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

Mediating effects of insomnia and resilience on COVID-19-related post-traumatic stress disorder and quality of life in adolescents

The coronavirus disease-2019 (COVID-19) pandemic has impaired the quality of life (QoL) for many due to its extensive impacts. However, few studies have addressed the specific impact of COVID-19 on the mental health of adolescents, particularly post-traumatic stress disorder (PTSD). This study considered the impact of COVID-19-related PTSD on the QoL of adolescents in China, the mediating effects of insomnia, and the moderating effects of resilience. Participants included 50,666 adolescents aged 12-18 years selected using a comprehensive sampling method. We performed data collection from January 8th to January 18th, 2023, using the Children's Revised Impact of Event Scale, Pittsburgh Sleep Quality Index, Ten-item Connor-Davidson Resilience Scale, and Screening for and Promotion of Health-related QoL in Children and Adolescents Questionnaire for data collection. Male adolescents exhibited significantly lower levels of PTSD and insomnia compared to females and scored significantly higher in psychological resilience and overall QoL. Insomnia played a mediating role between PTSD and QoL. Psychological resilience moderated the impact of COVID-19-related stress on adolescents' QoL through its influence on insomnia. PTSD resulting from the COVID-19 pandemic affects the QoL of adolescents through the presence of insomnia. Psychological resilience plays a moderating role in this process. Cultivating psychological resilience in adolescents can effectively enhance their ability to cope with the impacts of sudden public events.

An Exploratory Analysis of Preclinical and Clinical Factors Associated With Sleep Disturbance Assessed via the Neuro-QoL After Hemorrhagic Stroke

Background and Purpose

Sleep disturbance after hemorrhagic stroke (intracerebral or subarachnoid hemorrhage) can impact rehabilitation, recovery, and quality of life. We sought to explore preclinical and clinical factors associated with sleep disturbance after hemorrhagic stroke assessed via the Quality of Life in Neurological Disorders (Neuro-QoL) short form sleep disturbance inventory.

Methods

We telephonically completed the Neuro-QoL short form sleep disturbance inventory 3-months and 12-months after hemorrhagic stroke for patients >18-years-old hospitalized between January 2015 and February 2021. We examined the relationship between sleep disturbance (T-score >50) and social and neuropsychiatric history, systemic and neurological illness severity, medical complications, and temporality.

Results

The inventory was completed for 70 patients at 3-months and 39 patients at 12-months; 18 (26%) had sleep disturbance at 3-months and 11 (28%) had sleep disturbance at 12-months. There was moderate agreement (κ = .414) between sleep disturbance at 3-months and 12-months. Sleep disturbance at 3-months was related to unemployment/retirement prior to admission (P = .043), lower Glasgow Coma Scale score on admission (P = .021), higher NIHSS score on admission (P = .041) and infection while hospitalized (P = .036). On multivariate analysis, sleep disturbance at 3-months was related to unemployment/retirement prior to admission (OR 3.58 (95% CI 1.03-12.37), P = .044). Sleep disturbance at 12-months was related to premorbid mRS score (P = .046).

Conclusion

This exploratory analysis did not demonstrate a sustained relationship between any preclinical or clinical factors and sleep disturbance after hemorrhagic stroke. Larger studies that include comparison to patients with ischemic stroke and healthy individuals and utilize additional techniques to evaluate sleep disturbance are needed.

Health-related quality of life of patients with aneurysmal subarachnoid hemorrhage who were classified as having "good outcomes"

BACKGROUND

This study aimed to understand the health-related quality of life (HRQoL) of patients with aneurysmal subarachnoid hemorrhage (aSAH) classified as having "good outcomes" and determine associated sociodemographic, psychological, and clinical factors.

METHODS

Participants were 86 patients with aSAH with modified Rankin Scale (mRS) scores of 0-2 in our hospital between February 2003 and April 2014. Participants completed self-report questionnaires examining sociodemographic characteristics and the following self-rating scales: the hospital anxiety and depression scale, Pittsburgh sleep quality index, and EuroQoL-5 Dimension Index (EQ-5D). Further, we retrospectively reviewed clinical data from medical records and radiologic images. Average EQ-5D scores for each variable were compared using Student's t-test and analysis of variance. Correlations between EQ-5D and continuous variables were examined using Pearson correlation analysis. Factors associated with EQ-5D were then examined using univariate and stepwise multivariate analyses through simple and multiple regression.

RESULTS

The mean age of the 86 participants was 56.87 ± 10.28 years (range: 29-79 years), while the mean EQ-5D value was 0.738 ± 0.169. There were 54 women (62.8 %) and 33 men (37.2 %). The participants had depressive symptoms (30.2 %), anxiety (10.5 %), and sleep problems (51.2 %). Regarding sociodemographic variables, educational level (p = 0.017) and monthly income (p = 0.037) were positively correlated with HRQoL. Depressive symptoms (r = -0.505, p < 0.001), anxiety (r = -0.498, p < 0.001), sleep problems (r = -0.265, p = 017), and mRS (r = -0.352, p = 0.001) were negatively correlated with HRQoL. Depressive symptoms, diabetes mellitus, and past psychiatric history explained 48.8 % of the variance in HRQoL in good outcome aSAH according to stepwise multiple regression analysis.

CONCLUSIONS

Patients with good outcome aSAH had low EQ-5D values, which were negatively correlated with depressive symptoms, anxiety, and sleep problems. In addition, HRQoL in good outcome aSAH is associated with depressive symptoms, diabetes mellitus, and past psychiatric disease history. Depressive symptoms, anxiety, and sleep problems are frequent in patients with good outcome aSAH, and mediation of these factors may help improve HRQoL.

Neurologic Injury-Related Predisposing Factors of Post-Traumatic Stress Disorder: A Critical Examination

The present review aimed to identify the means through which neurologic injury can predispose individuals to Post-Traumatic Stress Disorder (PTSD). In recent years, comprehensive studies have helped to clarify which structures in the central nervous system can lead to distinct PTSD symptoms-namely, dissociative reactions or flashbacks-when damaged. Our review narrowed its focus to three common neurologic injuries, traumatic brain injury (TBI), subarachnoid hemorrhage (SAH), and stroke. We found that in each of the three cases, individuals may be at an increased risk of developing PTSD symptoms. Beyond discussing the potential mechanisms by which neurotrauma may lead to PTSD, we summarized our current understanding of the pathophysiology of the disorder and discussed predicted associations between the limbic system and PTSD. In particular, the effect of noradrenergic neuromodulatory signaling on the hypothalamic pituitary adrenal (HPA) axis as it pertains to fear memory recall needs to be further explored to better understand its effects on limbic structures in PTSD patients. At present, altered limbic activity can be found in both neurotrauma and PTSD patients, suggesting a potential causative link. Particularly, changes in the function of the limbic system may be associated with characteristic symptoms of PTSD such as intrusive memories and acute psychological distress. Despite evidence demonstrating the correlation between neurotrauma and PTSD, a lack of PTSD prognosis exists in TBI, SAH, and stroke patients who could benefit from early treatment. It should be noted that PTSD symptoms often compound with pre-existing issues, further deteriorating health outcomes for these patients. It is ultimately our goal to clarify the relationship between neurotrauma and PTSD so that earlier diagnoses and appropriate treatment are observed in clinic.

Interventions targeting psychosocial adaptation in people with stroke: A scoping review

OBJECTIVE

This scoping review aimed to describe and map interventions targeting psychosocial adaptation in people with stroke.

