Long-Term Complications and Influence on Outcome in Patients Surviving Spontaneous Subarachnoid Hemorrhage.

BACKGROUND: While the short-term clinical outcome of patients with subarachnoid hemorrhage (SAH) is well described, there are limited data on long-term complications and their impact on social reintegration. This study aimed to assess the frequency of complications post-SAH and to investigate whether these complications attribute to functional and self-reported outcomes as well as the ability to return to work in these patients. METHODS: This retrospective single-center study included patients with atraumatic SAH over a 5-year period at a tertiary care center. Patients received a clinical follow-up for 12 months. In addition to demographics, imaging data, and parameters of acute treatment, the rate and extent of long-term complications after SAH were recorded. The functional outcome was assessed using the modified Rankin Scale (mRS; favorable outcome defined as mRS = 0-2). Further outcomes comprised self-reported subjective health measured by the EQ-5D and return to work for SAH patients with appropriate age. Multivariable analyses including in-hospital parameters and long-term complications were conducted to identify parameters independently associated with outcomes in SAH survivors. RESULTS: This study cohort consisted of 505 SAH patients of whom 405 survived the follow-up period of 12 months (i.e., mortality rate of 19.8%). Outcome data were available in 359/405 (88.6%) patients surviving SAH. At 12 months, a favorable functional outcome was achieved in 287/359 (79.9%) and 145/251 (57.8%) SAH patients returned to work. The rates of post-acute complications were headache (32.3%), chronic hydrocephalus requiring permanent ventriculoperitoneal shunting (VP shunt 25.4%) and epileptic seizures (9.5%). Despite patient's and clinical characteristics, both presence of epilepsy and need for VP shunt were independently and negatively associated with a favorable functional outcome (epilepsy: adjusted odds ratio [aOR] (95% confidence interval [95% CI]): 0.125 [0.050-0.315]; VP shunt: 0.279 [0.132-0.588]; both p < 0.001) as well as with return to work (aOR [95% CI]: epilepsy 0.195 [0.065-0.584], p = 0.003; VP shunt 0.412 [0.188-0.903], p = 0.027). Multivariable analyses revealed presence of headache, VP shunt, or epilepsy to be significantly related to subjective health impairment (aOR [95% CI]: headache 0.248 [0.143-0.430]; epilepsy 0.223 [0.085-0.585]; VP shunt 0.434 [0.231-0.816]; all p < 0.01). CONCLUSIONS: Long-term complications occur frequently after SAH and are associated with an impairment of functional and social outcomes. Further studies are warranted to investigate if treatment strategies specifically targeting these complications, including preventive aspects, may improve the outcomes after SAH.

Treating Patients with Frontal Neurocognitive Deficits After SAH and Stroke.

Five frontal systems circuits connect with the basal ganglia and other structures to control and regulate thinking and behavior. Subarachnoid hemorrhage and stroke following anterior circulation aneurysms typically disrupt these circuits, sometimes markedly affecting a patient's function. This article reviews the primary pathways and associated brain functions. The principles of cognitively and behaviorally rehabilitating these functions are also discussed by creating external structure and building on what the brain is still capable of doing.

Safety and Feasibility of Early Mobilization in Patients with Subarachnoid Hemorrhage and External Ventricular Drain.

