorder explains reduced quality of life in subarachnoid hemorrhage patients in both the short and long term

OBJECTIVE

A subarachnoid hemorrhage reduces patients' quality of life (QoL) in both the short and long term. Neurological problems alone cannot explain this reduction. We examined whether posttraumatic stress disorder (PTSD) and fatigue provide an explanation.

METHODS

We prospectively studied a representative sample of 105 subarachnoid hemorrhage patients. Patients were examined at approximately 3 and 13 months postictus. Examinations included assessments of PTSD, fatigue, sleep, cognitive and physical outcomes, and QoL. Patients' coping skills were also assessed. Regression analyses identified predictors for QoL and PTSD.

RESULTS

Thirty-seven percent met the diagnostic criteria for PTSD at both assessment points. This is a fourfold increase compared with the rate of PTSD in the general population. Fatigue in patients was also consistently elevated, higher, in fact, than the notoriously high fatigue level reported for cancer patients undergoing chemotherapy. PTSD was the best predictor for mental QoL, the domain most persistently impaired. It also helped predict physical QoL. Moreover, PTSD was linked to increased sleep problems and may, therefore, have led to fatigue in both the acute and later stages of recovery. To establish the cause of PTSD, a logistic regression was performed. This showed that maladaptive coping was the best predictor of PTSD.

CONCLUSION

PTSD explains why some subarachnoid hemorrhage patients, despite relatively good clinical outcomes, continue to experience a reduced QoL. Given that maladaptive coping skills seem the main cause of PTSD, teaching patients better coping skills early on might prevent PTSD and QoL reduction.

Cerebral infarction associated with acute subarachnoid hemorrhage

BACKGROUND

Cerebral infarction is a common complication of aneurysmal subarachnoid hemorrhage (SAH), but usually occurs several days after onset as a complication of vasospasm or aneurysm repair. The frequency, causes, and clinical impact of acute infarction associated with the primary hemorrhage are poorly understood.

METHODS

We evaluated the presence of cerebral infarction on admission CT in 487 patients admitted within 3 days of SAH onset to our center between July 1996 and September 2002. Infarctions due to angiography or treatment complications were rigorously excluded. Outcome at 3 months was assessed with the modified Rankin Scale.

RESULTS

A total of 17 patients (3%) had acute infarction on admission CT; eight had solitary and nine had multiple infarcts. Solitary infarcts usually appeared in the vascular territory distal to the ruptured aneurysm, whereas multiple infarcts tended to be territorial and symmetric. Global cerebral edema (P < 0.001), coma on presentation (P = 0.001), intraventricular hemorrhage (P = 0.002), elevated APACHE-II physiological subscores (P = 0.026) and loss of consciousness at onset (P = 0.029) were associated with early cerebral infarction. Mortality (P = 0.003) and death or moderate-to-severe disability (mRS 4-6, P = 0.01) occurred more frequently in the early cerebral infarction group.

CONCLUSIONS

Early cerebral infarction on CT is a rare but devastating complication of acute SAH. The observed associations with coma, global cerebral edema, intraventricular hemorrhage, and loss of consciousness at onset suggest that intracranial circulatory arrest may play a role in the pathogenesis of this disorder.

Neuropsychological features of lesion-related epilepsy in adults: an overview

Lesional epilepsy is thought to be a direct consequence of focal brain lesions of dysgenetic, neoplastic, vascular, or traumatic origin. It has been estimated that at least half of all epilepsies are the result of such lesions. The current discussion includes an overview of the cognitive and behavioral presentations in adults with epilepsy secondary to focal pathology. The neuropsychological presentation in this population is influenced by many factors, including the location and nature of the underlying lesion, seizure characteristics, the effects of treatment, and patient variables. Few studies attempt to disentangle the specific contributions of these variables to cognitive performance. However, where available studies examining the separable effects of seizure-related variables on cognitive functioning in individuals with lesional epilepsy are also reviewed. This overview includes a discussion of focal malformations of cortical and vascular development and select foreign tissue and acquired lesions.