METHODS

A scoping review was conducted using the Joanna Briggs Institute methodology and reported according to Systematic Review and Meta-Analyses Extension for Scoping Reviews guidelines. We included original studies with interventions targeting psychosocial adaptation (concept) on people with stroke (population) in any setting (context). We searched five online electronic databases (PubMed, Embase, CINAHL, PsycINFO, and Cochrane Central Registry of Controlled Trials). We described interventions in terms of design characteristics, theoretical basis, details of interventions, and quantitative outcomes indicated in psychosocial adaptation.

RESULTS

Forty-three studies were identified. Five intervention categories were identified to describe the interventions targeting psychosocial adaptation. Quantitative outcomes indicated psychosocial adaptation in our review were grouped into four domains: global adaptation, psychological adaptation, social adaptation, and others.

CONCLUSIONS

The mapping and description brought to light the large heterogeneity of interventions targeting psychosocial adaptation in people with stroke.

PRACTICE IMPLICATIONS

Deepening understanding of psychosocial adaptation can help health professionals further develop effective interventions aiming at promoting psychosocial adaptation and reducing negative health sequelae, such as risk of reduced psychosomatic recovery post stroke.

Description of the Quality of Life of Patients With Subarachnoid Hemorrhage at King Abdulaziz University Hospital in Jeddah

Objective Stroke is a serious medical condition that causes long-term morbidity and disability. There are two types of stroke, i.e., ischemic and hemorrhagic stroke. Subarachnoid hemorrhage (SAH) accounts for 5% of all stroke cases worldwide. Stroke survivors may experience cognitive dysfunction in many forms. Evidence regarding the quality of life (QoL) of patients post-SAH in the Middle East is limited. Therefore, this study aims to describe the quality of life in patients with SAH at the King Abdulaziz University Hospital (KAUH) in Jeddah, Saudi Arabia, from April 2021 to October 2021. Methods We included patients who were diagnosed with SAH ≤ 10 years prior at our hospital and were admitted within 72 hours of the ictus. Patients were included using non-probability convenience sampling without randomization. We collected the Glasgow Coma Scale (GCS), World Federation of Neurosurgeons (WFNS), and Modified Glasgow Outcome Scale (MGOS) scores. Results We included 48 patients (mean age: 49.78 ± 19.44 years, male proportion: 62.5%). More than 50% of the participants had comorbidities. The mean baseline GCS, WFNS, and MGOS scores at admission were 12.62 ± 3.56, 2.19 ± 1.54, and 3.58 ± 1.67, respectively. Women had significantly higher MGOS scores than men (p ≤ 0.05). Death was significantly associated with low MGOS scores (p ≤ 0.05). Age showed a non-significant negative correlation with the MGOS score (r = - 0.17, p-value = 0.24). Finally, the MGOS score was significantly correlated with the baseline GCS and WFNS scores at admission (r = 0.68 and r = - 0.67, respectively). Conclusion Our findings demonstrated that a low MGOS score, which indicates more comorbidities, greatly affects the quality of life of patients with SAH. Moreover, the baseline GCS score was the best prognostic predictor for patients with SAH.

Are the Post-COVID-19 Posttraumatic Stress Disorder (PTSD) Symptoms Justified by the Effects of COVID-19 on Brain Structure? A Systematic Review

COVID-19 affects brain function, as deduced by the "brain fog" that is often encountered in COVID-19 patients and some cognitive impairment that is observed in many a patient in the post-COVID-19 period. Approximately one-third of patients, even when they have recovered from the acute somatic disease, continue to show posttraumatic stress disorder (PTSD) symptoms. We hypothesized that the persistent changes induced by COVID-19 on brain structure would overlap with those associated with PTSD. We performed a thorough PubMed search on 25 April 2023 using the following strategy: ((posttraumatic OR PTSD) AND COVID-19 AND (neuroimaging OR voxel OR VBM OR freesurfer OR structural OR ROI OR whole-brain OR hippocamp* OR amygd* OR "deep gray matter" OR "cortical thickness" OR caudate OR striatum OR accumbens OR putamen OR "regions of interest" OR subcortical)) OR (COVID-19 AND brain AND (voxel[ti] OR VBM[ti] OR magnetic[ti] OR resonance[ti] OR imaging[ti] OR neuroimaging[ti] OR neuroimage[ti] OR positron[ti] OR photon*[ti] OR PET[ti] OR SPET[ti] OR SPECT[ti] OR spectroscop*[ti] OR MRS[ti])), which produced 486 records and two additional records from other sources, of which 36 were found to be eligible. Alterations were identified and described and plotted against the ordinary PTSD imaging findings. Common elements were hypometabolism in the insula and caudate nucleus, reduced hippocampal volumes, and subarachnoid hemorrhages, while white matter hyperintensities were widespread in both PTSD and post-COVID-19 brain infection. The comparison partly supported our initial hypothesis. These data may contribute to further investigation of the effects of long COVID on brain structure and function.

Neurocognitive Sequelae and Rehabilitation after Subarachnoid Hemorrhage: Optimizing Outcomes

Subarachnoid hemorrhage (SAH) is a medical emergency that requires immediate intervention. The etiology varies between cases; however, rupture of an intracranial aneurysm accounts for 80% of medical emergencies. Early intervention and treatment are essential to prevent long-term complications. Over the years, treatment of SAH has drastically improved, which is responsible for the rapid rise in SAH survivors. Post-SAH, a significant number of patients exhibit impairments in memory and executive function and report high rates of depression and anxiety that ultimately affect daily living, return to work, and quality of life. Given the rise in SAH survivors, rehabilitation post-SAH to optimize patient outcomes becomes crucial. The review addresses the current rehabilitative strategies to combat the neurocognitive and behavioral issues that may arise following SAH.

Post-Intensive Care Syndrome in Patients Suffering From Acute Subarachnoid Hemorrhage: Results From an Outpatient Post-ICU Aftercare Clinic

Introduction Survivors of an acute subarachnoid hemorrhage (aSAH) may suffer from a long-term neurological disability, cognitive impairment, anxiety, and depression, which can also be related to post-intensive care syndrome (PICS). The aim of this study was to examine the prevalence of PICS symptoms in post-intensive care (ICU) aftercare aSAH patients. Methods We conducted an observational cohort study in aSAH patients from a post-ICU aftercare clinic (ICU-AC). PICS symptoms were evaluated using the Impact of Event Scale-Revised (IES-R), Hospital Anxiety and Depression Scale (HADS), and a medical questionnaire for physical and cognitive functioning. Results A total of 110 patients were included. The prevalence of anxiety and depressive symptoms was 23.6% and 19.1%, respectively. Post-traumatic stress disorder (PTSD) was seen in 26.4%. Cognitive complaints were lack of concentration (63.6%), short-term memory loss (45.8%), and reduced speed of thinking (60.9%). The most reported physical complaints were fatigue (73.6%), limitations in daily activity (72.7%), muscle weakness (41.8%), pain (36.4%), and weight loss (30.9%). PICS symptoms related to all three domains were present in 30% of patients. Conclusion The prevalence of PICS in patients after aSAH is high. Even in patients without aSAH-related neurological impairment who were discharged home, a high prevalence of PICS symptoms was reported. Early screening for PICS should comprise all three domains and is important to facilitate a better tailored rehabilitation of these patients.