BACKGROUND/OBJECTIVE: In November 2014, our Neurointensive Care Unit began a multi-phased progressive early mobilization initiative for patients with subarachnoid hemorrhage and an external ventricular drain (EVD). Our goal was to transition from a culture of complete bed rest (Phase 0) to a physical and occupational therapy (PT/OT)-guided mobilization protocol (Phase I), and ultimately to a nurse-driven mobilization protocol (Phase II). We hypothesized that nurses could mobilize patients as safely as an exclusively PT/OT-guided approach. METHODS: In Phase I, patients were mobilized only with PT/OT at bedside; no independent time out of bed occurred. In Phase II, nurses independently mobilized patients with EVDs, and patients could remain out of bed for up to 3 h at a time. Physical and occupational therapists continued routine consultation during Phase II. RESULTS: Phase II patients were mobilized more frequently than Phase I patients [7.1 times per ICU stay (± 4.37) versus 3.0 times (± 1.33); p = 0.02], although not earlier [day 4.9 (± 3.46) versus day 6.0 (± 3.16); p = 0.32]. All Phase II patients were discharged to home PT services or acute rehabilitation centers. No patients were discharged to skilled nursing or long-term acute care hospitals, versus 12.5% in Phase I. In a multivariate analysis, odds of discharge to home/rehab were 3.83 for mobilized patients, independent of age and severity of illness. Other quality outcomes (length of stay, ventilator days, tracheostomy placement) between Phase I and Phase II patients were similar. No adverse events were attributable to early mobilization. CONCLUSIONS: Nurse-driven mobilization for patients with EVDs is safe, feasible, and leads to more frequent ambulation compared to a therapy-driven protocol. Nurse-driven mobilization may be associated with improved discharge disposition, although exact causation cannot be determined by these data.

Common Data Elements for Unruptured Intracranial Aneurysm and Subarachnoid Hemorrhage Clinical Research: Recommendations from the Working Group on Long-Term Therapies.

OBJECTIVES: The goal for the long-term therapies (LTT) working group (WG) of the Unruptured Intracranial Aneurysm (UIA) and Subarachnoid Hemorrhage (SAH) common data elements (CDEs) was to develop a comprehensive set of CDEs, data definitions, case report forms, and guidelines for use in UIA and SAH LTT clinical research, as part of a new joint effort between the National Institute of Neurological Disorders and Stroke (NINDS) and the National Library of Medicine of the US National Institutes of Health. These UIA and SAH CDEs will join other neurological disease-specific CDEs already developed and available for use by research investigators. METHODS: The eight LTT WG members comprised international UIA, and SAH experts reviewed existing NINDS CDEs and instruments, created new elements when needed, and provided recommendations for future LTT clinical research. The recommendations were compiled, internally reviewed by the all UIA and SAH WGs and steering committee members. The NINDS CDE team also reviewed the final version before posting the SAH Version 1.0 CDE recommendations on the NINDS CDE website. RESULTS: The NINDS UIA and SAH LTT CDEs and supporting documents are publicly available on the NINDS CDE ( https://www.commondataelements.ninds.nih.gov/#page=Default ) and NIH Repository ( https://cde.nlm.nih.gov/home ) websites. The subcommittee members discussed and reviewed various parameters, outcomes, and endpoints in UIA and SAH LTT studies. The following meetings with WG members, the LTT WG's recommendations are incorporated into the disease/injury-related events, assessments and examinations, and treatment/intervention data domains. CONCLUSIONS: Noting gaps in the literature regarding medication and rehabilitation parameters in UIA and SAH clinical studies, the current CDE recommendations aim to arouse interest to explore the impact of medication and rehabilitation treatments and therapies and encourage the convergence of LTT clinical study parameters to develop a harmonized standard.

Early Progressive Mobilization of Patients with External Ventricular Drains: Safety and Feasibility.

BACKGROUND/OBJECTIVE: Early mobilization of critically ill patients has been shown to improve functional outcomes. Neurosurgery patients with an external ventricular drain (EVD) due to increased intracranial pressure often remain on bed rest while EVD remains in place. The prevalence of mobilizing patients with EVD has not been described, and the literature regarding the safety and feasibility of mobilizing patients with EVDs is limited. The aim of our study was to describe the outcomes and adverse events of the first mobilization attempt in neurosurgery patients with EVD who participated in early functional mobilization with physical therapy or occupational therapy. METHODS: We performed a single-site, retrospective chart review of 153 patients who underwent placement of an EVD. Hemodynamically stable patients deemed appropriate for mobilization by physical or occupational therapy were included. Mobilization and activity details were recorded. RESULTS: The most common principal diagnoses were subarachnoid hemorrhage (61.4%) and intracerebral hemorrhage (17.0%) requiring EVD for symptomatic hydrocephalus. A total of 117 patients were mobilized (76.5%), and the median time to first mobilization after EVD placement in this group of 117 patients was 38 h. Decreased level of consciousness was the most common reason for lack of mobilization. The highest level of mobility on the patient's first attempt was ambulation (43.6%), followed by sitting on the side of the bed (30.8%), transferring to a bedside chair (17.1%), and standing up from the side of the bed (8.5%). No major safety events, such as EVD dislodgment, occurred in any patient. Transient adverse events with mobilization were infrequent at 6.9% and had no permanent neurological sequelae and were mostly headache, nausea, and transient diastolic blood pressure elevation. CONCLUSION: Early progressive mobilization of neurosurgical intensive care unit patients with external ventricular drains appears safe and feasible.