The systemic implications of aneurysmal subarachnoid hemorrhage

Aneurysmal subarachnoid hemorrhage (SAH) is analogous to a pathophysiological watershed, disrupting brain integrity and function and precipitating an array of systemic derangements including cardiovascular, respiratory, endocrine, hematological, and immune dysfunction. Extracerebral organ dysfunction is closely linked to the magnitude of the primary neurological insult, suggesting neurogenic, neuroendocrine and neuroimmunomodulatory mechanisms. Systemic organ involvement is associated with increased mortality and neurological impairment, even after adjustment for other outcome predictors such as the severity of the initial neurological injury. This may be a reflection of secondary brain injury precipitated by hypoxemia, circulatory failure, fever, or hyperglycemia, all of which have been linked to adverse clinical outcomes. Interventions to avert or reverse these and other perturbations need to be tested in clinical trials as they represent opportunities to improve survival and neurological recovery in patients with SAH.

Neuropsychological evaluation of the treatments applied to intracranial aneurysms in a Spanish sample

Very few studies have examined the neuropsychological differences between the two types of aneurysm treatment, and these studies come from different countries. The purpose of this study is to compare the neuropsychological differences between surgical treatment and endovascular treatment in a Spanish sample of patients who have experienced an aneurysmal subarachnoid hemorrhage. The sample is composed of three groups: 40 patients who underwent surgical intervention, 24 who were treated by means of coiling, and a group of 29 healthy participants. An extensive neuropsychological evaluation was performed. The results presented show that no neuropsychological differences were found between the two types of treatment for aneurysms and that the most affected function was memory. This result coincides with findings from other studies.

Epidemiology of traumatic brain injury and subarachnoid hemorrhage

Incidence rates of traumatic brain injury are high in both industrialized and non-industrialized countries and have been estimated variously to be between 150-250 cases per 100,000 population per year. The estimated incidence rates for subarachnoid hemorrhage (SAH) are between 10 to 25 cases per 100,000 population per year. Seasonal variation in the occurrence of subarachnoid hemorrhage has been reported in studies from different countries, with significant seasonal variations and peak periods for aneurysmal SAH differing widely. A differential racial distribution for SAH has been found as well as a higher mortality rate for women than for men. The cognitive and behavioral consequences of TBI and SAH are significant and affect the quality of life of patients and their families. Recent publications have informed of hypopituitary deficits in patients sustaining TBI or SAH. It is not clear whether the cognitive deficits found in these patients are due to the consequences of the brain injury itself or are related to the hypopituitary deficits. There is a need for research distinguishing the differential cognitive and behavioral effects of the brain injury and the endocrinological deficits in these patients, and for developing adequate treatment.

Neuropsychological aspects of type of epilepsy and etiological factors in adults

Whether certain types of epilepsies and etiologies are related to profiles of cognitive impairment is of interest for diagnostics and treatment. The dichotomy between generalized and focal epilepsies (mesial temporal lobe, frontal lobe, parietal, and occipital lobe epilepsies) is considered. Then the most frequent etiologies are discussed. We conclude that specific associations between neuropsychological deficits and type of epilepsy and etiology are rather exceptions. However, knowledge of the type of epilepsy and pathology provides eminent information to evaluate the nature of deficits, to estimate chances of functional recovery, to provide rehabilitation recommendations, and to support decisions about treatment options.

Anxiety and Depression after Spontaneous Subarachnoid Hemorrhage

OBJECTIVE

Relatively little attention has been paid to emotional outcome after subarachnoid hemorrhage (SAH). This study assessed levels of anxiety and depression among SAH survivors and related these to clinical indices.

METHODS

Seventy SAH patients from a consecutive series of neurosurgical admissions participated in semistructured assessments of functional outcome; 52 of the patients also returned standardized measures of emotional outcome. These data were compared with clinical indices collected during the initial hospital admission.

RESULTS

Moderate to severe levels of anxiety were present in approximately 40% of patients 16 months after hemorrhage, with approximately 20% experiencing moderate to severe levels of depression. Although anxiety was more likely to be reported at interview by those with an SAH of Fisher Grade 4, the standardized measures of anxiety and depression were not associated with severity of hemorrhage or any other clinical variables. Both anxiety and depression were significantly associated with outcome indices such as return to work and engagement in social activities.

CONCLUSION

Anxiety is a significant and lasting problem for approximately 40% of survivors of SAH. It is suggested that measures taken to prevent or treat such anxiety among survivors of SAH may serve to significantly improve functional outcome.