Coping strategies in patients with good outcome but chronic fatigue after aneurysmal subarachnoid hemorrhage

BACKGROUND

Fatigue is a highly prevalent and debilitating symptom among patients in the chronic phase of aneurysmal subarachnoid haemorrhage (aSAH) with no identified effective treatment. Cognitive therapy has been shown to have moderate effects on fatigue. Delineating the coping strategies used by patients with post-aSAH fatigue and relating them to fatigue severity and emotional symptoms could be a step towards developing a behavioural therapy for post-aSAH fatigue.

METHODS

Ninety-six good outcome patients with chronic post-aSAH fatigue answered the questionnaires Brief COPE, (a questionnaire defining 14 coping strategies and three Coping Styles), the Fatigue Severity Scale (FSS), Mental Fatigue Scale (MFS), Beck Depression Inventory (BDI-II) and Beck Anxiety Inventory (BAI). The Brief COPE scores were compared with fatigue severity and emotional symptoms of the patients.

RESULTS

The prevailing coping strategies were "Acceptance", "Emotional Support", "Active Coping" and "Planning". "Acceptance" was the sole coping strategy that was significantly inversely related to levels of fatigue. Patients with the highest scores for mental fatigue and those with clinically significant emotional symptoms applied significantly more maladaptive avoidant strategies. Females and the youngest patients applied more "Problem-Focused" strategies.

CONCLUSION

A therapeutic behavioural model aiming at furthering "Acceptance" and reducing passivity and "Avoidant" strategies may contribute to alleviate post-aSAH fatigue in good outcome patients. Given the chronic nature of post-aSAH fatigue, neurosurgeons may encourage patients to accept their new situation so that they can start a process of positive reframing instead of being trapped in a spiral of futile loss of energy and secondary increased emotional burden and frustration.

Psychometric properties of the post-traumatic stress disorder checklist for DSM-5 (PCL-5) in Chinese stroke patients

BACKGROUND

Stroke is a devastating disease and can be sufficiently traumatic to induce post-traumatic stress disorder (PTSD). Post-stroke PTSD is attracting increasing attention, but there was no study assessing the psychometric properties of the PCL-5 in stroke populations. Our study was conducted to examine the psychometric properties of the PTSD Checklist for DSM-5 (PCL-5) in Chinese stroke patients.

METHODS

This was a cross-sectional observational study conducted at our hospital. Three hundred and forty-eight Chinese stroke patients came to our hospital for outpatient service were recruited. They were instructed to complete the PCL-5 scales and were interviewed for PTSD diagnosis with the Clinician Administered PTSD Scale for DSM-5 (CAPS-5). The cutoff scores, reliability and validity of the PCL-5 were analyzed.

RESULTS

PCL-5 scores in our sample were positively skewed, suggesting low levels of PTSD symptoms. The reliability of PCL-5 was good. Exploratory and confirmatory factor analyses indicated acceptable construct validity, and confirmed the multi-dimensionality of the PCL-5. By CFA analysis, the seven-factor hybrid model demonstrated the best model fit. The PCL-5 also showed good convergent validity and discriminant validity. Receiver operating characteristic (ROC) analyses revealed a PCL-5 score of 37 achieved optimal sensitivity and specificity for detecting PTSD.

CONCLUSIONS

Our findings supported the use of PCL-5 as a psychometrically adequate measure of post-stroke PTSD in the Chinese patients.

Long-term fatigue following aneurysmal subarachnoid haemorrhage and the impact on employment

BACKGROUND AND PURPOSE

Fatigue is common following aneurysmal subarachnoid haemorrhage (aSAH) but little is known about its frequency, prognosis and impact on employment. The aim of this study was to assess the frequency of fatigue, whether it changes over time and the relationship to employment in the long term.

METHODS

This was a retrospective observational study of aSAH cases and matched controls from the UK Biobank. The presence of fatigue was compared between cases and controls using the chi-squared test. The change in frequency over time was assessed using Spearman's rank correlation coefficient. The effect of fatigue on employment was assessed using mediation analysis.

RESULTS

Fatigue is more common following aSAH compared to matched controls (aSAH 18.7%; controls 13.7%; χ²  = 13.0, p < 0.001) at a mean follow-up of 123 months. Fatigue gradually improves over time with significant fatigue decreasing by 50% from ~20% in the first year to ~10% after a decade (p = 0.04). Fatigue significantly mediated 24.0% of the effect of aSAH status on employment.

CONCLUSIONS

Fatigue is common following aSAH and persists in the long term. It gradually improves over time but has a major impact on aSAH survivors, significantly contributing to unemployment following haemorrhage. Further work is required to develop treatments and management strategies for fatigue with a view to improving this symptom and consequently employment following aSAH.

Supportive psychological therapy can effectively treat post-stroke post-traumatic stress disorder at the early stage

Post-traumatic stress disorder (PTSD) can develop after stroke attacks, and its rate ranges from 4 to 37% in the stroke population. Suffering from PTSD not only decreases stroke patient’s quality of life, but also relates to their non-adherence of treatment. Since strokes often recur and progress, long-term medical management is especially important. However, previous studies generally focused on the epidemiological characteristics of post-stroke PTSD, while there are literally no studies on the psychological intervention. In our study, 170 patients with a first-ever stroke during the acute phase were recruited. They were randomized into Psycho-therapy group 1 and Control group 1, and were administered with preventive intervention for PTSD or routine health education, respectively. At 2-month follow-up, PTSD symptoms were evaluated. Participants who were diagnosed with post-stroke PTSD were further randomized into Psycho-therapy group 2 and Control group 2, and received supportive therapy or routine health counseling, respectively. At 6-month follow-up (1°month after the therapy was completed), PTSD symptoms were re-evaluated. Our results showed that at 2-month, the PTSD incidence in our series was 11.69%, and the severity of stroke was the only risk factor for PTSD development. The preventive intervention was not superior to routine health education for PTSD prevention. At 6-month, results indicated the supportive therapy did have a fine effect in ameliorating symptoms for diagnosed PTSD patients, superior to routine health counseling. Thus, our study was the first to provide evidence that the supportive therapy was effective in treating post-stroke PTSD early after its diagnosis. This clinical trial was preregistered on www.chictr.org.cn (ChiCTR2100048411).

Long-term follow-up in patients with brain arteriovenous malformation based on the Quality of Life Scale and socioeconomic status

OBJECTIVE

Intracranial haemorrhage (ICH) is associated with permanent neurological disability resulting in deterioration of the quality of life (QoL). Our study assesses QoL in patients with ruptured arteriovenous malformation (AVM) in long-term follow-up at least five years after ICH and compares their QoL with the QoL of patient with non-ruptured AVM.

METHODS

Using the Quality of Life Scale (QOLS), the Patient Health Questionnaire (PHQ-9) for depressive symptoms, and the socioeconomic status (SES), a prospective assessment was performed. The modified Rankin Scale (mRS) was assessed for outcome.

RESULTS

Of 73 patients, 42 (57.5%) had ruptured (group 1) and 31 (42.5%) a non-ruptured AVM (group 2). Mean follow-up time was 8.6 ± 3.9 years (8.5 ± 4.2 years in group 1 and 8.9 ± 3.7 years in group 2). Favourable outcome (mRS 0-1) was assessed in 60 (83.3%) and unfavourable in 12 (16.7%) patients. Thirty-one of 42 patients (73.8%) in group 1 and 29 of 30 patients in group 2 (96.7%) had favourable outcomes. Mean QOLS was 85.6 ± 14.1 (group 1 86.1 ± 15.9, group 2 84.9 ± 11.4). Patients in group 1 did not show a significant difference in QoL compared to patients in group 2 (p = 0.23). Additional analyses in group 2 (rho =  - 0.73; p < 0.01) and in untreated AVM patients (rho =  - 0.81; p < 0.01) showed a strong correlation between QOLS and PHQ-9.