Psychosocial Comorbidities Related to Return to Work Rates Following Aneurysmal Subarachnoid Hemorrhage.

Purpose Ability to return to work (RTW) after stroke has been shown to have positive psychosocial benefits on survivors. Although one-fifth of aneurysmal subarachnoid hemorrhage (aSAH) survivors suffer from poor psychosocial outcomes, the relationship between such outcomes and RTW post-stroke is not clear. This project explores the relationship between age, gender, race, marital status, anxiety and depression and RTW 3 and 12 months post-aSAH. Methods Demographic and clinical variables were collected from the electronic medical record at the time of aSAH admission. Anxiety and depression were assessed at 3 and 12 months post-aSAH using the State Trait Anxiety Inventory (STAI) and Beck's Depression Inventory-II (BDI-II) in 121 subjects. RTW for previously employed patients was dichotomized into yes/no at their 3 or 12 month follow-up appointment. Results Older age was significantly associated with failure to RTW at 3 and 12 months post-aSAH (p = 0.003 and 0.011, respectively). Female gender showed a trending but nonsignificant relationship with RTW at 12 months (p = 0.081). High scores of depression, State anxiety, and Trait anxiety all had significant associations with failure to RTW 12 months post-aSAH (0.007 ≤ p ≤ 0.048). At 3 months, there was a significant interaction between older age and high State or Trait anxiety with failure to RTW 12 months post-aSAH (p = 0.025, 0.042 respectively). Conclusions Patients who are older and suffer from poor psychological outcomes are at an increased risk of failing to RTW 1-year post-aSAH. Our interactive results give us information about which patients should be streamlined for therapy to target their psychosocial needs.

Predictors for Functional Outcome in Patients with Aneurysmal Subarachnoid Hemorrhage Who Completed In-Hospital Rehabilitation in a Single Institution.

BACKGROUND: Although many studies evaluated independent prognosis factors of functional outcome in patients with subarachnoid hemorrhage (SAH) at a suitable time point, some patients take a long time to get functional improvement. The purpose of this study is to evaluate predictors for functional outcome in SAH patients who underwent surgical clipping and in-hospital rehabilitation in our single institution using Modified Rankin Scale (MRS) and Barthel Index (BI). METHODS: Two-hundred fifty-one SAH patients were admitted to our hospital from January 2008 to December 2017. Of them, 144 patients who diagnosed aneurysmal SAH, underwent surgical clipping within 72 hours, and completed subsequent in-hospital rehabilitation were included in this study. We explored their clinical variables and evaluated the relationships between those factors and functional outcome using MRS and BI. RESULTS: In multivariate analysis, independent prognostic factors of both MRS and BI were age, World Federation of Neurologic Surgeons grade, and symptomatic vasospasm. CONCLUSIONS: We suggest that age, SAH severity, and symptomatic vasospasm are associated with functional outcome in patients with aneurysmal SAH who completed surgical clipping and in-hospital rehabilitation.

Early Ambulation in Patients With External Ventricular Drains: Results of a Quality Improvement Project.

