Relationship of Local Infarctions to Cognitive and Psychosocial Impairments after Aneurysmal Subarachnoid Hemorrhage

620

485

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.)

Section: Resultsmentioning

confidence: 96%

Section: Executive Functionmentioning

confidence: 99%

Cognitive and Functional Outcome After Aneurysmal Subarachnoid Hemorrhage

Al-Khindi

Macdonald

Schweizer

2010

620

485

“…2,12,25 It is possible that both procedures can contribute to infarction, for instance, through vessel manipulation during clipping or via thromboembolic events during endovascular treatment. Studies have often focused on cerebral infarction identified at long-term follow-up with imaging 3,12,[25][26][27] or have only identified infarcts on imaging in patients who became symptomatic and were subsequently imaged in hospital. 8,13 These strategies may significantly underestimate the incidence of both early and delayed infarction.…”

Section: Discussionmentioning

confidence: 99%

Dissociation of Early and Delayed Cerebral Infarction After Aneurysmal Subarachnoid Hemorrhage

Ayling

Ibrahim

Alotaibi

et al. 2016

Background and Purpose-Cerebral infarction after aneurysmal subarachnoid hemorrhage is a significant cause of substantial morbidity and mortality. Because early and delayed cerebral infarction after aneurysmal subarachnoid hemorrhage may be mediated by different processes, we evaluated whether aneurysm-securing methods contributed to infarcts and whether long-term outcomes differ between early and delayed infarcts. Methods-A post hoc analysis of the CONSCIOUS-1 study (Clazosentan to Overcome Neurological Ischemia and Infarction Occurring After Subarachnoid Hemorrhage) was performed. Using multivariate logistic regression analysis and propensity matching, independent clinical risk factors associated with infarctions were identified, and the contribution of cerebral infarcts to long-term outcomes was evaluated. Results-Within the cohort of 413 subjects, early infarcts were present in 76 subjects (18%), whereas delayed infarcts occurred in 79 subjects (19%), and 36 subjects (9%) had new infarctions that were present on both early and delayed imaging. Propensity score matching revealed a significantly higher proportion of early infarcts after clipping (odds ratio, 4.62; 95% confidence interval, 1.99-11.57; P=0.00012). Multivariate logistic regressions identified clipping as an independent risk factor for early cerebral infarction (odds ratio, 0.26; 95% confidence interval, 0.15-0.48; P<0.001), and angiographic vasospasm was an independent risk factor for delayed cerebral infarction (odds ratio, 1.79; 95% confidence interval, 1.03-3.13; P=0.039). Early infarcts were a significant independent risk factor for poor long-term outcomes at 3 months (odds ratio, 2.34; 95% confidence interval, 1.18-4.67; P=0.015). Conclusions-Clipping is an independent risk factor for the development of early cerebral infarcts, whereas delayed cerebral infarcts are associated with angiographic vasospasm. Early cerebral infarcts are stronger predictors of worse outcome than delayed infarction. Clinical Trial Registration-URL: http://www.clinicaltrials.gov. Unique identifier: NCT00111085.

“…[1][2][3][4] A high rate of hypodense lesions consistent with cerebral infarctions has been evident on delayed computed tomographic(CT) scanning among survivors. [5][6][7][8][9] Delayed cerebral infarction (DCI) was proposed to be the preferred surrogate outcome in SAH, to vasospasm or delayed cerebral ischemia. 10,11 In a post hoc path analysis, DCI also had a direct effect on outcome independent of angiographic vasospasm.…”

mentioning

confidence: 99%

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

Wong

Nung

Sitt

et al. 2015

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.