CONCLUSION

Long-term follow-up showed no difference in the QoL between patients with and without ICH caused by brain AVM. Outcome- and QoL-scores were high in both groups. Further studies are necessary to evaluate depression and anxiety symptoms in patients with AVM.

Sleep Disturbance and Self-management in Adults With Subarachnoid Hemorrhage: A Qualitative Study

Subarachnoid hemorrhage (SAH) survivors often experience sleep disturbances. Little is known about sleep-management practices used to improve their sleep. The purpose of this qualitative study was to explore interest in and engagement with self-management practices to promote sleep health in SAH survivors. We conducted a cross-sectional qualitative study using semi-structured interviews with a convenience sample of 30 SAH survivors recruited from a university hospital. We conducted content analysis of interview transcripts. Three themes and 15 subcategories were identified: (1) sleep disturbances (difficulties falling asleep, wake after sleep onset, daytime sleepiness, too much or insufficient sleep, and poor sleep quality); (2) sleep-management practices (exercise, regular sleep schedule, relaxation, keeping busy and staying active, changing beverage intake, taking supplements, taking medications, recharging energy, and barriers to sleep management); and (3) consulting with healthcare providers (discussing sleep problems with healthcare providers). Self-management strategies focusing on health-promoting behaviors may improve SAH survivors' sleep health.

Prevalence and influencing factors of chronic post-traumatic stress disorder in patients with myocardial infarction, transient ischemic attack (TIA) and stroke - an exploratory, descriptive study

BACKGROUND

Cardio- and cerebrovascular events such as myocardial infarction (MI), stroke and transient ischemic attack (TIA) are leading causes of death and disability and have also been associated with poor mental outcomes. In addition, cardio- and cerebrovascular events may pose the risk of experiencing a sudden traumatic occurrence of symptoms during ictus and thus contribute to high rates of PTSD as well as high rates of subsequent depression and anxiety. Moreover, MI, TIA and stroke survivors with PTSD, depressive and anxiety symptoms may have poorer health-related quality of life (HRQoL) and poorer disease prognosis than patients who do not develop psychiatric symptoms after ictus. However, data on the prevalence of PTSD, anxiety and depression, as well as the HRQoL, coping strategies and potential risk factors for development of PTSD in these patients, are rare.

METHODS

In an exploratory, descriptive study we interviewed 112 patients (54 MI, 18 TIA, 40 stroke; mean age: 69.5 years, 55.4% males) from three general physician practices and used psychometric self-assessment tools to determine the occurrence of PTSD and psychosomatic comorbidity, anxiety and depression and to assess HRQoL and coping strategies. We evaluated disease severity and compared the patient groups to each other. Moreover, we assessed psychological outcome differences between patients with or without PTSD after ictus.

RESULTS

The prevalence of PTSD after MI, TIA and stroke was 23.2%. The patients who developed PTSD had higher rates of depression, anxiety and maladaptive coping as well as reduced HRQoL. Adaptive coping was positively related to better mental HRQoL and negatively related to anxiety and depression. Disease severity of MI, TIA and stroke was not related to PTSD, depression, anxiety or physical HRQoL.

CONCLUSIONS

Experiencing MI, TIA or stroke means confronting a life-threatening event for those affected and, therefore, these can be regarded as traumatic events. Cerebral and cardiovascular events increase the risk of developing chronic PTSD with subsequent increased depression and anxiety and reduced HRQoL. These findings emphasize the need for early screening and diagnosis of PTSD in somatically ill patients, which should be followed by specialized treatment, as PTSD hampers overall (somatic) disease prognosis.

TRIAL REGISTRATION

German Clinical Trials Register, DRKS00021730, https://www.drks.de/drks_web/navigate.do?navigationId=trial.HTML&TRIAL_ID=DRKS00021730 , registered 05/19/2020 - Retrospectively registered.

Fatigue After Aneurysmal Subarachnoid Hemorrhage: Clinical Characteristics and Associated Factors in Patients With Good Outcome

Fatigue after aneurysmal subarachnoid hemorrhage (post-aSAH fatigue) is a frequent, often long-lasting, but still poorly studied sequel. The aim of the present study was to characterize the nature of post-aSAH fatigue with an itemized analysis of the Fatigue Severity Scale (FSS) and Mental Fatigue Scale (MFS). We further wanted to assess the association of fatigue with other commonly observed problems after aSAH: mood disorders, cognitive problems, health-related quality of life (HRQoL), weight gain, and return to work (RTW). Ninety-six good outcome aSAH patients with fatigue completed questionnaires measuring fatigue, depression, anxiety, and HRQoL. All patients underwent a physical and neurological examination. Cognitive functioning was assessed with a neuropsychological test battery. We also registered prior history of fatigue and mood disorders as well as occupational status and RTW. The patients experienced fatigue as being among their three most disabling symptoms and when characterizing their fatigue they emphasized the questionnaire items “low motivation,” “mental fatigue,” and “sensitivity to stress.” Fatigue due to exercise was their least bothersome aspect of fatigue and weight gain was associated with depressive symptoms rather than the severity of fatigue. Although there was a strong association between fatigue and mood disorders, especially for depression, the overlap was incomplete. Post-aSAH fatigue related to reduced HRQoL. RTW was remarkably low with only 10.3% of patients returning to their previous workload. Fatigue was not related to cognitive functioning or neurological status. Although there was a strong association between fatigue and depression, the incomplete overlap supports the notion of these two being distinct constructs. Moreover, post-aSAH fatigue can exist without significant neurological or cognitive impairments, but is related to reduced HRQoL and contributes to the low rate of RTW.

Sleep in Aneurysmal Subarachnoid Hemorrhage Patients During Critical and Acute Care

BACKGROUND

Nurses caring for intensive care patients diagnosed with an aneurysmal subarachnoid hemorrhage (aSAH) conduct frequent neurological assessments and vital signs over an extended period during which patients are at risk of vasospasm. The frequency of assessments can negatively impact sleep, resulting in altered thought processes and mood, including delirium. There are 2 types of sleep during the night: non-rapid eye movement (non-REM) sleep and REM sleep (also called stage R). Non-REM sleep is subdivided into 3 stages: stage N1, stage N2, and stage N3. These 4 stages of sleep are referred to as sleep architecture.

OBJECTIVE

The aim of this study was to explore patterns of sleep in patients with aSAH over time during hospitalization.

METHODS

Sleep data of stages and cycles were collected with use of a Fitbit activity tracker in this pilot, exploratory research study. Demographic data included age and gender. Six English-speaking patients, diagnosed with an aneurysmal SAH, confirmed by diagnostic angiogram, were followed in neuro-intensive care unit (ICU), neuro-step-down, neuroscience unit, and inpatient rehabilitation.

RESULTS

There were a total of 226 sleep events. A sleep event encompassed a recorded start and end time on a single date. Each event included several sleep cycles. Each sleep cycle consisted of wakefulness, light sleep, deep sleep, and REM sleep. In 79 sleep events, light and deep sleep did add up to more than 4 hours; only 38 sleep events indicated more than 90 minutes of REM/night; 61 events showed the cycle of light-deep-light-REM cycles; 80 events showed 3 to 5 REM periods/night; and only 46 events demonstrated that the early-morning REM cycle was the longest. The average number of REM cycles increased from ICU (n = 4.6) to rehabilitation (n = 6.5). The percentage of days with sleep cycles also increased from ICU to rehabilitation (42 to 64).