INTRODUCTION: Prolonged immobility in patients in the intensive care unit (ICU) can lead to muscle wasting and weakness, longer hospital stays, increased number of days in restraints, and hospital-acquired infections. Increasing evidence demonstrates the safety and feasibility of early mobilization in the ICU. However, there is a lack of evidence in the safety and feasibility of mobilizing patients with external ventricular drains (EVDs). The purpose of this study was to determine the safety and feasibility of early mobility in this patient population. METHODS: We conducted a prospective, observational study. All patients in the study were managed with standard protocols and procedures practiced in our ICU including early mobility. Patients with an EVD who received early mobilization were awake and following commands, had a Lindegaard ratio <3.0 or middle cerebral artery (MCA) mean flow velocity <120 cm/s, a Mean Arterial Pressure (MAP) > 80 mm Hg, and an intracranial pressure consistently <20 mm Hg. Data were collected by physical therapists at the time of encounter. RESULTS: Ninety patients with a total of 185 patient encounters were recorded over a 12-month period. The average time between EVD placement and physical therapy (PT) session was 8.3 ± 5.5 days. In 149 (81%) encounters, patients were at least standing or better. Patients were walking with assistance or better in 99 (54%) encounters. There were 4 (2.2%) adverse events recorded during the entire study. CONCLUSION: This observational study suggests that PT is feasible in patients with EVDs and can be safely tolerated. Further research is warranted in a larger patient population conducted prospectively to assess the potential benefit of early mobility in this patient population.

The effect of time on cognitive impairments after non-traumatic subarachnoid haemorrhage and after traumatic brain injury.

OBJECTIVES: To compare the effect of time on cognitive impairments after Subarachnoid Haemorrhage and Traumatic Brain Injury and explore associations with baseline variables and global function. METHODS: Patients with a Glasgow Coma Scale score of 3-13, were assessed at 3, 6 and 12 months post injury by use of BNIS for cognitive impairment, RLAS-R to categorise cognitive and behavioural function, Barthel Index to assess performance of daily living, HADS to screen for depression and anxiety, and EuroQoL-5D, LiSat-11 and Glasgow Outcome Scale Extended to assess global function. RESULTS: BNIS T-scores did not differ significantly between groups and the proportion of patients with cognitive impairments was not significantly different at any time point. Cognition improved significantly between all time points in both groups except from 6 to 12 months after TBI. Generalised estimating equation showed non-significant signs of slower recovery of BNIS T-scores over time after SAH. Acute GCS scores were associated with BNIS T-scores after TBI but not after SAH. At 12 months, similar proportions of patients with SAH and TBI had good outcome. CONCLUSIONS: Cognitive improvements after SAH and TBI exhibit similarities and correlate with global function. GCS scores are associated with outcome after TBI but not after SAH.

Injury of the Precommissural Fornix in a Patient with Subarachnoid Hemorrhage: A Case Report.

OBJECTIVES: We investigated injury of the pre- or postcommissural fornix in a patient with subarachnoid hemorrhage (SAH) using diffusion tensor imaging. CASE DESCRIPTION: A 48-year-old male patient was diagnosed as SAH due to rupture of the right middle cerebral artery bifurcation aneurysm. After 9 weeks from onset, he was transferred to the rehabilitation department and he showed memory impairment. The whole fornix was reconstructed using single-tract fornix model based on a fiber assignment by continuous tracking, and separated fornices (pre- and postcommissural fornices) were reconstructed using 2-tract fornix model based on a probabilistic tractography method. The fractional anisotropy (FA), mean diffusivity, and fiber volume were measured in the patient and 6 normal control subjects. The integrities of both reconstructed whole fornices that were reconstructed using probabilistic tractography method were preserved. By contrast, in the results of 2-tract fornix model, the precommissural fornices showed discontinuations in both fornical cruses. In addition, the FA and fiber volume of both precommissural fornices in the patient were decreased by more than 2 standard deviations of those of normal control subjects. CONCLUSIONS: Separate evaluations of the pre- and postcommissural fornices using 2-tract fornix model would be useful for diagnosis in patients with memory impairment following SAH.

Functional Independence: A Comparison of the Changes During Neurorehabilitation Between Patients With Nontraumatic Subarachnoid Hemorrhage and Patients With Intracerebral Hemorrhage or Acute Ischemic Stroke.

