Characteristics of patients without neuropsychological deficits following aneurysmal subarachnoid haemorrhage.

BACKGROUND: Previous studies have shown that the incidence of neuropsychological deficits (NPD) after aneurysmal subarachnoid haemorrhage (aSAH) is high despite excellent outcome evaluated by traditional neurological grading scales. The aim of this study was to elucidate the clinical characteristics in patients presenting with aSAH who had a good clinical outcome without NPD. METHODS: Files of patients treated for aSAH between January 2009 and August 2012 at the neurovascular centres of the Kantonsspital St. Gallen (KSSG) and Kantonsspital Aarau (KSA), respectively, were reviewed. Neuropsychological outcome was assessed by an experienced, independent neuropsychologist. Patients were graded as regular, or as having minimal-, moderate-, or severe disability according to normative population data. RESULTS: A total of 92 patients (35 men and 57 women) with a mean age of 51.4 ± 11.6 years were analysed. Eight of 92 patients (8.7 %) had no NPD at follow-up. Patients without NPD were admitted with lower median WFNS (1.00 vs. 2.00; p = 0.011) and Fisher grades (2.00 vs. 3.00; p = 0.001). They were equally distributed between clipping and coiling (four patients each). No patient with regular neuropsychological outcome displayed chronic hydrocephalus (p = 0.019) or developed delayed cerebral ischaemia (DCI) during the hospital course (p = 0.100). Five patients were graded as modified Rankin Scale (mRS) 0 and three patients as mRS 1 at discharge. CONCLUSION: Patients without NPD after aSAH are likely to present with mild admission scores, develop neither chronic hydrocephalus nor DCI. In this series the aneurysm occlusion modality did not influence the cognitive outcome.

Current practice in neuropsychological outcome reporting after aneurysmal subarachnoid haemorrhage.

BACKGROUND: Neuropsychological deficits (NPD) are common in patients with aneurysmal subarachnoid haemorrhage (aSAH). NPD are one of the major limiting factors for patients with an otherwise acceptable prognosis for sustained quality of life. There are only a few studies reporting outcome after aSAH, which used a standardized neuropsychological test battery as a primary or secondary outcome measure. Aim of this study was to determine the current practice of reporting NPD following aSAH in clinical studies. METHODS: A MEDLINE analysis was performed using the search term "subarachnoid haemorrhage outcome". The latest 1,000 articles were screened. We recorded study design, number of patients, and the presence of neuropsychological outcome report. Additionally, the time of testing after aSAH, the neuropsychological tests administered, as well as the percentage of patients with NPD were analyzed. RESULTS: A total of 324 publications between 2009 and 2012 were selected for further review. Of those, 21 studies (6.5%) reported neuropsychological outcome, in 2,001 of 346,666 patients (0.6%). The assessment of NPD differed broadly using both subjective and objective cognitive evaluation, and a large variety of tests were used. CONCLUSION: Neuropsychological outcome is underreported, and there is great variety in assessment in currently published clinical articles on aSAH. Prospective randomized trials treating aSAH may benefit from implementing more comprehensive and standardized neuropsychological outcome measures. This approach might identify otherwise unnoticed treatment effects in future interventional studies of aSAH patients.

Delayed cerebral ischemia predicts neurocognitive impairment following aneurysmal subarachnoid hemorrhage.

BACKGROUND: Prior studies have shown that the incidence of neuropsychological deficits (NPDs) after aneurysmal subarachnoid hemorrhage (aSAH) is high despite excellent outcome according to neurologic grading scales. Delayed cerebral ischemia (DCI) occurs in 30% of patients after aSAH and significantly contributes to the mortality and morbidity of aSAH. We tested the hypothesis that DCI is associated with neuropsychological outcome. METHODS: Files of patients treated between January 2009 and August 2012 at 2 neurovascular centers were reviewed. Neuropsychological outcome was assessed in a face-to-face-interview of 2-2.5 hours' duration and graded as no (regular), minimal, moderate, or severe deficit according to normative population data by an experienced, independent neuropsychologist. The test battery was applied with consideration of the patients' individual premorbid level of workload and social activities and accounted for the following cognitive domains: memory, attention, executive function, visual and spatial perception, language and calculation, and behavior. RESULTS: Of 226 patients treated at 2 centers, 187 were discharged alive. Full neuropsychological outcome assessment was available in 92 patients. DCI developed in 28 (30.4%) patients; 24 of these patients (85.7%) showed moderate to severe NPD. From a univariate perspective, patients with DCI were 6.38 times as likely to experience moderate to severe NPD after aSAH as patients without DCI (odds ratio [OR]; 95% confidence interval [CI], 1.98-20.50; P = 0.002), which remained statistically significant after correction for admission World Federation of Neurological Surgeons Grading System and Fisher scores, patient age, hydrocephalus, and further potential confounders (OR, 4.9; 95% CI, 1.26-19.58; P = 0.022). Of all factors analyzed, DCI was the strongest predictor of NPD in the multivariate analysis, followed by chronic hydrocephalus (OR, 4.85; 95% CI, 1.26-18.63; P = 0.022) and patient age ≥ 50 years (OR, 4.06; 95% CI, 1.39-11.92; P = 0.001). CONCLUSIONS: Patients with evidence of DCI during their hospital course have a 5-fold increased risk of experiencing moderate to severe NPD compared with patients who do not develop DCI after aSAH. Secondary events occurring during acute hospitalization (DCI, hydrocephalus) may be more important to the overall neuropsychological outcome than hemorrhage (Fisher) and clinical severity (World Federation of Neurological Surgeons Grading System) scores at admission.