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.

A discussion of the optimal treatment of intracranial aneurysm rupture in elderly patients.

This study aimed to find an optimal treatment for intracranial aneurysm rupture in elderly patients. We adopted endovascular embolization and combined it with mini-invasive aspiration, vascular stenosis stenting, and rehabilitation training to treat 13 elderly patients with intracranial aneurysm rupture. When the 13 patients were discharged and evaluated by the Glasgow Outcome Score (GOS), 7 patients were grade 5, 4 patients were grade 4, and 2 patients were grade 2. We found that a combination of endovascular embolization with mini-invasive aspiration and vascular stenosis stenting allowed us to adapt this treatment to various types of aneurysms. Our approach is especially suitable for elderly patients, because it reduces the occurrence of complications, improves patient prognoses, shortens the duration of hospitalization, and improves the quality of life.

Recovery and quality of life in patients with ruptured cerebral aneurysms.

PURPOSE: Subarachnoid hemorrhage (SAH) secondary to ruptured cerebral aneurysm is a common and frequently devastating condition with a high mortality and morbidity among survivors. The purpose of this study was to conduct a long-term follow-up of SAH patients, assess the changes in functional outcomes, describe quality of life (QOL), and determine its predictors 3.6 years after the hemorrhage. DESIGN: The study design is an exploratory, descriptive correlational design. METHODS: Results were collected from a sample of 113 SAH survivors treated in our institution over a 2-year period (January 2006 until December 2007). We collected data on early and long-term functional outcomes and compared the differences. The health-related QOL was measured using the Polish version of The Short Form - 36 Health Survey Questionnaire (SF-36v2). Multivariable logistic regression was derived to define independent predictors of the QOL. FINDINGS: The mean follow-up time was 3.6 years. Sixty-six percent of patients had improvement in functional outcomes and among previously employed people 56% returned to work. QOL deteriorated in 24% of patients with the most affected dimension of Physical Role. Factors that predict good QOL are male gender, younger age, good economic/professional status, lack of physical handicaps, rehabilitation in a professional center, subjective improvement in health status, and absence of headaches or physical decline. CONCLUSIONS AND CLINICAL RELEVANCE: Recovery process in SAH patients is dynamic and progresses over time. Since physical handicaps and low economic status significantly reduce the quality of life, an effort should be made to provide intensive rehabilitation and to encourage SAH survivors to return to work.

Verbal memory capacity after treatment for ruptured intracranial aneurysm--the outcomes of three psychological tests: within a month, 1 year after and 5-7 years after treatment.

BACKGROUND: Verbal memory is an essential cognitive ability with scope for adequate treatment of information and for orientation in everyday life. Our study is centered on memory performance in the wake of treatment for ruptured intracranial aneurysm. METHODS: Three psychological tests were performed: (1) within a month of the neurosurgical intervention, (2) 1 year and (3) 5-7 years after the ruptured aneurysm treatment. Under comparison are the overall results of tests for verbal memory capacity in a cohort of patients (N = 59) and in the control group. RESULTS: Three post-treatment measurements revealed a persistent deficit of verbal memory. The cohort's average performance improved from -1.3 SD (standard deviation) below the average of the norm to -0.5 SD below the norm at the second test 1 year after treatment, while at the third test the deficit had worsened to -0.68 SD. Similarly, testing for long-term recovery at 5-7 years postoperatively showed the patients' performances to be 2/3 SD below the average of the general population. CONCLUSIONS: The results of the study imply the need for long-term rehabilitation of memory in this particular group of patients.

Evaluating the impact of personalized rehabilitation nursing management in the perioperative nursing of patients with intracranial aneurysm: A protocol for systematic review and meta-analysis.

BACKGROUND: Patients who suffer from aneurysmal subarachnoid hemorrhage continue to die at a high rate, despite large geographical and risk factor-related variability in death rates. Hemorrhagic stroke has a greater death rate than ischemic stroke, which is often permanent, although patients who survive have less impairment than those who do not. Because of this, nurses must offer appropriate nursing care throughout the perioperative period for patients suffering from this prevalent neurological condition. Patients with intracranial aneurysms (IA) will be the subjects of this research, which will be carried out to thoroughly investigate the effect of tailored rehabilitative nurse treatment throughout the perioperative period. METHODS: The influence of customized rehabilitative nurse management in the perioperative nursing of patients with IA has been studied in both randomized controlled trials and observation studies, according to the authors. From the time of the database's creation until February 2022, information about studies will be gathered from 3 Chinese databases (Wanfang, China National Knowledge Infrastructure, and Chinese BioMedical database) and 4 English databases (PubMed, EMBASE, Cochrane Library, and CINAHL database). After the data extraction and risk of bias evaluation of the included studies are completed, the data synthesis will be carried out using the RevMan 5.3 program. Egger's regression test and funnel plots will be used to determine whether or not there is any publication bias. The I2 statistics will be used to determine the degree of heterogeneity. A sensitivity analysis will be conducted to determine the robustness as well as stability of our results and conclusions. RESULTS: This research is anticipated to offer high-quality evidence of tailored rehabilitative nurse treatment in the perioperative nursing of patients with IA. CONCLUSION: Results of this research will synthesize the current data to determine whether or not tailored rehabilitation nursing treatment may enhance the surgical recovery of patients with IA.