OBJECTIVE: To compare the changes in functional independence measured by the FIM after specialized neurorehabilitation between patients with nontraumatic subarachnoid hemorrhage (SAH) and patients with intracerebral hemorrhage (ICH) or acute ischemic stroke (AIS). DESIGN: Historical cohort study comparing changes in functional independence between patients with nontraumatic SAH and those with ICH/AIS, using FIM scores from a local database and clinical information from the Danish National Patient Registry. SETTING: Postacute specialized inpatient neurorehabilitation. PARTICIPANTS: Participants (N=660) comprised patients with a first-time nontraumatic SAH (n=212) and age-matched patients with a first-time ICH/AIS (n=448). INTERVENTIONS: Not applicable. MAIN OUTCOME MEASURES: Crude and adjusted comparisons of FIM (total and item by item) measured at baseline and at discharge. RESULTS: Patients with nontraumatic SAH were admitted with a lower functional level compared with patients with ICH/AIS (median total FIM score, 25 [interquartile range (IQR), 18-81] vs 78.5 [IQR, 47-107]), and discharged with a lower functional level (median total FIM score, 98 [IQR, 40-116] vs 110 [IQR, 82.5-119]), although they made more progress during neurorehabilitation (median change in total FIM score, 27 [IQR, 4-60] vs 17 [IQR, 7-35]). Statistically, patients with nontraumatic SAH had significantly better odds for obtaining functional independence than did patients with ICH/AIS in 6 of the 18 FIM items: eating (odds ratio [OR]=3.2; 95% confidence interval [CI], 1.7-5.8); dressing-upper body (OR=2.0; 95% CI, 1.1-3.5); transfer tub/shower (OR=2.0; 95% CI, 1.1-3.6); stair walking (OR=2.2; 95% CI, 1.3-3.7); comprehension (OR=2.3; 95% CI, 1.3-3.9); and expression (OR=3.6; 95% CI, 2.0-6.5). CONCLUSIONS: Patients with nontraumatic SAH made significantly more progress during neurorehabilitation, although they were discharged with a lower level of functional independence compared with patients with ICH/AIS. However, both patients with nontraumatic SAH and those with ICH/AIS improved their functional outcome significantly. Also, patients with nontraumatic SAH admitted with severe functional outcome were shown to be capable of recovering to a moderate level of functional independence.

Course of Participation after Subarachnoid Hemorrhage.

OBJECTIVES: The study aimed to investigate participation problems in patients with subarachnoid hemorrhage (SAH), and the course of participation between 3 and 12 months post-SAH, and to identify determinants of this course. DESIGN: This is a prospective cohort study. SETTING: The study was done in the SAH outpatient clinic at the University Medical Center Utrecht. SUBJECTS: Subjects included patients independent in activities of daily living who visited the SAH outpatient clinic for a routine follow-up visit 3 months after the event. MAIN MEASURES: Participation was assessed using the restrictions scale of the Utrecht Scale for Evaluation of Rehabilitation-Participation at 3, 6, and 12 months post-SAH. Repeated measures analysis of variance was conducted to identify possible determinants of participation (demographic and SAH characteristics, mood, and cognition). RESULTS: One hundred patients were included. Three months after SAH, the most commonly reported restrictions concerned work/unpaid work/education (70.5%), housekeeping (50.0%), and going out (45.2%). Twelve months post-SAH, patients felt most restricted in work/unpaid work/education (24.5%), housekeeping (23.5%), and chores in and around the house (16.3%). Participation scores increased significantly between 3 and 6 months, and between 3 and 12 months, post-SAH. The course of participation was associated with mood, cognition, and gender, but was in the multivariate analysis only determined by mood (F [1, 74] = 18.31, P = .000, partial eta squared: .20), showing lower participation scores at each time point for patients with mood disturbance. CONCLUSIONS: Participation in functionally independent SAH patients improved over time. However, 1 out of 3 patients (34.9%) still reported one or more participation restrictions 12 months post-SAH. Mood disturbance was negatively associated with the course of participation after SAH.

Effect of stress hyperglycemia and intensive rehabilitation therapy in non-diabetic hemorrhagic stroke: Korean Stroke Cohort for Functioning and Rehabilitation.