Neurological and neuropsychological outcome after SAH

The fact that neurological status and physical integrity alone do not sufficiently assess the overall state of patients after aneurysmal subarachnoid hemorrhage (SAH) gives rise to the necessity for complementary neuropsychological investigation. Neuropsychological work-up should also cover an emotional state, psychosocial adjustment and competence in everyday life of the patients. In our prospective study we investigated 82 patients three months and one year after SAH and early clipping of the aneurysm. For the evaluation of postoperative neurological functions the Glasgow Outcome Scale (GOS) was used. For the neuropsychological assessment we used standardized measures of verbal and figural learning and memory, verbal and figural fluency, speed of information processing, visuospacial abilities and affective function. One year after SAH 95.6% of patients with Hunt&Hess Grade 1 and 2 on admission showed good neurological results (GOS 4 and 5). However, only 30.1% (18 of 63 patients with a favourable neurological outcome--GOS 4 and 5) did not show any neuropsychological deficit. Localization of the ruptured aneurysm significantly correlated with cognitive measures. The best cognitive outcome was shown in patients with aneurysms on the anterior communicating artery (ACoA) followed by posterior communicating artery (PCoA) and those located on the internal carotid artery (ICA) on the right side.

Aneurysmal subarachnoid hemorrhage in Baltic population: experience from Latvia (1996-2000)

Better knowledge of clinical epidemiology and course of aneurysmal subarachnoid hemorrhage (ASAH) is essential for dedicated planning of the need for services. The aim of the study was to obtain a picture of epidemiology and clinical course of ASAH in Riga City (the capital of Latvia). A retrospective population-based study included residents of Riga City who suffered their first ASAH during a 5-year period from the beginning of 1996 till the end of 2000. The total number of ASAH events in the population during the study period was 292, of which 56 (19%) were fatal before reaching the hospital. There was no significant difference between age-specific incidence rates in men and women. The mean ASAH rates per 100 000 per year were 10.3 for age-adjusted incidence (in the population aged 20-79 years) and 7.2 for crude incidence. The mean age-adjusted case fatality rates were 57% for all ASAH events and 45% for those who survived admission. Our data suggest that incidence of ASAH in Baltic population can be recognized as average compared with other European regions. However, the case fatality rate of ASAH in the study population was higher than those of SAH reported from MONICA Collaborating Centers.

Cholinergic dysfunction in cognitive impairments after aneurysmal subarachnoid hemorrhage

OBJECTIVE

Although cognitive impairments have been observed after subarachnoid hemorrhage (SAH), little is known about their neurobiological bases. To examine cholinergic function in such patients, we used a known test for Alzheimer's disease based on an exaggerated pupil dilation response to a cholinergic antagonist, tropicamide (the tropicamide drop test).

METHODS

Seventeen patients who were treated surgically after aneurysmal SAH were divided into two groups on the basis of their scores on the Mini-Mental State Examination (MMSE): Group A (MMSE > or =28) and Group B (MMSE < or =27). The mean interval of time between surgery and administration of the MMSE was 4.7 +/- 2.1 years for Group A and 4.2 +/- 1.3 years for Group B. The tropicamide drop test was performed within 1 month after the MMSE for each patient. After measurement of the baseline pupil diameter (R1, right pupil size: L1, left pupil size), one drop of 0.01% tropicamide was applied to the right eye and physiological saline to the left eye. Pupil diameter (R2, right pupil size; L2, left pupil size) was then remeasured. Data were represented as the dilation ratio of the right pupil (R2/R1) and as the relative dilation ratio of the right pupil to that of the left pupil (R2L1/R1L2).

RESULTS

The mean dilation ratio of the right pupil (R2/R1) was higher in Group B (1.13 +/- 0.09) than in Group A (1.07 +/- 0.11), although the difference did not reach statistical significance (P = 0.18). The relative dilation ratio (R2L1/R1L2) was significantly higher in Group B (1.41 +/- 0.36) than in Group A (1.06 +/- 0.20) (P < 0.05).

CONCLUSION

We determined cholinergic dysfunction in patients with cognitive impairment after SAH on the basis of the pupillary response to tropicamide. The results provide an insight into the pathophysiology of cognitive impairments after SAH, which might lead to future treatment strategies.

Surgical management of unruptured aneurysms: prognostic indicators

BACKGROUND

The treatment of unruptured aneurysms (UA) remains controversial. Therefore, it has become necessary to define various prognostic indicators in the surgical treatment of unruptured aneurysms not associated with previously ruptured aneurysms.

