Aneurysmal SAH

We prospectively enrolled patients with SAH presenting to an academic neurosurgical referral center (Prince of Wales Hospital, the Chinese University of Hong Kong) in Hong Kong during a 3-year period. Joint CUHK-NTEC Clinical Research Ethics Committee approved the study. This study conformed to the Declaration of Helsinki and written informed consent was obtained from all the participants or their next of kin.The patient inclusion criteria were (1) spontaneous SAH with angiography-confirmed intracranial aneurysms; (2) hospital admission Background and Purpose-Aneurysmal subarachnoid hemorrhage is a serious disease with high case fatality and morbidity.Delayed cerebral infarction (DCI) is an important surrogate marker. How location and infarct load affected outcomes was unclear. We aimed to assess the effects of load and location of DCI on outcomes of aneurysmal subarachnoid hemorrhage at 3 months. Methods-We prospectively enrolled patients with subarachnoid hemorrhage presenting to an academic neurosurgical unit in Hong Kong during a 3-year period. DCI was defined by new hypoattenuation on computed tomography at 4 to 6 weeks, which was not present in the postaneurysm-treatment computed tomography at 24 to 48 hours. DCI was assessed for location according to cerebral artery territories and load semiquantitatively. Cognitive and functional outcome assessments were carried out 3 months after ictus. Results-One hundred twenty-six patients with subarachnoid hemorrhage consented for this study. DCI occurred in 56 (44%) patients and was associated with poorer cognitive and functional outcomes (Montreal Cognitive Assessment, MiniMental State Examination, modified Rankin Scale, and Lawton Instrumental Activity of Daily Living) at 3 months. In patients with DCI, the presence of perforator zone infarct was associated with poorer cognitive and functional outcomes, and cortical middle cerebral artery infarct was associated with poorer modified Rankin Scale. After adjustment for age, admission World Federation of Neurosurgical Societies Grade and mode of aneurysm treatment, both middle cerebral artery cortical infarct load and perforator infarct load were independently associated with poor cognitive outcomes (Montreal Cognitive Assessment and Mini-Mental State Examination) and modified Rankin Scale. Conclusions-Middle cerebral artery cortical and perforator zone infarct loads are potential surrogate marker to assess the severity of delayed cerebral ischemia.

Section: Discussionmentioning

confidence: 99%

Location, Infarct Load, and 3-Month Outcomes of Delayed Cerebral Infarction After Aneurysmal Subarachnoid Hemorrhage

Wong

Nung

Sitt

et al. 2015

“…Other small nonrandomized studies have also found less cognitive impairment with endovascular treatment. 24 However, both studies had limitations; the former was conducted on a relatively small sample and the latter on a nonrandomized group. We have shown in N-ISAT that cognitive impairment was common in patients who were not otherwise disabled according to the mRS and that cognitive impairment was more frequent in the neurosurgery group.…”

Section: Discussionmentioning

confidence: 99%

Improved Cognitive Outcomes With Endovascular Coiling of Ruptured Intracranial Aneurysms