DISCUSSION

"Normal" sleep patterns are disrupted in aSAH patients throughout their hospitalization. Data in this study revealed that the patients do sleep; however, it is rarely organized. Patients were not always able to progress through the expected sleep cycle of light to deep to light to REM. Hospitalized aSAH patients do engage in REM sleep, but its pattern is abnormal. Staff should strategize on minimizing interruptions, clustering care, and minimizing sounds. Nurses should advocate for the frequency of assessments and vital signs based on hospital/unit policy and individual patient needs.

Prevalence and correlates of post-traumatic stress disorder after ischaemic stroke

Although most often considered a consequence of traumatic event, post-traumatic stress disorder (PTSD) also occurs after illness. The aim of this study was to establish prevalence of PTSD in patients with ischaemic stroke (IS) and its correlation to lesion location, degree of disability, age, gender and marital status. The study included 85 patients with IS. PTSD was diagnosed using a modified version of the PTSD Checklist Specific for a stressor (PCL-S). Depression and anxiety were assessed using Hospital Anxiety and Depression Scale (HADS). We defined stroke localisation as right cerebral hemisphere, left cerebral hemisphere, brainstem and cerebellum. Stroke severity was measured using the modified Rankin scale (mRS). Demographic information including age, gender and marital status was collected from medical history. Of the 85 patients with IS, 11 (12.9%) fulfilled PCL-S criteria for PTSD. We found a positive correlation between PTSD and higher degree of disability, P < 0.001. Patients with PTSD had lesions more frequently localised in the right cerebral hemisphere and the brainstem. We found no statistically significant correlation of PTSD with age, gender and marital status. Our results show that a significant number of IS patients develop PTSD after IS. Determining correlates of post-stroke PTSD can help to identify those at higher risk for its development. If proven by additional large sample studies, more patients can benefit from screening for the PTSD symptoms.

Quality of life in parents of seriously Ill/injured children: a prospective longitudinal study

PURPOSE

Parents of children with serious childhood illness or injury (SCII) are at risk of experiencing poor quality of life (QoL). This study investigated the nature of parent QoL at the time of child diagnosis and seven months post-diagnosis, the change in parent QoL over time, and early factors influencing short-term and longer-term parent QoL.

METHODS

The sample was drawn from a prospective longitudinal cohort study conducted within a paediatric hospital setting. Participants comprised 223 parents of 167 children diagnosed with a life-threatening illness and hospitalised in the cardiology, oncology, or intensive care departments. Examined data included QoL ratings completed by parents within four weeks of diagnosis and seven months post-diagnosis, and demographic, illness-related, and psychosocial predictor measures collected within four weeks of diagnosis, or four months post-diagnosis.

RESULTS

Generalised Estimating Equations were utilised to analyse data. Results indicated poor parent QoL at diagnosis, and normalised parent QoL at seven months. Improvement occurred most noticeably in the psychosocial domain. Reduced acute stress symptomatology and increased psychological flexibility were associated with higher parent QoL at diagnosis. Increased perceived emotional resources predicted enhanced parent QoL at seven months.

CONCLUSION

Paediatric medical care teams should consider the challenges to QoL experienced by parents of children with SCII. Parents reporting acute stress symptoms during the acute-illness phase should be prioritised for intervention. Further, parent-dyads presenting at post-acute care settings reporting poor emotional resources would benefit from psychosocial and educative support.

Clinical Efficacy and Quality of Life Follow-Up of Reconstructive Endovascular Therapy for Acute Intracranial Vertebral Artery Dissection Aneurysms

Background: Intracranial vertebral artery dissection aneurysms (VADAs) may cause acute ischemia or hemorrhage, in which case urgent endovascular treatment will be needed. Although the majority of patients obtain a good functional outcome after surgery, a surprising finding has been a poor quality of life (QOL) in follow-up. The purpose of this study was to evaluate clinical efficacy in reconstructive endovascular therapy for acute intracranial VADAs and to analyze the factors contributing to subsequent QOL.

Methods: In this prospective study, 33 consecutive VADA patients with subarachnoid hemorrhage were recruited for comparison with 37 VADA patients with posterior circulation cerebral ischemia. All VADA patients were treated using a reconstructive strategy. Clinical, radiological, neurological, and cognitive data, as well as QOL, were assessed at admission and 6 months after surgery. Stoke Specific Quality of Life (SS-QOL) was evaluated for patients with good functional outcome [modified Ranking Scale (mRS) scoring 0-2] for subgroup analysis. Predictors for QOL at follow-up were analyzed by regression model.

Results: Immediate angiography after surgery showed complete VADA obliteration in 57 (81.4%) patients and partial obliteration in 13 (18.6%) patients. Three (4.3%) cases suffered from perioperative complications, comprising two cases of stent thrombosis in the hemorrhagic group and one case of posterior inferior cerebellar artery occlusion in the ischemic group. Twenty-five (75.8%) patients in the hemorrhagic group and 30 (81.1%) patients in the ischemic group had a favorable outcome (mRS scoring 0-2) at 6-month follow-up. Follow-up angiography displayed that one case of recurrence occurred separately in both groups. Fifteen of the 33 hemorrhagic patients (45.5%) and 19 of the 37 ischemic patients (51.4%) rated QOL at follow-up as bad (SS-QOL score ≤ 3.9) despite a good functional outcome. Severity of neurological disorder and impaired neurocognition at baseline in VADA patients are proved to be independent predictors for the decline of QOL according to regression analysis.

Conclusion: Reconstructive endovascular therapy for acute intracranial VADAs is a safe and effective method with a low complication rate. VADAs lead to impaired QOL at 6-month follow-up, which is attributable to multiple factors. This study demonstrated that neurological and cognitive status at baseline is of significant importance for QOL after VADAs.

Neuropsychiatric issues after stroke: Clinical significance and therapeutic implications

A spectrum of neuropsychiatric disorders is a common complication from stroke. Neuropsychiatric disorders after stroke have negative effects on functional recovery, increasing the rate of mortality and disability of stroke survivors. Given the vital significance of maintaining physical and mental health in stroke patients, neuropsychiatric issues after stroke have raised concerns by clinicians and researchers. This mini-review focuses on the most common non-cognitive functional neuropsychiatric disorders seen after stroke, including depressive disorders, anxiety disorders, post-traumatic stress disorder, psychosis, and psychotic disorders. For each condition, the clinical performance, epidemiology, identification of the therapeutic implication, and strategies are reviewed and discussed; the main opinions and perspectives presented here are based on the latest controlled studies, meta-analysis, or updated systematic reviews. In the absence of data from controlled studies, consensus recommendations were provided accordingly.

Associations Between Baseline Total PTSD Symptom Severity, Specific PTSD Symptoms, and 3-Month Quality of Life in Neurologically Intact Neurocritical Care Patients and Informal Caregivers

BACKGROUND

The objective is to pilot test the feasibility of assessing severity of posttraumatic stress disorder (PTSD) symptoms, as well as specific lower-order PTSD symptoms, experienced during neurological intensive care unit (neuro-ICU) admission and their relationship with 3-month quality of life (QoL) scores in multiple domains (i.e., physical, psychological, social, and environmental) in both patients and caregivers.