METHODS

During a 6-year period, 78 unruptured aneurysms were managed. The results of management were retrospectively reviewed to define the prognostic indicators.

RESULTS

There were 104 patients with unruptured aneurysms who underwent surgical treatment. Seventy-five patients without previous subarachnoid hemorrhage (SAH) were selected for data analysis. Eighty-seven percent of the aneurysms were on the anterior circulation. The most common location was the middle cerebral artery (MCA) followed by the posterior communicating artery (PCom), ophthalmic artery, and anterior communicating artery (ACom). Six percent were found on the basilar artery. The mean size of aneurysms was 12.5 mm (range = 3-30 mm, SD = 7.4). At surgery, rupture of the aneurysm was encountered in eight cases with temporary control of the parent vessel being required in 31 procedures. In four cases, intraoperative angiography warranted clip reapplication. The Glasgow Outcome Scale (GOS) was used as an outcome measure. Surgical treatment resulted in good outcome (GOS 1) in 87% and 10.7% had fair outcome; 2.3% were in GOS 3 (severe disability) at 6 month follow-up. There was no mortality. Logistic regression identified significant relationships between GOS and intraoperative rupture (p < 0.0002), rupture and size (p < 0.003), and size and age (p < 0.01).

CONCLUSIONS

Large size aneurysms were associated with intraoperative rupture, which had a strong correlation with poor outcome. Increased age showed a linear relationship with the size of the aneurysm. Overall results of treatment for UA are gratifying. There was no mortality. Early diagnosis and surgical extirpation of UA may reduce both intraoperative difficulties as well as poor outcome probability.

Functional outcome after inpatient rehabilitation in persons with subarachnoid hemorrhage

OBJECTIVES

To describe inpatient rehabilitation outcome in persons with nontraumatic subarachnoid hemorrhage (SAH) and to explore the predictive capacity of acute measures of SAH severity and demographic and disease variables.

DESIGN

Retrospective with descriptive and relational analyses.

SETTING

Free-standing, acute, inpatient brain injury rehabilitation unit.

PARTICIPANTS

Forty-two consecutive persons with nontraumatic SAH and for whom complete data were available were studied. Mean age of the group was 56.5 years, mean acute hospital stay was 26.2 days, and 60% were women. Over 40% experienced rupture of an anterior communicating artery aneurysm. The time from injury to rehabilitation admission varied from 11 to 227 days (mean, 43.8d).

INTERVENTIONS

Not applicable.

MAIN OUTCOME MEASURE

Change in FIMtrade mark instrument scores, home discharge rate, and rehabilitation length of stay (LOS.)

RESULTS

The mean admission and discharge FIM scores were 57.7 and 85.5 points, respectively. There was a 27.8-point mean change in FIM score over a 24.1-day mean rehabilitation LOS for a FIM efficiency (points/day) of 1.15. Over 80% of the sample was discharged home. No demographic or disease characteristic variables, including acute severity measures, were statistically significant predictors of outcome.

CONCLUSIONS

Functional gains during inpatient rehabilitation made in this group of 42 persons with SAH are in line with earlier studies. Our rehabilitation LOS is the shortest reported among 4 studies to date and is probably a reflection of managed care in the United States. A small sample, uneven cell sizes, and variability of patients might have contributed to a lack of significant findings. Future study should explore the prediction of rehabilitation outcome using larger sample sizes and longer follow-up periods.

Aneurysmal subarachnoid haemorrhage: outcomes of early rehabilitation after surgical repair of ruptured intracranial aneurysms

OBJECTIVES

The aim was to analyse functional and cognitive outcomes in patients receiving early rehabilitation treatment after surgery for aneurysmal subarachnoid haemorrhage (SAH).

METHODS

The assessment protocol included all relevant clinical data, the Hunt-Hess scale, the functional independence measure (FIM), and the mini mental state examination (MMSE).

RESULTS

Of 59 patients included in the study, 52.5% (31) were men and 47.5% (28) were women. The patients' average age was 52 years, and 57.6% were employed at the time of the aneurysm rupture. The mean duration of hospital stay was 25 days; 67.8% (40) of the patients were discharged home. At discharge, 72.7% of the patients were without any motor impairment, but 59.6% showed cognitive impairment. By the time of discharge, 43.4% (23) of the patients had attained independence in activites of daily living, 18.9% (10) needed intermittent supervision, and 37.7% (20) required constant supervision in the performance of these activities.