BACKGROUND AND PURPOSE: We investigated the effect of stress hyperglycemia on the functional outcomes of non-diabetic hemorrhagic stroke. In addition, we investigated the usefulness of intensive rehabilitation for improving functional outcomes in patients with stress hyperglycemia. METHODS: Non-diabetic hemorrhagic stroke patients were recruited and divided into two groups: intracerebral hemorrhage (ICH) (n = 165) and subarachnoid hemorrhage (SAH) (n = 156). Each group was divided into non-diabetics with or without stress hyperglycemia. Functional assessments were performed at 7 days and 3, 6 and 12 months after stroke onset. The non-diabetic with stress hyperglycemia groups were again divided into two groups who either received or did not receive intensive rehabilitation treatment. Serial functional outcome was compared between groups. RESULTS: For the ICH group, patients with stress hyperglycemia had worse modified Rankin Scale, National Institutes of Health Stroke Scale, Functional Ambulatory Category and Korean Mini-Mental State Examination scores than patients without stress hyperglycemia. For the SAH group, patients with stress hyperglycemia had worse scores on all functional assessments than patients without stress hyperglycemia at all time-points. After intensive rehabilitation treatment of patients with stress hyperglycemia, the ICH group had better scores on Functional Ambulatory Category and the SAH group had better scores on all functional assessments than patients without intensive rehabilitation treatment. CONCLUSIONS: Stress hyperglycemia affects the long-term prognosis of non-diabetic hemorrhagic stroke patients. Among stress hyperglycemia patients, intensive rehabilitation can enhance functional improvement after stroke.

Health Related Quality of Life and support needs for sub-arachnoid haemorrhage survivors in New South Wales Australia.

BACKGROUND: Subarachnoid haemorrhage (SAH) is commonly a devastating injury with long lasting physical and psychosocial consequences for survivors. Support after hospital discharge through chronic care services for this patient group is limited. This study aimed to measure Health Related Quality of Life (HRQoL) and needs of survivors after discharge from hospital. METHODS: A population of patients that were diagnosed with SAH were contacted, up to 2 years post discharge, to participate in a postal survey including the Short Stroke Specific Quality of Life Scale (SSQoL-12), a service utilisation questionnaire and attitudes towards participating in a support group. FINDINGS: There were 28 responders. HRQoL was lowest in the psychosocial domain and particularly in relation to fatigue and memory. Most notably many responders indicated they wanted to be interviewed but a support group was not favoured with few responders (n=11) indicating interest with most in favour of a face to face format (n=10). CONCLUSIONS: HRQoL was reduced particularly in the psychosocial domain. Although there was low utilisation of support services in the post-acute care phase, these patients may benefit from greater opportunities to participate in both physical and psychosocial rehabilitation programs.

Dichotomous "Good Outcome" Indicates Mobility More Than Cognitive or Social Quality of Life.

OBJECTIVE: Worthwhile interventions for intracerebral hemorrhage or subarachnoid hemorrhage generally hinge on whether they improve the odds of good outcome. Although good outcome is correlated with mobility, correlations with other domains of health-related quality of life, such as cognitive function and social functioning, are not well described. We tested the hypothesis that good outcome is more closely associated with mobility than other domains. DESIGN: We defined "good outcome" as 0 through 3 (independent ambulation or better) versus 4 through 5 (dependent) on the modified Rankin Scale at 1, 3, and 12 months. We simultaneously assessed the modified Rankin Scale and health-related quality of life using web-based computer adaptive testing in the domains of mobility, cognitive function (executive function and general concerns), and satisfaction with social roles and activities. We compared the area under the curve between different health-related quality of life domains. SETTING: Neurologic ICU with web-based follow-up. PATIENTS: One hundred fourteen patients with subarachnoid hemorrhage or intracerebral hemorrhage. INTERVENTIONS: None. MEASUREMENT AND MAIN RESULTS: We longitudinally followed 114 survivors with data at 1 month, 62 patients at 3 months, and 58 patients at 12 months. At 1 month, area under the curve was highest for mobility (0.957; 95% CI, 0.904-0.98), higher than cognitive function-general concerns (0.819; 95% CI, 0.715-0.888; p = 0.003 compared with mobility), satisfaction with social roles and activities (0.85; 95% CI, 0.753-0.911; p = 0.01 compared with mobility), and cognitive function-executive function (0.879; 95% CI, 0.782-0.935; p = 0.058 compared with mobility). Optimal specificity and sensitivity for receiver operating characteristic analysis were approximately 1.5 SD below the U.S. population mean. CONCLUSIONS: Health-related quality of life assessments reliably distinguished between good and poor outcomes as determined by the modified Rankin Scale. Good outcome indicated health-related quality of life about 1.5 SD below the U.S. population mean. Associations were weaker for cognitive function and social function than mobility.