METHODS

Between 2015 and 2016, we enrolled neurologically intact patients and informal caregivers of patients who reported demographics and PTSD symptoms (PTSD Checklist-Specific; PCL-S) during neuro-ICU admission and completed a QoL assessment (World Health Organization Quality of Life; WHOQOL-BREF) 3 months later. Clinical data were extracted from medical records. We ran two bivariate correlation matrices among PTSD symptom dimensions in patients and caregivers. Then, we used multiple linear regression to examine the prospective association of total PCL-S scores with each QoL domain in both patients and caregivers after adjusting for clinically important variables. Next, we explored differential associations between the 4 PTSD symptom dimensions and each QoL domain in both patients and caregivers, adjusting for sex and age.

RESULTS

A total of 70 patients (45.7% women, 84.3% white, mean age 52.08 years) and 64 caregivers (64.1% women, 90.6% white, mean age 53.12 years) were included. PTSD symptom dimensions were moderately strongly correlated among patients (r = 0.65-0.79, p < 0.001) and caregivers (r = 0.55-0.78, p < 0.001). For both patients and caregivers, greater PTSD symptom severity was prospectively associated with lower QoL in all domains (β = - 0.289 to - 0.622; p < 0.05). Our exploratory analysis revealed that greater numbing symptoms were associated with lower psychological QoL in patients (β: - 0.397, p = 0.038), and lower physical (β: - 0.409, p = 0.014), psychological (β: - 0.519, p = 0.001), and social QoL (β: - 0.704, p < 0.001) in caregivers. Greater re-experiencing symptoms were associated with lower physical QoL in both patients (β: - 0.422, p = 0.047) and caregivers (β: - 0.4, p = 0.041).

CONCLUSIONS

Our preliminary results indicated that greater severity of PTSD symptoms, and specifically numbing and re-experiencing symptoms, experienced by patients and caregivers during neuro-ICU admission was predictive of worse 3-month QoL. Continued study is needed to identify treatment targets for PTSD and QoL in this population.

Incidence and predictors of post-traumatic stress symptoms in a cohort of patients with intracerebral hemorrhage

OBJECTIVES

Examine the incidence and predictors of PTSD symptoms in a cohort of patients with ICH.

PATIENTS AND METHODS

This study uses a prospective cohort of 108 patients with complete follow-up data including a questionnaire regarding stress symptoms (PCL-S: PTSD checklist specific for a stressor) at 3, 6, and 12 months.

RESULTS

The incidence of novel stress symptoms following ICH was approximately 6.5%. Age was negatively associated with PTSD symptoms with only trend-level significance (3 months: OR = 0.83, p = 0.087; 6 months: OR = 0.70, p = 0.015; 12 months: OR = 0.88, p =  0.087). Gender did not affect PTSD symptom development, (t = 1.34, p =  0.18). Pre-morbid functioning, initial stroke prognosis, total number of complications, and length of hospital/ICU stay were not associated with PTSD symptoms; however, each was significantly correlated with poorer functional outcomes. Yet, poorer functional outcomes were observed in those with higher reports of PTSD symptoms (r = 0.24, p = 0.01).

CONCLUSION

Functional outcomes in ICH are correlated with PTSD symptoms, however the mechanism and relationship are difficult to elucidate. Further research is needed to determine possible mechanisms by which a stroke patient may develop PTSD.

Contributing factors to quality of life after vertebral artery dissection: a prospective comparative study

BACKGROUND

Vertebral artery dissection (VAD) may cause cerebral ischemia and impair quality of life (QOL) despite of good functional outcome. The aim of this study was the multimodal analysis of patient characteristics after VAD to identify contributing factors.

METHODS

In an exploratory study, 34 consecutive patients with first-ever spontaneous VAD were prospectively examined in comparison to 38 patients with cerebral ischemia without dissection and 25 stroke mimics as control groups. Multimodal assessment was performed for clinical, neurological, cognitive, psychological and radiological data at baseline and for QOL, functional outcome, and stress symptoms by questionnaire at six months follow-up. Subgroup analysis stratified for QOL by Stroke Specific Quality of Life Scale (SS-QOL) were done for patients with good functional outcome (modified Ranking Scale (mRS) scoring 0-2). Predictors for QOL at follow-up were analyzed by regression model.

RESULTS

88.2% of patients with VAD suffered from acute cerebral ischemia. Thirteen of 32 VAD patients (40.6%) rated QOL at follow-up as bad (SS-QOL score ≤ 3.9) despite of good functional outcome (mRS score 0-2). Subgroup analysis yielded significantly higher scores for posttraumatic stress symptoms (p = 0.002) in this subgroup. Posttraumatic stress symptoms, severity of neurological disorders, and impaired neuropsychological baseline performance proved to be independent predictors for reduced QOL at follow-up according to regression analysis.

CONCLUSION

VAD leads to impaired QOL at 6 months follow-up due to multiple factors. The data suggest that posttraumatic stress symptoms are of significant importance for the QOL after VAD. Clinical monitoring should address this topic to make timely treatment possible.

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.

A Twelve-Week Moderate Exercise Programme Improved Symptoms of Depression, Insomnia, and Verbal Learning in Post-Aneurysmal Subarachnoid Haemorrhage Patients: A Comparison with Meningioma Patients and Healthy Controls

OBJECTIVES

Deficits in psychological functioning, cognitive functioning, and sleep are frequently experienced by individuals who have survived aneurysmal subarachnoid haemorrhage (aSAH). Exercise has been shown to improve these domains; to date, it has never been explored in patients following aSAH. The aim of this exploratory study is to compare the effects of an exercise programme in this population with another patient group, and a group of healthy controls.

METHODS

The present study explored the effects of 12 weeks of moderate aerobic exercise training on 15 aSAH patients, 16 meningioma patients, and 17 healthy controls. Data on symptoms of depression, hypochondria, perceived stress, satisfaction with life, verbal learning and memory, and subjective and objective sleep, were gathered at baseline, following intervention, and at 6-month follow-up.

RESULTS

aSAH patients and meningioma patients had decreased symptoms of depression and insomnia at follow-up. While perceived stress decreased in the meningioma group, in aSAH patients it increased. Total learning performance increased in all three groups.

CONCLUSIONS

An exercise programme had a positive effect on symptoms of depression, insomnia, and verbal learning in patients following aSAH. No positive changes in other domains were observed. This may be due to the cautious approach taken with regard to exercise intensity.

Exploratory study of the course of posttraumatic stress disorder after aneurysmal subarachnoid hemorrhage

OBJECTIVE

Posttraumatic stress disorder (PTSD) occurs often in aneurysmal subarachnoid hemorrhage (aSAH) survivors, but how PTSD develops over time post-aSAH is still unclear. We examined the course of PTSD symptoms during the first year after aSAH.

METHOD

In this prospective cohort study, the Impact of Event Scale (IES) was applied in 128 patients 3, 6 and 12 months after aSAH. Multilevel modelling was used to assess changes in levels of PTSD symptoms over time and to explore if demographic characteristics, aSAH characteristics, level of education, cognitive functioning and neuroticism are associated to the course of PTSD symptoms.

RESULTS

Multilevel analyses showed at group level no differences in the average level of PTSD symptoms between 3, 6 of 12 months post-aSAH (p = 0.22). At individual level, changes in PTSD symptoms over time were present (X² (121) = 149.73 p = 0.04). None of the factors could explain the variance in change of PTSD symptoms over time.

CONCLUSIONS

The course of PTSD appears to differ between individuals after aSAH. We found no factors that explain these differences. There is not one optimal moment in time to assess PTSD. Therefore, it is important to assess PTSD at several time points after aSAH.

