Microstructural White Matter Abnormalities and Cognitive Impairment After Aneurysmal Subarachnoid Hemorrhage.

Background and Purpose- Aneurysmal subarachnoid hemorrhage (aSAH) may have detrimental effects on white matter microstructure, which may in turn explain the cognitive impairments that occur often after aSAH. We investigated (1) whether the white matter microstructure is altered in patients with aSAH compared with patients with an unruptured intracranial aneurysm and (2) whether these abnormalities are associated with cognitive impairment 3 months after ictus. Methods- Forty-nine patients with aSAH and 22 patients with an unruptured intracranial aneurysm underwent 3T brain magnetic resonance imaging, including a high-resolution diffusion tensor imaging sequence. Patients with aSAH were scanned 2 weeks and 6 months after ictus. Microstructural white matter alterations were quantified by the fractional anisotropy and mean diffusivity (MD). Cognition was evaluated 3 months after ictus. Results- Patients with aSAH had higher white matter MD 2 weeks after ictus than patients with an unruptured intracranial aneurysm (mean difference±SEM, 0.3±0.01×10-3 mm2/s; P≤0.01), reflecting an abnormal microstructure. After 6 months, the MD had returned to the level of the unruptured intracranial aneurysm group. No between-group differences in fractional anisotropy were found (-0.01±0.01; P=0.16). Higher MD at 2 weeks was associated with cognitive impairment after 3 months (odds ratio per SD increase in MD, 2.6; 95% CI, 1.1-6.7). The association between MD and cognitive impairment was independent of conventional imaging markers of aSAH-related brain injury (ie, cerebral infarction, hydrocephalus, total amount of subarachnoid blood, total brain volume, or white matter hyperintensity severity). Conclusions- Patients with aSAH have temporary white matter abnormalities in the subacute phase that are associated with cognitive impairment at 3 months after ictus.

Patients With and Without COVID-19 in the Intensive Care Unit: Physical Status Outcome Comparisons 3 Months After Discharge.

OBJECTIVE: Many patients with coronavirus disease 2019 (COVID-19) infections were admitted to an intensive care unit (ICU). Physical impairments are common after ICU stays and are associated with clinical and patient characteristics. To date, it is unknown if physical functioning and health status are comparable between patients in the ICU with COVID-19 and patients in the ICU without COVID-19 3 months after ICU discharge. The primary objective of this study was to compare handgrip strength, physical functioning, and health status between patients in the ICU with COVID-19 and patients in the ICU without COVID-19 3 months after ICU discharge. The second objective was to identify factors associated with physical functioning and health status in patients in the ICU with COVID-19. METHODS: In this observational, retrospective chart review study, handgrip strength (handheld dynamometer), physical functioning (Patient-Reported Outcomes Measurement Information System Physical Function), and health status (EuroQol 5 Dimension 5 Level) were compared between patients in the ICU with COVID-19 and patients in the ICU without COVID-19 using linear regression. Multilinear regression analyses were used to investigate whether age, sex, body mass index, comorbidities in medical history (Charlson Comorbidity Index), and premorbid function illness (Identification of Seniors At Risk-Hospitalized Patients) were associated with these parameters in patients in the ICU with COVID-19. RESULTS: In total, 183 patients (N = 92 with COVID-19) were included. No significant between-group differences were found in handgrip strength, physical functioning, and health status 3 months after ICU discharge. The multilinear regression analyses showed a significant association between sex and physical functioning in the COVID-19 group, with better physical functioning in men compared with women. CONCLUSION: Current findings suggest that handgrip strength, physical functioning, and health status are comparable for patients who were in the ICU with COVID-19 and patients who were in the ICU without COVID-19 3 months after ICU discharge. IMPACT: Aftercare in primary or secondary care in the physical domain of postintensive care syndrome after ICU discharge in patients with COVID-19 and in patients without COVID-19 who had an ICU length of stay >48 hours is recommended. LAY SUMMARY: Patients who were in the ICU with and without COVID-19 had a lower physical status and health status than healthy people, thus requiring personalized physical rehabilitation. Outpatient aftercare is recommended for patients with an ICU length of stay >48 hours, and functional assessment is recommended 3 months after hospital discharge.

Mental, cognitive and physical outcomes after intensive care unit treatment during the COVID-19 pandemic: a comparison between COVID-19 and non-COVID-19 patients.