[Rehabilitation of patients following subarachnoid haemorrhage as a result of ruptured intracranial aneurysms]. / Rehabilitacja pacjentów po krwawieniu podpajeczynówkowym z peknietego tetniaka wewnatrzczaszkowego.

The aim of the present paper is to discuss how neuropsychological impairments affect the functioning of patients in the aftermath of aneurysmal SAH and to highlight the need for complex professional rehabilitation services for this group of patients. Following the acute stage of illness, when treatment efforts are focused on life-saving measures, a significant proportion of patients are left with long-term consequences of cerebral damage in the form of specific cognitive impairments or emotional changes. The resultant functional deficits require specialist treatment, but few patients have sufficient knowledge in this regard to allow them to seek help and the availability of specialist services is frequently restricted only to large centres of population. Patients and their families usually do not know where to turn in the face of a sudden, life-threatening illness, which changes their lives diametrically, still less, what kind of specialist help might be available to them. Bearing in mind the needs of patients and their families, there are but few centers offering cognitive therapy or other forms of psychotherapeutic intervention, that are funded under the auspices of the National Health Fund (NFZ). Furthermore, healthcare policies do not place high priority on employing adequately trained psychological therapists in neurosurgical or neurological departments, and the lack of effective cooperation between specialists from different disciplines places significant limitations on the effective rehabilitation of patients who have undergone SAH. In the following article we review the opportunities for effective rehabilitation in order to optimize the functioning of patients with brain damage following SAH.

Dynamics of outcome after aneurysmal subarachnoid hemorrhage.

In this observational study, we analyzed and described the dynamics of the outcome after aneurysmal subarachnoid hemorrhage (SAH) in a collective of 203 cases. We detected a significant improvement of the mean aggregate modified Rankin Score (mRS) in every time interval from discharge to 6 months and up to 1 year. Every forth to fifth patient with potential of recovery (mRS 1-5) at discharge improved by 1 mRS point in the time interval from 6 month to 1 year (22.6%). Patients with mRS 3 at discharge had a remarkable late recovery rate (73.3%, p = 0.000085). Multivariate analysis revealed age ≤ 65 years (odds ratio 4.93; p = 0.0045) and "World Federation of Neurological Surgeons" (WFNS) grades I and II (odds ratio 4.77; p = 0.0077) as significant predictors of early improvement (discharge to 6 months). Absence of a shunting procedure (odds ratio 8.32; p = 0.0049) was a significant predictor of late improvement (6 months to 1 year), but not age ≤ 65 years (p = 0.54) and WFNS grades I and II (p = 0.92). Thus, late recovery (6 month to 1 year) is significant and independent from age and WFNS grade.

Feasibility and efficacy of enhanced recovery after surgery protocol in Chinese elderly patients with intracranial aneurysm.

OBJECTIVE: Intracranial aneurysm is a kind of severe intracranial disease mainly responsible for subarachnoid hemorrhage, and the rupture of intracranial aneurysm results in a mortality rate of 30%-40%. For the first time in the world, this study aimed to assess the feasibility and efficacy of enhanced recovery after surgery (ERAS) protocol in Chinese elderly patients with intracranial aneurysm. METHODS: In this study, 300 elderly patients with intracranial aneurysm were recruited and divided into two groups as follows: ERAS group (n=150, ERAS protocol) and control group (n=150, conventional management). RESULTS: Age of whole cohort was 65 (64-67) years with 140 males (46.7). There was no difference between two groups in baseline features of patients, such as age, sex, medical histories, percentages of aneurysmal location, aneurysmal number >1 per patient, aneurysmal diameter >5 mm, or lobular aneurysm (P>0.05 for all). There was no occurrence of death in two groups. Compared with those in the control group, patients in the ERAS group had significantly shorter length of hospital stay (P<0.05). Between two groups, patients had not only similar Glasgow Outcome Scale (GOS) and Modified Rankin Scale (MRS) at discharge but also occurrence of readmission at follow-up (P>0.05 for all). Patients in the ERAS group had significantly higher GOS and lower MRS at follow-up (P<0.05 for all). CONCLUSION: ERAS protocol significantly shortened the length of hospital stay and improved GOS and MRS without any increase in the mortality or readmission in Chinese elderly patients with intracranial aneurysm.