Well-being among survivors of out-of-hospital cardiac arrest: a cross-sectional retrospective study in Sweden

OBJECTIVES

The psychological outcome of out-of-hospital cardiac arrest (OHCA) has been studied more extensively in recent years. Still, not much is known about the well-being among OHCA survivors. In this retrospective cross-sectional study, we aim to investigate post-OHCA well-being among patients with a good neurological outcome, 3 months after the cardiac event. To assess well-being, we analyse the frequency of anxiety, depression, post-traumatic stress disorder (PTSD) and health within this group. Further, we aim to evaluate the importance of five prognostic factors for post-OHCA well-being.

METHODS

Data collection took place between 2008 and 2012, and every OHCA survivor within one region of Sweden, with a cerebral performance category (CPC) score of ≤2 at discharge, was asked to participate. Survivors were identified through the Swedish Cardiopulmonary Resuscitation Registry, and postal questionnaires were sent out 3 months after the OHCA. The survey included Hospital Anxiety and Depression scale (HADS), PTSD Checklist Civilian version (PCL-C) and European Quality of Life 5 Dimensions 3 level (EQ-5D-3L).

RESULTS

Of 298 survivors, 150 were eligible for this study and 94 responded. The mean time from OHCA to follow-up was 88 days. There was no significant difference between respondents and non-respondents in terms of sex, age, cardiac arrest circumstances or in-hospital interventions. 48 participants reported reduced well-being, and young age was the only factor significantly correlated to this outcome (p=0.02). Women reported significantly higher scores in HADS (p=0.001) and PCL-C (p<0.001). Women also reported significantly lower EQ-5D index values (p=0.002) and EQ-visual analogue scale scores (p=0.002) compared with men.

CONCLUSION

Reduced well-being is experienced by half of OHCA survivors with a CPC score ≤2, and young age is negatively correlated to this outcome. The frequency of anxiety and PTSD is higher among women, who also report worse health.

Relation of gray-white matter ratio with long-term cognitive functions and quality of life in patients with mild to moderate aneurysmal subarachnoid hemorrhage: a prospective observational study

BACKGROUND

In the present study, we hypothesized that a low gray matter-white matter ratio (GWR) is associated with poor cognitive function and low quality of life in patients with mild to moderate (WFNS ≤3) aneurysmal subarachnoid hemorrhage (aSAH).

METHODS

All patients with aSAH who were admitted to the neurointensive care unit (Neuro ICU) and whose WFNS score was ≤ 3 were enrolled in the study. During the Neuro ICU follow-up period, the following variables were recorded: demographics, neurological status, comorbidities, time elapsed between onset of bleeding and Neuro ICU admission, treatment method, number of days with vasospasm symptoms (DVS) and vasopressor usage. One year after bleeding, all patients except those who could not answer the questionnaires appropriately were administered the MoCA and SF-36 tests, and brain magnetic resonance imaging and then volumetric brain analysis were performed.

RESULTS

Eighty-two patients completed the study. One year after aSAH, cognitive dysfunction and low quality of life were observed in 59.8% and 25.6% of patients, respectively. Among the variables obtained during Neuro ICU follow-up, DVS was found to be a major risk factor for cognitive dysfunction (OR: 3.9, 95% CI: 1.9-7.8; p < 0.001), poor quality of life (OR: 2.8, 95% CI: 1.4-5.3, p = 0.002) and a lower GWR value (p < 0.001, correlation coefficient = -0.410, R2 = 0.234). One year after aSAH, higher GWR values were associated with higher MoCA (R2 = 0.506 for males, R2 = 0.413 for females) and SF-36 (R2 = 0.270 for males, R2 = 0.364 for females) scores in both genders. Also, GWR ≤ 1.35 in males and GWR ≤1.33 in females indicated MoCApoor patients with over 80% specificity and sensitivity.

CONCLUSION

GWR has good correlation with the MoCA and SF-36 score, and a low GWR can indicate cognitive dysfunction. In this context, GWR can be used as an additional method to evaluate cognitive function and quality of life.

The prevalence of growth hormone deficiency in survivors of subarachnoid haemorrhage: results from a large single centre study

OBJECTIVE

The variation in reported prevalence of growth hormone deficiency (GHD) post subarachnoid haemorrhage (SAH) is mainly due to methodological heterogeneity. We report on the prevalence of GHD in a large cohort of patients following SAH, when dynamic and confirmatory pituitary hormone testing methods are systematically employed.

DESIGN

In this cross-sectional study, pituitary function was assessed in 100 patients following SAH. Baseline pituitary hormonal profile measurement and glucagon stimulation testing (GST) was carried out in all patients. Isolated GHD was confirmed with an Arginine stimulation test and ACTH deficiency was confirmed with a short synacthen test.

RESULTS

The prevalence of hypopituitarism in our cohort was 19% and the prevalence of GHD was 14%. There was no association between GHD and the clinical or radiological severity of SAH at presentation, treatment modality, age, or occurrence of vasospasm. There were statistically significant differences in terms of Glasgow Outcome Scale (GOS; p = 0.03) between patients diagnosed with GHD and those without. Significant inverse correlations between GH peak on GST with body mass index (BMI) and waist hip ratio (WHR) was also noted (p < 0.0001 and p < 0.0001 respectively).

CONCLUSION

Using the current testing protocol, the prevalence of GHD detected in our cohort was 14%. It is unclear if the BMI and WHR difference observed is truly due to GHD or confounded by the endocrine tests used in this protocol. There is possibly an association between the development of GHD and worse GOS score. Routine endocrine screening of all SAH survivors with dynamic tests is time consuming and may subject many patients to unnecessary side-effects. Furthermore the degree of clinical benefit derived from growth hormone replacement in this patient group, remains unclear. Increased understanding of the most appropriate testing methodology in this patient group and more importantly which SAH survivors would derive most benefit from GHD screening is required.

[Depression and depression-related disorders after a subarachnoid hemorrhage]

Psychiatric disorders often develop after subarachnoid hemorrhage (SAH); the most frequent of them are depression and depression-related disorders (anxiety, apathy, pathological fatigue, posttraumatic stress disorder, etc.). Both biological and psychological mechanisms may underlie the development of these disorders. Depression and depression-related disorders decrease patients' quality of life and prevent the full recovery after SAH. Identification and correction of these disorders should take a prominent place in the rehabilitation of post-SAH patients. More research is needed in this area.

Sleep Quality, Sleep EEG Pattern, Mental Well-Being and Cortisol Secretion in Patients with Ruptured Aneurysm Post-Treatment: A Comparison with Post-Surgery Meningioma Patients and Controls

BACKGROUND

Although the chance of surviving an aneurysmal subarachnoid haemorrhage (aSAH) has increased steadily, disturbed sleep and persistent psychological complaints are frequently experienced post-ictus. To date, however, few studies have sought to determine whether physiological parameters, such as objectively measured sleep and cortisol secretion, interrelate significantly with low sleep quality and psychological complaints such as depression. Furthermore, there is little evidence as to whether post-ictal complaints differ between aSAH patients and other groups who have experienced stressful medical intervention.

METHODS

Data on objective and subjective sleep, sleep-related dysfunctional cognitions, psychological functioning and cortisol secretion were collected from 15 patients who had undergone medical intervention for aSAH. Data were also collected from a group of 16 individuals who had undergone surgery for a meningioma and a third group made up of 17 healthy participants.