To compare mental, cognitive and physical outcomes between COVID-19 and non-COVID-19 patients, 3-6 months after Intensive Care Unit (ICU) treatment during the COVID-19 pandemic and to compare mental outcomes between relatives of these patients. This retrospective cohort study included 209 ICU survivors (141 COVID-19 patients and 68 non-COVID-19 patients) and 168 of their relatives (maximum one per patient) during the COVID-19 pandemic. Primary outcomes were self-reported occurrence of mental, cognitive and/or physical symptoms 3-6 months after ICU discharge. The occurrence of mental symptoms did not differ between former COVID-19 patients (34.7% [43/124]) and non-COVID-19 patients (43.5% [27/62]) (p = 0.309), neither between relatives of COVID-19 patients (37.6% [38/101]) and relatives of non-COVID-19 patients (39.6% [21/53]) (p = 0.946). Depression scores on the Hospital Anxiety and Depression Scale were lower in former COVID-19 patients, compared to non-COVID-19 patients (p = 0.025). We found no differences between COVID-19 and non-COVID-19 patients in cognitive and physical outcomes. Mental, cognitive and physical outcomes in COVID-19 ICU survivors were similar to non-COVID-19 ICU survivors. Mental symptoms in relatives of COVID-19 ICU survivors did not differ from relatives of non-COVID-19 ICU survivors, within the same time frame.

Long-term health-related quality of life after aneurysmal subarachnoid hemorrhage: relationship with psychological symptoms and personality characteristics.

BACKGROUND AND PURPOSE: Many patients who survive an aneurysmal subarachnoid hemorrhage experience decreased health-related quality of life (HRQoL). Physical factors have been identified as determinants of HRQoL. We describe long-term HRQoL and assessed whether psychological symptoms and personality characteristics determine HRQoL after subarachnoid hemorrhage. METHODS: In a cross-sectional study in 141 patients living independently in the community 2 to 4 years after subarachnoid hemorrhage, we assessed whether HRQoL, evaluated by the Stroke Specific Quality of Life scale, was related to psychological symptoms (mood disorders, fatigue, and cognitive complaints), personality characteristics (neuroticism and passive coping style), demographic characteristics, and subarachnoid hemorrhage disease characteristics. RESULTS: Best Stroke Specific Quality of Life scale scores were found in the physical domain and worst in the emotional and social domains. Thirty-two percent reported anxiety, 23% depression, and 67% fatigue. Mood (beta between -0.42 and -0.18), fatigue (beta between -0.40 and -0.24), and cognitive complaints (beta between -0.46 and -0.16) were strongly associated with Stroke Specific Quality of Life scale scores in multivariate regression analyses. CONCLUSIONS: Depression, anxiety, and fatigue were present in a substantial proportion of patients and were strongly related to decreased HRQoL. These symptoms identified are helpful to tailor rehabilitation to the needs of patients in the chronic phase after subarachnoid hemorrhage.

Utrecht Pediatric Wheelchair Mobility Skills Test: Reliability, Validity, and Responsiveness in Youths Using a Manual Wheelchair.

BACKGROUND: The assessment of wheelchair mobility skills (WMS) in youths using a manual wheelchair is important. More information is needed regarding the psychometric properties of the newly developed Utrecht Pediatric Wheelchair Mobility Skills Test (UP-WMST). OBJECTIVE: The purpose of this study was to evaluate the reliability, content validity, construct validity, and responsiveness of the UP-WMST 2.0 in youths using a manual wheelchair. DESIGN: This was a repeated-measurements, cross-sectional study. METHODS: A total of 117 children and adolescents who use a manual wheelchair participated in this study. The UP-WMST 2.0 contains the same 15 WMS items as the original UP-WMST but has an adaptation of the scoring method. Test-retest reliability was estimated in 30 participants. Content validity was assessed through floor and ceiling effect analyses. Construct validity was assessed through hypothesis testing. Preliminary estimates of responsiveness were assessed in 23 participants who participated in a WMS training program. RESULTS: Test-retest reliability analysis showed weighted Cohen kappa coefficients ranging from 0.63 to 0.98 for all but 1 item. The total UP-WMST 2.0 score had an intraclass correlation coefficient of 0.97. No floor or ceiling effects were detected. Independent-sample t test analysis confirmed our hypotheses regarding direction and difference in scores between age and diagnostic groups. Within-group analysis in the responsiveness study showed a positive significant change in UP-WMST 2.0 score (8.3 points). LIMITATIONS: The small sample size used in the responsiveness study was a limitation of this study. CONCLUSIONS: This study provided evidence of the test-retest reliability, content, and construct validity of the UP-WMST 2.0. It also provided initial evidence of the responsiveness of the UP-WMST 2.0 for measuring change in WMS in youths using a manual wheelchair.