Results of rehabilitation in patients after subarachnoid haemorrhage from ruptured intracranial aneurysm and after surgical treatment.

BACKGROUND AND PURPOSE: Non-traumatic, or spontaneous subarachnoid haemorrhage (SAH) is responsible for 5-7% of strokes. In Podkarpackie voivodeship, 217 patients were hospitalized in 2003 with spontaneous SAH. The aim of this study was to assess the relationship between the results of rehabilitation carried out in patients after surgical treatment of SAH estimated on the Brunnström, Barthel, and Rankin scales and patients' initial condition measured by means of the Hunt-Hess Scale. MATERIAL AND METHODS: The examined group consisted of 55 patients after surgically treated SAH (clipping). Severity of bleeding was graded with the Hunt-Hess Scale on admission to the neurosurgery ward. Patients' clinical status was assessed with the Barthel Index and Rankin and Brunnström scales on admission to a rehabilitation ward, and rehabilitation effects were assessed after 4 weeks of the rehabilitation period and after at least 6 months from the end of rehabilitation on the ward. RESULTS: The study did not reveal any significant correlation between severity of bleeding and the results of rehabilitation. No explicit advantage was observed in the process of treatment of patients with grade I or II grade according to the Hunt-Hess Scale in the later period. In each group of patients (grades I to IV) there were patients whose final condition improved evidently. CONCLUSIONS: No significant correlation was observed between the clinical status at the onset of the disease and clinical or functional status in early and late periods of rehabilitation.

Recovery of cognitive function after surgery for aneurysmal subarachnoid hemorrhage.

BACKGROUND AND PURPOSE: Abnormalities in neurocognitive function are common after surgery for aneurysmal subarachnoid hemorrhage, even among patients with good functional outcomes. The time course of neurocognitive recovery, along with the long-term effects of mild intraoperative hypothermia (33 degrees C) and aneurysm location, is unknown. We determined these in a subset of subarachnoid hemorrhage patients enrolled in the Intraoperative Hypothermia for Aneurysm Surgery Trial (IHAST). METHODS: We performed a longitudinal, multicenter, prospective, blinded study of adult IHAST patients with a Glasgow Outcome Score=1 or 2 (independent function), 3 months postsurgery and a matched control group (n=45). Subjects were tested with a 5-test cognitive function battery and standard neurological evaluations at 3, 9 and 15 months postsurgery. The primary outcome measure was a composite score on cognitive test performance. RESULTS: There were 303 IHAST patients available for inclusion: 218 eligible, 185 enrolled (89 hypothermic, 96 normothermic). Significant cognitive improvement was noted from 3 to 9 (P<0.001) and 3 to 15 (P<0.001) months in both hypothermic and normothermic groups, even after adjusting for practice effects observed in the control group. No significant change was identified between 9 and 15 months. Neither mild hypothermia nor aneurysm location (anterior communicating artery versus others) had a significant effect on recovery over time or frequency of cognitive impairment. Compared with control group, the frequency of cognitive impairment (Z score <-1.96) in all patients at 3, 9 and 15 months was 36%, 26% and 23%, respectively. CONCLUSIONS: In this population, cognitive improvement continued beyond 3 months, with a plateau between 9 and 15 months. This was not affected by the use of intraoperative hypothermia or anatomical location of aneurysm.

Rupture of a non-traumatic anterior communicating artery aneurysm: Does location of aneurysm associate with functional independence following post-acute in-patient neurorehabilitation?