Leisure and social participation in patients 4-10 years after aneurysmal subarachnoid haemorrhage.

OBJECTIVE: To investigate the long-term resumption of leisure and social activities in patients with aneurysmal subarachnoid haemorrhage (aSAH) and to determine the role of executive dysfunction and aneurysms in anterior brain regions in particular. METHOD: Leisure and social functioning of 200 patients with aSAH having anterior or posterior aneurysms was determined using the Role Resumption List (RRL). Executive functioning was investigated using the Dysexecutive Questionnaire (DEX) and sub-scales Social Convention (SC) and Executive Cognition (EC). Mood, fatigue and cognitive problems were investigated with the Hospital Anxiety and Depression Scale (HADS) and Brain Injury Symptom Checklist (BISC). RESULTS: Of all patients, 46.5% reported complete return to previous leisure activities and 61.5% reported no changes in social interactions. HADS depression score, fatigue, DEX-EC sub-scale score and work status post-aSAH were predictors of leisure resumption. For social re-integration, HADS depression score, cognitive problems and fatigue were predictors. Aneurysm location did not influence leisure and social re-integration. CONCLUSIONS: A substantial number of the patients still experience problems in resuming previous activities in the chronic phase post-aSAH, influenced by cognitive, executive and depressive problems, as well as current work status and fatigue. Aneurysm location does not seem to influence this resumption.

Behavioral Assessment With the Coma Recovery Scale-Revised Is Safe and Feasible in Critically Ill Patients With Disorders of Consciousness.

OBJECTIVES: Accurate classification of disorders of consciousness (DoC) is key in developing rehabilitation plans after brain injury. The Coma Recovery Scale-Revised (CRS-R) is a sensitive measure of consciousness validated in the rehabilitation phase of care. We tested the feasibility, safety, and impact of CRS-R-guided rehabilitation in the ICU for patients with DoC after acute hemorrhagic stroke. DESIGN: Retrospective cohort study. SETTING: This single-center study was conducted in the neurocritical care unit at the University of Maryland Medical Center. PATIENTS: We analyzed records from consecutive patients with subarachnoid hemorrhage (SAH) or intracerebral hemorrhage (ICH), who underwent serial CRS-R assessments during ICU admission from April 1, 2018, to December 31, 2021, where CRS-R less than 8 is vegetative state/unresponsive wakefulness syndrome (VS/UWS); CRS-R greater than or equal to 8 is a minimally conscious state (MCS). INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: Outcomes included adverse events during CRS-R evaluations and associations between CRS-R and discharge disposition, therapy-based function, and mobility. We examined the utility of CRS-R compared with other therapist clinical assessment tools in predicting discharge disposition. Seventy-six patients (22 SAH, 54 ICH, median age = 59, 50% female) underwent 276 CRS-R sessions without adverse events. Discharge to acute rehabilitation occurred in 4.4% versus 41.9% of patients with a final CRS-R less than 8 and CRS-R greater than or equal to 8, respectively (odds ratio [OR] 13.4; 95% CI, 2.7-66.1; p < 0.001). Patients with MCS on final CRS-R completed more therapy sessions during hospitalization and had improved mobility and functional performance. Compared with other therapy assessment tools, the CRS-R had the best performance in predicting discharge disposition (area under the curve: 0.83; 95% CI, 0.72-0.94; p < 0.0001). CONCLUSIONS: Early neurorehabilitation guided by CRS-R appears to be feasible and safe in the ICU following hemorrhagic stroke complicated by DoC and may enhance access to inpatient rehabilitation, with the potential for lasting benefit on recovery. Further research is needed to assess generalizability and understand the impact on long-term outcomes.