CONCLUSIONS

The severity of cognitive impairment has predictive value for the functional status and the level of supervision required at discharge.

Health-related quality of life after aneurysmal subarachnoid hemorrhage: impacts of bleeding severity, computerized tomography findings, surgery, vasospasm, and neurological grade

OBJECT

Based on the results of earlier studies it is agreed that the significance of aneurysm location and surgery for neuropsychological impairments after subarachnoid hemorrhage (SAH) is secondary to the effects of the bleeding itself. Therefore, the present study was performed to evaluate whether bleeding, acute clinical course, and surgery have persistent effects on health-related quality of life (QOL) after SAH.

METHODS

A series of 116 patients was examined for 4 to 5 years (mean 52.2 months) after aneurysmal SAH by means of a QOL questionnaire. Eighty-six patients (74.1%) had undergone surgery early (< or = 72 hours post-SAH). There were 77 women (66.4%) and 39 men (33.6%) in the study group, and the mean age of the patients was 50.3+/-13.3 years (range 30-69 years). Patients who had undergone surgery for a left-sided middle cerebral artery (MCA) aneurysm complained of significantly more impairments in social contact, communication, and cognition than those treated for a right-sided MCA aneurysm. No other effects of aneurysm location (including the anterior communicating artery) emerged. Multiple aneurysms, intraoperative aneurysm rupture, and partial resection of the gyrus rectus had no adverse effects on later daily life. Only temporary clipping was associated with increased complaints in some QOL areas. Disturbances of the circulation of cerebrospinal fluid and the presence of intraventricular hemorrhage led to more impairments in daily life. Specific effects of the anatomical pattern of the bleeding could be identified, but no adverse effects of vasospasm were found. Multivariate analyses revealed, in particular, that patient age and admission neurological status (Hunt and Hess grade) are substantial predictors of the psychosocial sequelae of SAH.

CONCLUSIONS

In contrast to the mild effects of aneurysm surgery, patient's age, initial neurological state on admission, and the bleeding pattern substantially influence late QOL after SAH.

Cognitive impairments after surgical repair of ruptured and unruptured aneurysms

OBJECTIVES

To determine the frequency and severity of neuropsychological impairments associated with aneurysmal subarachnoid haemorrhage, and associated with repair of intracerebral aneurysms.

METHODS

Two groups of patients who underwent repair of intracerebral aneurysms were studied: patients with unruptured aneurysms (n=20) and patients with ruptured aneurysms (n=27). All patients were administered a battery of standardised neuropsychological tests about 3 months after surgery. A subset of 12 patients with unruptured aneurysms were administered the battery both before and after elective repair of the aneurysm(s). A subset of six patients with ruptured aneurysms were given the test at both 3 months and 1 year after surgery.

RESULTS

As previously reported for patients with ruptured aneurysms, patients with both ruptured and unruptured aneurysms performed, as a group, significantly below published norms on many of the neuropsychological tests after surgery. However, there were significant differences between preoperative and postoperative performance in the unruptured aneurysm group only on a few tests: measures of word fluency, verbal recall, and frontal lobe function. Performance of patients with ruptured aneurysms was significantly below that of patients with unruptured aneurysms only on a few tests of verbal and visual memory. In addition, group differences compared with published norms reflected severely impaired performance by a minority of patients, rather than moderately impaired performance in a majority of patients.

CONCLUSIONS

Although patients who undergo repair of ruptured aneurysms perform, as a group, below published norms on many neuropsychological tests, significant impairments are seen in a minority of patients. Some of the impairments are associated with subarachnoid haemorrhage, whereas others (found in patients who underwent repair of unruptured aneurysms) are due to general effects of neurosurgery and perioperative management. Finally, some of the postoperative deficits are merely a reflection of premorbid weaknesses.

Perceptual differences between stroke patients with cerebral infarction and intracerebral hemorrhage

OBJECTIVE

To assess perceptual performances of patients with intracerebral hemorrhage (ICH) compared with those of ischemic patients early after stroke and to analyze the psychometric properties of three perceptual tests used in the study.

DESIGN

Cross-sectional study.

SETTING

A rehabilitation unit at a teaching hospital.

PATIENTS

Twenty-two stroke patients with ICH and 22 demographically matched stroke patients with infarction.