OBJECTIVE: Patients with non-traumatic rupture of an aneurysm located at the anterior communicating artery (ACoA) often experience cognitive disabilities. It is unknown whether location of aneurysm also affects the possibility for improvement in functional independence compared to patients with an aneurysmal subarachnoid hemorrhage (a-SAH) located elsewhere. The aim was to explore the association between location of aneurysm (ACoA versus other) and level of functional independence, measured by Functional Independence Measure (FIM), at discharge from rehabilitation. Additionally, age and FIM at admission were explored. METHOD: Historical cohort study among 107 patients with a-SAH based on data from a clinical database and a population-based register. Data were analyzed using multivariable logistic regression. RESULTS: Patients with ACoA were admitted with poorer cognitive FIM (median 6 (IQR 5-14) compared to patients with aneurysms located elsewhere (median 12 (IQR 6-23) (p = 0.0129); no difference at discharge. No association between aneurysm location and functional independence was observed. Higher age was associated with poorer outcome in bowel management OR 0.54 (95% CI 0.31-0.92), bladder management OR 0.59 (95% CI 0.35-0.98), comprehension OR 0.53 (95% CI 0.30-0.94), and memory OR 0.48 (95% CI 0.25-0.93). Overall, FIM at admission was associated with functional independence at discharge with the exception of stair walking and bladder management which did not reach statistical significance. CONCLUSION: ACoA was not associated with poorer level of functional independence compared to patients with a-SAH located elsewhere. Higher age was associated with poorer outcome in continence, comprehension, and memory, whereas higher FIM was associated with better functional independence across items at discharge.

The impact of hybrid neurosurgeons on the outcomes of endovascular coiling for unruptured cerebral aneurysms.

OBJECTIVE The impact of combined practices on the outcomes of unruptured cerebral aneurysm coiling remains an issue of debate. The authors investigated the association of combined open and endovascular expertise with the outcomes of unruptured cerebral aneurysm coiling. METHODS The authors performed a cohort study of 100% of Medicare fee-for-service claims data for elderly patients who underwent endovascular coiling for unruptured cerebral aneurysms between 2007 and 2012. To control for confounding, the authors used propensity score conditioning, with mixed effects to account for clustering at the hospital referral region level. RESULTS During the study period, there were 11,716 patients who underwent endovascular coiling for unruptured cerebral aneurysms and met the inclusion criteria. Of these, 1186 (10.1%) underwent treatment performed by hybrid neurosurgeons, and 10,530 (89.9%) by proceduralists who performed only endovascular coiling. Multivariable regression analysis with propensity score adjustment demonstrated a lack of association of combined practice with 1-year postoperative mortality (OR 0.84; 95% CI 0.58-1.23), discharge to rehabilitation (OR 1.0; 95% CI 0.66-1.51), 30-day readmission rate (OR 1.07; 95% CI 0.83-1.38), and length of stay (adjusted difference, 0.41; 95% CI -0.26 to 1.09). Higher procedural volume was independently associated with improved outcomes. CONCLUSIONS In a cohort of Medicare patients, the authors did not demonstrate a difference in mortality, discharge to rehabilitation, readmission rate, and LOS between hybrid neurosurgeons and proceduralists performing only endovascular coiling.

Effect of early mobilization and rehabilitation on complications in aneurysmal subarachnoid hemorrhage.

OBJECTIVE Early rehabilitation is effective in an array of acute neurological disorders but it is not established as part of treatment guidelines after aneurysmal subarachnoid hemorrhage (aSAH). This may in part be due to the fear of aggravating the development of cerebral vasospasm, which is the most feared complication of aSAH. The aim of this study was to evaluate the effect of early rehabilitation and mobilization on complications during the acute phase and within 90 days after aSAH. METHODS This was a prospective, interventional study that included patients with aSAH at the neuro-intermediate ward after aneurysm repair. The control group received standard treatment, whereas the early rehab group underwent early rehabilitation and mobilization in addition to standard treatment. Clinical and radiological characteristics of patients with aSAH, progression in mobilization, and treatment variables were registered. The frequency and severity of cerebral vasospasm, cerebral infarction acquired in conjunction with the aSAH, and acute and chronic hydrocephalus, as well as pulmonary and thromboembolic complications, were compared between the 2 groups. RESULTS Clinical and radiological characteristics of patients with aSAH were similar between the groups. The early rehab group was mobilized beginning on the first day after aneurysm repair. The significantly quicker and higher degree of mobilization in the early rehab group did not increase complications. Clinical cerebral vasospasm was not as frequent in the early rehab group and it also tended to be less severe. Each step of mobilization achieved during the first 4 days after aneurysm repair reduced the risk of severe vasospasm by 30%. Acute and chronic hydrocephalus were similar in both groups, but there was a tendency toward earlier shunt implantation among patients in the control group. Pulmonary infections, thromboembolic events, and death before discharge or within 90 days after the ictus were similar between the 2 groups. CONCLUSIONS Early rehabilitation of patients after aSAH is safe and feasible. The earlier and higher degree of mobilization does not increase neurosurgical complications. Rather, the frequency and severity of cerebral vasospasm following aSAH are alleviated and are not aggravated by early rehabilitation. Clinical trial registration no.: NCT01656317 ( www.clinicaltrials.gov ).