The Effect of Noninvasive Brain Stimulation on Poststroke Cognitive Function: A Systematic Review.

INTRODUCTION: Cognitive impairment after stroke has been associated with lower quality of life and independence in the long run, stressing the need for methods that target impairment for cognitive rehabilitation. The use of noninvasive brain stimulation (NIBS) on recovery of language functions is well documented, yet the effects of NIBS on other cognitive domains remain largely unknown. Therefore, we conducted a systematic review that evaluates the effects of different stimulation techniques on domain-specific (long-term) cognitive recovery after stroke. METHODS: Three databases (PubMed, EMBASE, and PsycINFO) were searched for articles (in English) on the effects of NIBS on cognitive domains, published up to January 2018. RESULTS: A total of 40 articles were included: randomized controlled trials (n = 21), studies with a crossover design (n = 9), case studies (n = 6), and studies with a mixed design (n = 4). Most studies tested effects on neglect (n = 25). The majority of the studies revealed treatment effects on at least 1 time point poststroke, in at least 1 cognitive domain. Studies varied highly on the factors time poststroke, number of treatment sessions, and stimulation protocols. Outcome measures were generally limited to a few cognitive tests. CONCLUSION: Our review suggests that NIBS is able to alleviate neglect after stroke. However, the results are still inconclusive and preliminary for the effect of NIBS on other cognitive domains. A standardized core set of outcome measures of cognition, also at the level of daily life activities and participation, and international agreement on treatment protocols, could lead to better evaluation of the efficacy of NIBS and comparisons between studies.

Subjective hearing impairment after subarachnoid haemorrhage: Prevalence and risk factors.

BACKGROUND: Sensorineural hearing impairment is a key symptom in patients with superficial siderosis of the central nervous system, a disease caused by chronic or intermittent haemorrhage into the subarachnoid space. We investigated the prevalence and risk factors of subjective hearing impairment after SAH. METHODS: We systematically interviewed all SAH patients admitted between June 2011 and December 2014, who were able to visit the SAH outpatient clinic six to eight weeks after hospital discharge. We calculated the proportion of patients with subjective hearing impairment noticed after SAH onset, and adjusted risk ratios (aRR) with 95% confidence intervals (CI) for potential risk factors with Poisson regression. RESULTS: We included 277 patients. Subjective hearing impairment was reported by 54/277 (19%) patients (aneurysmal SAH: 42/212 [20%;95%CI:15-26%]; perimesencephalic haemorrhage 8/36 [22%;95%CI:12-38%], non-aneurysmal non-perimesencephalic SAH: 4/29 [14%;95%CI:6-31%]). Hearing impairment was associated with a poor clinical condition on admission (defined as PAASH score 4-5) (aRR3.00;95%CI:1.43-6.28), aneurysm rupture at the middle cerebral artery (aRR2.72;95%CI:1.38-5.39), and moderate/severe disability 3months after ictus (aRR2.25;95%CI:1.28-3.97), but not with large amounts of extravasated blood (highest vs. lowest tertile of Hijdra score) (aRR0.77;95%CI:0.33-1.81) or endovascular treatment (aRR1.19;95%CI:0.61-2.33). CONCLUSION: Subjective hearing impairment occurs in 1 of every 5 SAH patients. It is related to the clinical condition on admission, aneurysm rupture at the middle cerebral artery, and functional outcome, but not to the amount of subarachnoid blood or the method of aneurysm occlusion. Audiometric tests, auditory cognitive assessments, and follow-up studies are needed to determine the cause and prognosis of hearing impairment after SAH.

A comparison of 3 generic health status questionnaires among stroke patients.

Several generic multidimensional health status questionnaires are available, but it is not clear whether or not these measures are interchangeable in terms of content. Consequently, we investigated the content validity of the Sickness Impact Profile 68 (SIP68), Medical Outcome Study Short Form 36 (SF-36), and the Darmouth COOP Functional Health Assessment Charts/World Organization of National Colleges, Academies and Academic Associations of General Practitioners/Family Physicians (COOP/WONCA) charts. A total of 198 stroke patients referred to inpatient rehabilitation were interviewed 1 year poststroke. Subscales of the generic questionnaires were compared with one another and also with 3 domain-specific scales: the Barthel Index (BI) for physical functioning, the Center of Epidemiology Studies Depression (CES-D) scale for mental functioning, and the Frenchay Activities Index (FAI) for social functioning. Nonparametric Spearman correlations of at least 0.6 were accepted as evidence of content validity. Half of the physical subscales correlated with each other by at least 0.6. None of the 3 correlations in the mental domain and only 1 of 21 correlations in the social domain met the 0.6 threshold. Physical-oriented subscales correlated with BI almost as expected. In the mental domain, only the correlation of the CES-D with the SF-36 mental health scale was above 0.6, and in the social domain, only the correlation of the FAI with the SIP68 mobility range was above 0.6. The findings of this study suggest that generic health questionnaires are not mutually interchangeable. Physical and social health status of stroke patients is adequately covered by the SIP68. However, the SF-36 is more suitable for measuring the mental consequences of stroke.