MAIN OUTCOME MEASURES

Loewenstein Occupational Therapy Cognitive Assessment (LOTCA), Rivermead Perceptual Assessment Battery (RPAB), and Motor-Free Visual Perception Test (MVPT).

RESULTS

Stroke patients with ICH had significantly more severe deficits on a task of thinking operations than did patients with infarction. A significant lateralized effect of stroke existed in the ICH group, with patients with right-hemisphere strokes scoring lower than patients with left-hemisphere strokes on the figure-ground discrimination subtest of the RPAB. A considerable overlap among the three instruments was found. Yet, the observed correlations between supposedly similar subtests from the tests proved to be moderate, indicating that to a certain extent these test measures tap different perceptual processes. Four factors were generated from a joint LOTCA-RPAB-MVPT factor analysis. They assessed different facets of perceptual functioning, including higher-level and lower-level perceptual skills, part/whole conceptual integration, and color perception. This factor pattern accounted for 75.5% of the variance.

CONCLUSIONS

Higher-level perceptual functions tend to be relatively susceptible to ICH stroke pathology early in the course of the disease. This information has important clinical implications in the early treatment planning for the stroke patients with ICH, such that specific compensatory strategies for these deficiencies should be devised to facilitate a successful rehabilitation. Knowledge regarding the influences of specific deficits on the performance of daily activities may also be useful to the patients' family.

Cognition following subarachnoid hemorrhage from anterior communicating artery aneurysm: relation to timing of surgery

OBJECT

This study was conducted to define neuropsychological changes following operation for subarachnoid hemorrhage (SAH) caused by rupture of an anterior communicating artery (ACoA) aneurysm and to assess the influence of the timing of surgery to clip the aneurysm.

METHODS

Cognitive outcome was evaluated using the Cambridge Neuropsychological Test Automated Battery in patients with an ACoA aneurysm that had caused an SAH. Adult patients younger than 70 years of age who had achieved a favorable neurological outcome (Glasgow Outcome Scale scores of 4 or 5) were studied 6 to 24 months postsurgery. Patients were divided into early (Days 0-3) and late surgery groups (after Day 3) according to the timing of surgery after the ictus. Neuropsychological analysis was performed by reviewers who were blinded to the timing of surgery. Forty-seven patients whose mean age was 51.5 years were tested. They were compared with age- and intelligence quotient (IQ)matched controls by using premorbid IQ as estimated on the National Adult Reading Test. Patients showed deficiencies in several tasks of verbal fluency, pattern recognition, and spatial working memory; this profile of deficits was similar to that seen in patients who underwent temporal lobe excisions. However, there was no significant difference in cognitive performance between the early and late surgery groups.

CONCLUSIONS

After open surgery for ruptured ACoA aneurysms, patients who have achieved a favorable neurological outcome still exhibit significant cognitive deficits, primarily in tests sensitive to temporal lobe dysfunction. However, early surgery does not carry a higher risk of neuropsychological disability.

Persisting symptoms and carers' views of outcome after subarachnoid haemorrhage

OBJECTIVE

To report the outcome of aneurysmal subarachnoid haemorrhage (SAH) in terms of subjective symptoms and carers' perspective over a period of two years.

DESIGN

Forty-four consecutive patients admitted to a Regional Neurosurgical Unit and who survived aneurysmal SAH were invited for outpatient assessment at 6, 12 and 24 months post haemorrhage.

MEASURES

The Glasgow Outcome Scale (GOS) was used to measure global outcome; the Hospital Anxiety and Depression Scale (HAD) to screen for affective symptoms; the Head Injury Symptom Checklist (HISC) to detect symptoms commonly reported after head trauma; and information was collected from a close friend or relative of the patient using the Relative's Questionnaire (RQ).

RESULTS

GOS outcome was significantly related to the severity of the original haemorrhage, as classified by the World Federation of Neurological Surgeons (WFNS) Grading Scale, on admission to hospital. However, even in cases where patients had made a good recovery according to the GOS, a variety of problems were frequently reported by patients and relatives, and many of these persisted for the duration of the study. The three most common and persistent symptoms were tiredness (63%, 59% and 59% at 6, 12 and 24 months respectively), memory disturbance (50%, 52% and 56%) and passivity (61%, 47% and 46%). In contrast, the prevalence of disturbed mood, as reported using the HAD, was similar to that of the general population.