Scott

Eccles

Molyneux

et al. 2010

123

Background and Purpose-The International Subarachnoid Aneurysm Trial (ISAT) reported lower rates of death and disability with endovascular versus neurosurgical treatment of ruptured intracranial aneurysms. However, assessment of functional outcome was limited to the modified Rankin Scale, which is known to be insensitive to cognitive function. A neuropsychological substudy (N-ISAT) was therefore done in all recruits from 8 ISAT centers in the United Kingdom. Methods-Detailed neuropsychological assessment was performed at a 12-month follow-up visit. Impairment was defined as performance below the 5th percentile of the study population on at least 2 tests in Ն2 major cognitive domains. Analysis was restricted to patients who were not known to be otherwise disabled according to the modified Rankin Scale (ie, modified Rankin Scale 0 to 2). initially reported the primary clinical outcomes on the modified Rankin Scale (mRS) at 2 months and 1 year after neurosurgical clipping or endovascular coiling as a treatment for ruptured intracranial aneurysms. 1,2 Unfavorable outcomes at 12 months (ie, mRS Grade 3 to 6) were reported in 30.9% of cases randomized to neurosurgery and 23.5% to embolization with a difference in mortality still evident at 5-year follow-up. 3 However, clinical disability and handicap scales such as the mRS are insensitive to poor neuropsychological outcomes, 4,5 and the effect of endovascular versus neurosurgical treatment on cognitive outcomes in patients without physical disability is uncertain. Previous small studies have identified clinically significant neuropsychological impairments with an impact on overall quality of life in patients with an apparently "good" neurological outcome (ie, Glasgow Outcome Scale Grade 1) after subarachnoid hemorrhage (SAH). [5][6][7] The ISAT protocol therefore included a substudy (N-ISAT) in which detailed neuropsychological assessments at 12-month follow-up were performed in all patients randomized from 8 UK centers. We report the rates of cognitive impairment in patients who had no major physical disability (mRS 0 to 2) to Results-Of MethodsThe eligibility, recruitment, and characteristics of ISAT, from which the N-ISAT subsample was drawn, have been reported together with the main trial design and methods. 1 The detailed methods of N-ISAT in terms of organization, training, recruitment, and assessment protocols have also been reported together with an analysis of data quality. 8,9 The study was approved by the Oxford Research Ethics Committee. All patients who had been enrolled in the 8 UK centers participating in N-ISAT and who had survived to 12 months were followed-up as per the main ISAT protocol 1 and were also eligible for face-to-face neuropsychological assessment as part of N-ISAT. Patients were contacted by letter followed by a telephone call initially. Multiple attempts were made to contact nonresponders. 9 Given the uncertainty about the number of cases that would be randomized in the United Kingdom, the pragmatic aim was to study all randomized cas...

“…16,27,28,45,77,94 A few studies, however, indicate that clipped patients are more depressed and perform poorer on tests of executive function, visual memory, and verbal memory relative to their coiled counterparts. 16,45,95,96 Why clipping is associated with greater cognitive impairment in these studies is unclear.…”

Section: Al-khindi Et Al Outcome After Aneurysmal Subarachnoid Hemorrmentioning

confidence: 91%

“…Another possibility is that clipped patients may have more brain injury; Hadjivassiliou and colleagues 95 found that 48% of clipped patients had focal encephalomalacia compared with 0% of coiled patients. Moreover, a significantly greater proportion of clipped patients had infarcts (87%) relative to coiled patients (57%).…”

Section: Al-khindi Et Al Outcome After Aneurysmal Subarachnoid Hemorrmentioning

confidence: 99%

“…Interestingly, of the 4 studies that observed poorer prognosis among clipped patients, 16,45,95,96 3 examined cognitive function at least 1 year after aSAH. 16,45,95 Clipping and coiling may thus have different effects on cognitive outcome depending on time since treatment with clipped patients having superior cognitive outcome in the short-term and coiled patients having superior cognitive outcome in the long-term. Future studies should investigate the relative efficacy of clipping and coiling on cognitive and functional outcome over longer durations.…”

Section: Al-khindi Et Al Outcome After Aneurysmal Subarachnoid Hemorrmentioning

confidence: 99%

See 1 more Smart Citation

Cognitive and Functional Outcome After Aneurysmal Subarachnoid Hemorrhage

Al-Khindi

Macdonald

Schweizer

2010

647

478

Background and Purpose-Aneurysmal subarachnoid hemorrhage (aSAH) is a medical emergency characterized by the accumulation of blood in the subarachnoid space surrounding the brain. The acute treatment of aSAH is well documented but less is known about the long-term effects of aSAH on cognition and day-to-day functioning. Methods-We reviewed all studies in the past 10 years that have focused on the effects of aSAH on cognition and day-to-day functioning. Results-Sixty-one empirical studies examining cognitive and functional outcome in patients with aSAH met inclusion criteria. Survivors of aSAH commonly experience deficits in memory, executive function, and language. These cognitive impairments interact to affect patients' day-to-day functioning, including activities of daily living, instrumental activities of daily living, return to work, and quality of life. Deficits in cognition and day-to-day functioning are further compounded by depression, anxiety, fatigue, and sleep disturbances. Conclusions-Much remains to be learned about the brain changes underlying cognitive and functional deficits, including the role of diffuse brain damage and secondary complications like vasospasm and elevated intracranial pressure. A consideration of these issues is necessary to obtain a better understanding of how aSAH affects cognition and day-to-day functioning in the long-term. (Stroke. 2010;41:e519-e536.)