Determinants of health-related quality of life after aneurysmal subarachnoid hemorrhage: a systematic review.

BACKGROUND AND PURPOSE: Many persons with subarachnoid hemorrhage (SAH) from a ruptured intracranial aneurysm recover to functional independence but nevertheless experience reduced quality of life (QoL). The aim of this study was to summarize the evidence on determinants of reduced QoL in this diagnostic group. METHODS: Databases PubMed, PsychINFO, and CINAHL were used to identify empirical studies reporting on quantitative relationships between possible determinants and QoL in persons with aneurysmal SAH and published in English. Determinants were classified using the International Classification of Functioning, Disability and Health (ICF). RESULTS: Twenty studies met the inclusion criteria for this review, in which 13 different HRQoL questionnaires were used. Determinants related to Body Structure & Function (clinical condition at admission, fatigue, and disturbed mood), Activity limitations (physical disability and cognitive complaints), and Personal factors (female gender, higher age, neuroticism, and passive coping) are consistently related to worse HRQoL after aneurysmal SAH. Treatment characteristics were not consistently related to HRQoL. CONCLUSION: This study identified a broad range of determinants of HRQoL after aneurysmal SAH. The findings provide clues to tailor multidisciplinary rehabilitation programs. Further research is needed on participation, psychological characteristics, and environmental factors as determinants of HRQoL after SAH.

Acute neurorehabilitation versus treatment as usual.

Several clinical and government reviews have recommended specialised rehabilitation services for those recovering from neurological insult or neurosurgical intervention. Despite this, provision of 'rapid access'/acute neurorehabilitation units is extremely limited in the UK. In some areas, millions of people have no access to such facilities. Numerous articles have indicated that delayed access to neurorehabilitation in the acute recovery stage may worsen clinical outcomes and increase length of stay for patients. However, there has been a lack of studies directly comparing clinical outcomes between matched samples of patients in acute neurorehabilitation units versus patients receiving treatment-as-usual. In a study believed to be the first of its kind, this paper: (A) Describes the rationale and evidence base for acute neurorehabilitation. (B) Provides a comparison of clinical outcome scores Functional Independence Measure/Functional Assessment Measure (FIM-FAM) and also length of stay times for both of the aforementioned groups. The results show that all outcome areas except the 'communication' domain saw clinically and statistically significant improvements in the acute neurorehabilitation group. Length of stay was significantly reduced in the acute neurorehabilitation group. The case for reviewing the provision of acute neurorehabilitation units is now even more urgent and difficult to ignore.

The effect of intraventricular thrombolysis in combination with low-frequency head motion after severe subarachnoid hemorrhage: interim analysis of safety, clot clearance rate and delayed cerebral ischemia.

OBJECTIVE: The current clinical prospective randomized phase II study was initiated in order to analyze the effect of enhanced washout by discontinuous intraventricular thrombolysis in combination with low-frequency head-motion therapy on side effects, clot clearance rate, cerebral vasospasm and clinical outcome after severe subarachnoid hemorrhage (SAH). METHODS: Data from 40 adult patients with aneurysmal SAH were included in this interim analysis. Patients randomized to the study group achieved additional intraventricular application of rt-PA (Actilyse(®)) bolus 5 mg every 12 h and lateral rotational therapy (RotoRest(®)). Clot clearance rate was evaluated based on computed tomography (CT). Delayed cerebral ischemia (DCI) and early clinical outcome of patients were determined. RESULTS: No severe side effects due to the combined therapy were documented. The clot clearance rate was significantly higher in the study group than in the control group regarding the cranial and basal CT slices (p = 0.003 cranial slices and p = 0.037 basal slices). Delayed ischemic neurological deficits (DIND) were increased in the control group (p = 0.016). CONCLUSION: The present study demonstrates that a combination of intraventricular thrombolysis and lateral rotational therapy is not associated with a higher complication rate. Furthermore, the therapy leads to a significant acceleration of the clot clearance rate.