Functional outcome and quality of life 5 and 12.5 years after aneurysmal subarachnoid haemorrhage.

Patients who recover from aneurysmal subarachnoid haemorrhage (SAH) often remain disabled or have persisting symptoms with a reduced quality of life (QoL). We assessed functional outcome and QoL 5 and 12.5 years after SAH. In a consecutive series of 64 patients with mean age at SAH of 51 years, initial outcome assessments had been performed at 4 and 18 months after SAH. At the initial and current outcome assessments, functional outcome was measured with the modified Rankin Scale (mRS) and QoL with the SF-36 and a visual analogue scale (VAS). We studied the change in outcome measurements over time. We used the non-parametric Wilcoxon test to compare differences in mRS grades and calculated differences with corresponding 95% confidence intervals in the domain scores of the SF-36 and the VAS. After 5 years, seven patients had died and five patients had missing data. Compared with the 4-month follow-up, the mRS had improved in 29 of the 52 patients, remained similar in 19 patients. The overall QoL (SF-36 domains and VAS score) was better. At 12.5 years an additional six patients had died. Compared to the 4-month study, 25 of the 46 remaining patients had improved mRS, 12 had remained the same and in nine patients the mRS had worsened. Between the 5 and the 12.5 years follow-up, the improvement in mRS had decreased but patients reported overall a better QoL. Among long-time survivors, QoL may improve more than a decade after SAH.

Spouses' satisfaction with caregiver support in stroke rehabilitation.

OBJECTIVE: To examine the satisfaction of spouses of stroke patients with the support given to them during clinical rehabilitation and to explore the relationships between satisfaction and characteristics of the support received. METHODS: Spouses of patients with a first-ever supratentorial stroke were included (n = 194). Satisfaction was measured on a 0-10 scale. Bivariate and multivariate relationships were studied between overall satisfaction score and characteristics of the support provided (number of full days of attendance, participation in caregiver group, discipline providing most support), the spouses (age, gender, family situation, education and employment) and the patients (activity of daily living (ADL) dependency (Functional Independence Measure), length of stay). RESULTS: The median satisfaction score was 7, and 44% of all spouses scored >or=8 (very satisfied) but 23% were dissatisfied. Spouses' and patients' characteristics and satisfaction scores were not associated. Of the support characteristics the number of full days of attendance (p = 0.02), participation in a caregiver group (p = 0.006) and support received from a team member (p = 0.000) were related to satisfaction. No differences in spouses' satisfaction scores were found between the participating rehabilitation centres. Only 39% of the spouses participated in a caregiver group. The most important reason for not participating in such a group was not being aware of the opportunity to take part in a group (49%). Spouses participating in a group showed more depressive symptoms and had a more severely disabled partner. Caregiver support was primarily given by the nurse and the social worker. One in five spouses indicated not to have been supported at all by the rehabilitation team. CONCLUSION: A large proportion of the caregivers were satisfied with the care they had received, although one in four was dissatisfied. Satisfaction was related to support characteristics.

Measures used to assess burden among caregivers of stroke patients: a review.

OBJECTIVE: To describe measures used to evaluate the burden of caregiving experienced by caregivers of stroke patients and their clinimetric properties. DESIGN: A review of the literature was conducted to examine burden scales with regard to concept, feasibility, internal consistency, validity, reliability and responsiveness. RESULTS: The literature search resulted in 45 measures of caregiver outcomes, including 16 different measures of caregiver burden. About half of the scales were used only once and were not further described. Nearly all instruments measure the various dimensions of burden (competency, negative feelings, social relations, participation problems, physical and mental health and economic aspects), but not in the same proportions. Most measures showed good internal consistency, and validity was demonstrated for all measures except one. However, not much is known about the reliability and responsiveness of these measures. CONCLUSIONS: No measure has proven superiority above others. Future research should focus on comparisons between existing instruments and on their reliability and responsiveness.