RESULTS

aSAH patients and meningioma patients had significantly poorer subjective sleep than healthy controls and reported more sleep-related dysfunctional cognitions and hypochondriacal beliefs. They also had a significantly higher morning cortisol response. Finally, a non-significant trend was found showing that aSAH patients and meningioma patients reported poorer psychological functioning than healthy controls.

CONCLUSION

Following treatment, aSAH patients and meningioma patients experience poorer subjective sleep and some differences in objectively measured sleep, which might be attributable to increased sleep-related dysfunctional cognitions and poorer overall psychological functioning. Differences in cortisol production were also observed, suggesting that some physiological imbalances are still present post-ictus.

[Posttraumatic stress disorder : Trigger and consequence of vascular diseases]

Posttraumatic stress disorder (PTSD) was previously thought to be a psychological reaction precipitated by exposure to war, sexual and physical violence; however, PTSD is also prevalent after life-threatening medical events, such as stroke and myocardial infarction. After such events PTSD is often underdiagnosed despite the fact that it is clearly associated with adverse clinical outcomes including recurrence of cardiac events and increased mortality. Moreover, PTSD increases the risk of vascular events. This review summarizes the bidirectional relationship between PTSD and vascular diseases and outlines current knowledge regarding clinical features, prevalence and the putative underlying pathophysiological mechanisms.

Increased prevalence of posttraumatic stress disorder in CRPS

BACKGROUND

Although specific psychological disorders in complex regional pain syndrome (CRPS) have not been identified, studies suggest that CRPS patients may have increased rates of traumatic life events. Because these events do not always lead to apparent psychological symptoms, we systematically screened CRPS patients for posttraumatic stress disorder (PTSD) to determine if PTSD could be a risk factor for CRPS.

METHODS

Consecutive CRPS patients referred to two university hospital centres (University of Erlangen, UMC Mainz) between December 2011 and April 2013 were prospectively examined using a diagnostic PTSD instrument (Post-traumatic Stress Diagnostic Scale (PDS). We also tested maladaptive coping strategies (brief-COPE inventory) and the PDS severity score as predictors for CRPS. Patients with non-CRPS extremity pain and healthy individuals were used as control groups.

RESULTS

We collected data from 152 patients with CRPS, 55 control patients and 55 age- and sex-matched healthy individuals. Fifty-eight CRPS patients (38%), six non-CRPS pain patients (10%) and two healthy individuals (4%) met diagnostic criteria for PTSD. Initial PTSD symptom onset was prior to CRPS in 50 CRPS patients (86%) and during the course of CRPS in eight patients. Results of a logistic regression revealed that the PTSD severity score was associated with CRPS (p < 0.0001). Maladaptive coping strategies (p < 0.0001) were related to PTSD.

CONCLUSIONS

posttraumatic stress disorder (PTSD) is more frequent in patients with CRPS than it is in the general population.

SIGNIFICANCE

Research has not yet provided support for specific psychological predictors for CRPS.

Reduced Quality of Life in Patients with Pituitary Dysfunction After Aneurysmal Subarachnoid Hemorrhage: A Prospective Longitudinal Study

OBJECTIVE

Pituitary dysfunction (PD) after aneurysmal subarachnoid hemorrhage (SAH) has been demonstrated in several studies. Given the similarities between psychological symptoms and reduced quality of life (QoL) in patients with PD and fatigue commonly seen in patients after SAH, we investigated the relationship between QoL and PD after SAH.

METHODS

There were 51 patients with aneurysmal SAH prospectively recruited and evaluated for health-related QoL using the Psychological General Well-Being Index. Evaluations were conducted 3-6 months (n = 45), 6-12 months (n = 44), and 12-24 months (n = 44) after SAH, with concomitant assessment of endocrine function. The study protocol also included a magnetic resonance imaging examination 3 months after SAH.

RESULTS

Mean general well-being scores showed a positive trend from 97.3 at 3-6 months to 104.3 at 12-24 months for all patients. Multiple regression analysis identified age, sex, Hunt and Hess grade, and PD as independent predictors for general well-being. Patients with PD had significantly lower scores compared with patients with normal pituitary function at 3-6 months (85.4 vs. 101.7) and 6-12 months (90.4 vs. 105.3). This result was due to central hypoadrenalism (score 81.6 at 3-6 months and score 82.2 at 6-12 months) but not other types of PD. The extent of magnetic resonance imaging lesions had a significant negative correlation to Glasgow Outcome Scale score at all follow-up evaluations. All patients with hypothalamic magnetic resonance imaging lesions had evidence of PD at some point during the follow-up period.

CONCLUSIONS

The results support PD, and central hypoadrenalism in particular, as a contributing factor for impaired health-related QoL in patients after SAH.

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.

Compared to controls, patients with ruptured aneurysm and surgical intervention show increase in symptoms of depression and lower cognitive performance, but their objective sleep is not affected

OBJECTIVES

Patients with aneurysmal subarachnoid haemorrhage (aSAH) have impaired sleep and cognitive performance together with more difficulties in social and everyday life. Hypocortisolism has also been reported. However, a study assessing all dimensions between aSAH severity, objective and subjective sleep, cortisol secretion, cognitive performance and social and everyday life has not so far been performed. The aim of the present study was therefore two-fold: (1) to assess, in a sample of patients with aSAH, objective and subjective sleep, cognitive functioning, social skills and cortisol secretion concurrently, and (2) to compare patients on these variables with a control group.

METHODS

Twenty-one patients (17 females; mean age: 58.80 years) with ruptured aneurysm and surgical intervention and 21 (14 females; mean age: 58.90 years) age- and gender-matched controls took part in the study. Assessments covered objective sleep-EGG recordings, subjective sleep, salivary cortisol analysis, and psychological functioning including memory performance, mood, and emotion recognition.

RESULTS

Compared to healthy controls, patients had lower scores for verbal memory performance and emotion recognition; they also reported more marked depressive symptoms and complained of poor sleep. However, no differences were found for objective sleep or cortisol secretion. Subjective and objective sleep, cortisol secretion and psychological functioning were unrelated.

CONCLUSIONS

Findings indicate that patients with aSAH face psychological rather than physiological issues.

Increased prevalence of posttraumatic stress disorder in patients after transient ischemic attack

BACKGROUND AND PURPOSE

A transient ischemic attack (TIA) involves temporary neurological symptoms but leaves a patient symptom-free. Patients are faced with an increased risk for future stroke, and the manifestation of the TIA itself might be experienced as traumatizing. We aimed to investigate the prevalence of posttraumatic stress disorder (PTSD) after TIA and its relation to patients' psychosocial outcome.

METHODS

Patients with TIA were prospectively studied, and 3 months after the diagnosis, PTSD, anxiety, depression, quality of life, coping strategies, and medical knowledge were assessed via self-rating instruments.

RESULTS

Of 211 patients with TIA, data of 108 patients were complete and only those are reported. Thirty-two (29.6%) patients were classified as having PTSD. This rate is 10× as high as in the general German population. Patients with TIA with PTSD were more likely to show signs of anxiety and depression. PTSD was associated with the use of maladaptive coping strategies, subjectively rated high stroke risk, as well as with younger age. Finally, PTSD and anxiety were associated with decreased mental quality of life.

CONCLUSIONS

The experience of TIA increases the risk for PTSD and associated anxiety, depression, and reduced mental quality of life. Because a maladaptive coping style and a subjectively overestimated stroke risk seem to play a crucial role in this adverse progression, the training of adaptive coping strategies and cautious briefing about the realistic stroke risk associated with TIA might be a promising approach. Despite the great loss of patients to follow-up, the results indicate that PTSD after TIA requires increased attention.