Injury of optic radiation and visual field defect in a patient with aneurysmal subarachnoid hemorrhage: A case report.

RATIONALE: Little is known about optic radiation (OR) injury following aneurysmal subarachnoid hemorrhage (SAH). In the current study, we report on a patient who showed a visual field defect and injury of the OR following aneurysmal SAH, using diffusion tensor tractography (DTT). PATIENT CONCERNS: At 4 weeks from onset, when a 62-year old female started rehabilitation, she complained of a visual field defect. Peripheral field defects were detected on both eyes using the Humphrey visual field test. DIAGNOSES: The patient underwent aneurysm clipping for a ruptured aneurysm in the left posterior communicating artery and extraventricular drainage (the left prefrontal approach) for subarachnoid hemorrhage. She also underwent conservative management for intracerebral hemorrhage in the left internal capsule detected at 2 days after onset. INTERVENTIONS: DTT data were acquired at 4 weeks after onset OUTCOMES:: Regarding DTT parameters, fiber numbers of both ORs of the patient were decreased over 2 standard deviations of that of 7 age- and sex-matched normal subjects normal control subjects. However, the value of fractional anisotropy was similar to that of normal control subjects. On the configuration of the OR of the patient, both ORs were thinner than those of normal control subjects. LESSONS: Injury of the OR was demonstrated in a patient with a visual field defect following aneurysmal SAH, using DTT.

[Quality of life assessment in patients after the embolization of aneurysms of cerebral arteries]. / Ocena jakosci zycia chorych po embolizacji tetniaków tetnic mózgowych.

UNLABELLED: THE OBJECTIVE OF THE PAPER: The objective of the paper has been to assess the quality of the patients lives after subarachnoid haemorrhage and the embolization of aneurysms of cerebral arteries, and to specify correlations between different aspects of the patients life under examination and selected socio-demographic factors. MATERIAL AND METHOD: The examination covered 28 patients having been subject to embolization of aneurysms of cerebral arteries including 12 women and 16 men at the age of 33 up to 62 (48.4 years of age on average) in the years 2000-2002. A 6- month period at least after embolization served as a major criterium for selecting respective patients to be examined. The control group covered 30 healthy people (including 16 women and 14 men) at an average age of 46.2. The examination was made on the basis of the Polish version of questionnaire RNL-Index (Reintegration to Normal Life Questionnaire). Medical documentation from hospital archives served as an additional source of data. RESULTS: The most numerous group (56%) included patients between 40 and 50 years of age. 82% of patients lived in towns, for 61% of patients disability pension constituted the only source of income. All patients were hospitalized on an instant basis. 82.1% of patients suffered from headaches, 50% of patients suffered from nausea, vomits and eyesight disturbances, 40.9% of patients were diagnosed with one-side paresis, and 57.1% of patients under examination suffered from loss of consciousness. After embolization 85.7% of patients experienced mood swings, 57.1% of patients suffered from vision disorders, 39.3% had phonological impairments. 25% of patients suffered from epilepsy. After embolization 75% of patients were subjected to the convalescence process. The comparison of RNL Index in respective aspects of the patients life before and after embolization indicated its substantial decrease in the group of patients subject to embolization. There was a big difference in physical self-sufficiency, work, education and recreation. There was no correlation between the quality of the patients lives after embolization and sex, age, domicile and the fact of living together with other family members. There was a plus correlation (R = 0.48) for the quality of life and education. Patients with higher education assessed the quality of their lives as being much higher. CONCLUSIONS: The quality of the patients lives after the subarachnoid haemorrhage and the embolization of aneurysms of cerebral arteries worsened to a great extent resulting from RNL Index decreasing from 98.0 to 71.5. The illness had the most negative influence on professional career, sociable life and how to cope with everyday situations. The quality of the life the embolization of cerebral arteries did not differ much from that of the people from the control group. No influence of sociodemographic factors on the quality of the patients lives under examination was indicated.

Impact of early mobilization and rehabilitation on global functional outcome one year after aneurysmal subarachnoid hemorrhage.