CONCLUSIONS

Studies of outcome following SAH should address these subtle disturbances, and information pertaining to potential long-term problems should be provided to patients and relevant others.

[Cognitive performance in patients with surgically treated cerebral aneurysms]

Twenty five patients with cerebral aneurysms submitted to surgery were evaluated with cognitive tests to quantify late disorders in language, praxis, orientation, logics, comprehension, memory, depression, dementia and visual gnosis. Results were correlated with age, Hunt-Hess scale, blood at CT (Fisher), angiographic vasospasm (George), side, site, and size of aneurysm. Delayed cognitive disorder was absent in 8 (32%), slight in 5 (20%), moderate in 6 (24%) and severe in 6 (24%). Logics was more affected with 7 severe and moderate patients (28%), praxis was similarly affected in 6 (24%), orientation in 5 (20%), language and memory in 4 (16%); visual gnosis abnormalities, dementia and depression were rarely seen. Patients aged 25-50 years had best cognitive results with sequels absent or slight in 9 patients (75%). Aneurysms of right posterior communicating artery had cognitive sequels absent or slight in 5 (71.42%), right medium cerebral artery in 2 (66.66%). Aneurysms of left medium cerebral artery had the worse results with severe and moderate disabilities in 5 patients (71.42%). Delayed post operative cognitive results in patients operated with cerebral aneurysms are directly related to Hunt-Hess scale, amount of blood at CT, angiographic vasospasm and site of the aneurysm.

Cognitive deficits in the acute stage after subarachnoid hemorrhage

OBJECTIVE

In spite of fundamentally improved medical management of subarachnoid hemorrhage (SAH), many patients remain mentally impaired. However, the causes of these disturbances are unclear. The present study was performed to elucidate the significance of the hemorrhage itself and related events in the neuropsychological performance of patients in the acute stage after SAH.

METHODS

A series of 51 patients were examined, by means of a battery of cognitive tests, 1 to 13 days (mean, 5.9 d) after SAH. Thirty-three patients had experienced ruptured aneurysms, and 18 had sustained SAH of unknown origin. Furthermore, 25 patients who had undergone surgical treatment (a mean of 5.0 d earlier) of prolapsed lumbar discs served as a control group.

RESULTS

The cognitive deficits of the patients after aneurysmal SAH proved to be comparable to those after spontaneous SAH of unknown origin, with the single exception of a significantly worse (P = 0.003) concentration capacity in the surgically treated group. The severity of SAH in computed tomographic scans correlated (up to r = 0.57, P < 0.001) with poor performance on tests of memory, concentration, divided attention, and perseveration. Frontal intracerebral hemorrhage led to significantly more errors in an aphasia screening test (P < 0.001) and a test of perseveration (P < 0.001). If acute hydrocephalus was present, the patients exhibited worse long-term memory (P < 0.001), showed slower reaction times (P = 0.01), and made more errors in the perseveration test (P = 0.004). Patients with intraventricular blood performed at significantly lower levels in the concentration (P = 0.001), divided attention (P = 0.01), long-term memory (P < 0.001), and perseveration (P = 0.003) tests.

CONCLUSION

The results emphasize that the severity of SAH (Fisher score) is the most important factor related to cognitive dysfunction, but frontal hematoma, intraventricular hemorrhage, and acute hydrocephalus were also associated with cognitive deficits, compared with patients with SAH without these findings.

Recovery and rehabilitation following subarachnoid haemorrhage: Part II. Long-term follow-up

BACKGROUND AND PURPOSE

Subarachnoid haemorrhage (SAH) accounts for 5-10% of all strokes, strikes at a mean age of 50 years and results in a pattern of deficits similar to that of traumatic brain injury. This study is an extension of a previous study which described outcome at discharge from inpatient rehabilitation. The purpose of this follow-up study was to describe long-term functional, cognitive and psychosocial outcome in a cohort of SAH survivors who received inpatient rehabilitation.

METHODS

Subjects were interviewed by telephone. Functional status was assessed using the Functional Independence Measure (FIM) and cognitive status with the Telephone Interview for Cognitive Status (TICS). Social function was determined via a brief questionnaire.