OBJECTIVE: To assess the impact of early mobilization and rehabilitation on global functional outcome one year after aneurysmal subarachnoid haemorrhage. METHODS: Prospective, controlled, interventional study comprising patients managed in the neuro-intermediate ward following repair of a ruptured intracranial aneurysm. Patients in the Control group (n = 76) received standard treatment, whereas those in the Early Rehab group (n = 92) in addition underwent early mobilization and rehabilitation. Demographic, clinical and intervention data were registered. Global functional outcome was assessed using the modified Rankin Scale and the Glasgow Outcome Scale Extended. RESULTS: The 2 groups were similar in their demographic and clinical characteristics. Early Rehab group patients were mobilized more quickly (p < 0.001), median 1.4 days (range 0-23 days) after aneurysm repair. After 1 year, 47% of the patients had made a good recovery, whereas 6.5% had died. Regression analysis did not reveal any significant effect of early rehabilitation on functional outcome. However, in poor-grade patients, early rehabilitation more than doubled the chance of a favourable outcome (adjusted odds ratio = 2.33; confidence interval 1.04-5.2, p = 0.039). CONCLUSION: Early mobilization and rehabilitation probably increases the chance of a good functional outcome in poor-grade aneurysmal subarachnoid haemorrhage patients.

Incidence of recurrent subarachnoid hemorrhage after clipping for ruptured intracranial aneurysms.

BACKGROUND AND PURPOSE: Because intracranial aneurysms develop during life, patients with subarachnoid hemorrhage (SAH) and successfully occluded aneurysms are at risk for a recurrence. We studied the incidence of and risk factors for recurrent SAH in patients who regained independence after SAH and in whom all aneurysms were occluded by means of clipping. METHODS: From a cohort of patients with SAH admitted between 1985 and 2001, we included those patients who were discharged home or to a rehabilitation facility. We interviewed these patients about new episodes of SAH. We retrieved all medical records and radiographs in case of reported recurrences. If patients had died, we retrieved the cause of death. We analyzed the incidence of and risk factors for recurrent SAH by Kaplan-Meier curves and Cox regression analysis. RESULTS: Of 752 patients with 6016 follow-up years (mean follow up 8.0 years), 18 had a recurrence. In the first 10 years after the initial SAH, the cumulative incidence of recurrent SAH was 3.2% (95% confidence interval [CI], 1.5% to 4.9%) and the incidence rate 286 of 100,000 patient-years (95% CI, 160 to 472 per 100,000). Risk factors were smoking (hazard ratio [HR], 6.5; 95% CI, 1.7 to 24.0), age (HR, 0.5 per 10 years; 95% CI, 0.3 to 0.8) and multiple aneurysms at the time of the initial SAH (HR, 5.5; 95% CI, 2.2 to 14.1). CONCLUSIONS: After SAH, the incidence of a recurrence within the first 10 years is 22 (12 to 38) times higher than expected in populations with comparable age and sex. Whether this increased risk justifies screening for recurrent aneurysms in patients with a history of SAH requires further study.

Early rehabilitation in patients with acute aneurysmal subarachnoid hemorrhage.

PURPOSE: The aim of this study was to describe and quantify the content of early rehabilitation adapted to patients with acute aneurysmal subarachnoid hemorrhage (aSAH) and to assess its feasibility. METHODS: This was a prospective, observational study including 37 aSAH patients. Early rehabilitation was applied according to a mobilization algorithm. Clinical parameters, the time that rehabilitation team used on early rehabilitation and progression in mobilization were recorded. The patients' clinical conditions were graded according to the World Federation of Neurological Surgeons scale (WFNS). RESULTS: Poor-grade patients (WFNS 3, 4, 5) (n = 12) received more rehabilitation (median 412 min) than did good-grade patients (WFNS 1, 2) (median 240 min). Mobilization to 60° of head elevation in good-grade patients began on day one after securing the aneurysm. Out-of-bed mobilization was possible on day three. Poor-grade patients were mobilized to 60° after two days and were out of bed on day seven. At discharge, 67% of poor-grade patients were mobilized to walking versus 78% of good-grade patients. No serious adverse effects to early rehabilitation were observed. CONCLUSIONS: Early rehabilitation in aSAH patients is feasible from the first day after securing the aneurysm. The rehabilitation content varied according to the patient's clinical grade. Implications for Rehabilitation Early rehabilitation is feasible from the first day after securing the ruptured aneurysm in patients with aneurysmal subarachnoid hemorrhage (aSAH). Early rehabilitation requires close monitoring and continuous adjustment for the content and amount according to the patient's clinical condition. Interdisciplinary collaboration is recommended to match the rehabilitation needs to the medical condition on a daily basis.