RESULTS

Thirty two out of 80 subjects who received inpatient rehabilitation participated in the study. The 32 did not differ from the original group of 80 on any demographic or clinical criteria. The mean time from onset of SAH to follow-up was 28 months. Total FIM scores improved significantly between discharge and follow up (p < 0.0001) and most subjects functioned at a physically independent level. However, almost 40% scored in the cognitively impaired range on the TICS. Between 40% and 50% required help with common household activities, and none returned to full-time work. Functional and cognitive outcome was not related to any demographic or clinical characteristics at SAH onset.

CONCLUSION

The majority of SAH survivors who received inpatient rehabilitation attain physical independence, but many continue to have cognitive impairments which result in social and vocational disabilities.

Too little, too late: does tirilazad mesylate reduce fatigue after subarachnoid hemorrhage?

OBJECTIVE

Trials assessing drug effectiveness for treatment of subarachnoid hemorrhage (SAH) often use mortality rates and Glasgow Outcome Scale scores as outcome measures. Neuropsychological and psychosocial measures might be more sensitive to outcomes, especially for patients of better-grade status.

METHODS

Eighteen of a total of 31 patients enrolled in the New Zealand arm of the Upjohn international, double-blind, therapeutic trial of tirilazad mesylate for women with SAH were assessed neuropsychologically and psychosocially 3 months after SAH. The 13 not assessed either had died or remained vegetative (9 patients), did not speak English (1 patient), or did not consent (3 patients). The drug code was broken after all assessments had been scored.

RESULTS

Sixteen of the 31 patients had received the drug and 15 the vehicle. There were no differences between the two groups with respect to age, grades assessed at admission and 14 weeks after SAH, Glasgow Outcome Scale scores assessed at 3 months, or mortality rates. In the subgroup assessed neuropsychologically, nine patients were in each of the drug- and vehicle-treated groups. No differences were found with respect to grades, Glasgow Outcome Scale scores, or values for an index that measured cognitive impairment in all tests, but vehicle-treated patients were more impaired with respect to measures of concentration, sustained attention, and psychomotor speed (P < 0.02), as well as debilitating fatigue (P < 0.01).

CONCLUSION

The finding that the patients in the drug-treated group exhibited fewer impairments typical of diffuse cortical damage could be viewed as being consistent with the hypothesis that tirilazad mesylate protects neurons. Given the small size of this study, these results require confirmation with larger patient groups. Future drug trials should consider including neuropsychological tests in assessments of outcomes after SAH. If this is too costly, questions regarding fatigue levels might prove worthwhile.

Evaluation of outcome after intracranial aneurysm surgery: the neuropsychiatric approach

BACKGROUND

With the reduction of mortality and gross neurologic morbidity of patients undergoing intracranial aneurysm surgery, the interest in outcome is shifting towards more subtle aspects such as cognitive deficits and psychosocial adjustment.

METHODS

We discuss two different ways of measuring outcome in a sample of 20 patients who had intracranial aneurysm surgery. Patients were evaluated at discharge using the Karnofsky Scale and the Glasgow Outcome Scale. Six months after discharge we conducted a neuropsychiatric evaluation including cognitive, behavioral, and mood status assessment.

RESULTS

Although 13 of out patients had a "good recovery, " 18 had some neuropsychiatric impairment. Comparing patients with "good recovery" with the remainder, patients with poorer outcomes tended to have a left pterional approach, a poorer "drive", and language disorders (p < 0.05). There was no correlation between out cognitive, mood, and behavioral assessment and the results of the Karnofsky and Glasgow Outcome Scales ( p > 0.05).

CONCLUSIONS

we conclude that neuropsychiatric deficits are common after intracranial aneurysm surgery and that for our study the Karnofsky Scale and Glasgow Outcome Scale were not sensitive enough to detect residual impairment. therefore, it is important to develop brief tests and scales able to identify these problems and to complement the standard clinical neurological examination.

Aneurysm of the anterior communicating artery: a review of neuroanatomical and neuropsychological sequelae

For over 100 years, the study of amnesia in humans has been limited primarily to subjects with either diencephalic or mesial temporal lobe lesions. However, over the last 30 years, it has been reported that individuals who survived aneurysms of the anterior communicating artery (ACoA) often displayed an amnestic syndrome, despite the fact that diencephalic and mesial temporal structures were intact. This article presents a comprehensive review of the ACoA literature concerning the neurobehavioral and neuroanatomical substrates of what has been termed the "ACoA syndrome". Various theoretical models regarding the neural substrates of amnesia are discussed. Possible directions for future research are outlined.