Elsevier

World Neurosurgery

Volume 79, Issue 1, January 2013, Pages 130-135
World Neurosurgery

Peer-Review Report
Cognitive, Physical, and Psychological Status After Intracranial Aneurysm Rupture: A Cross-Sectional Study of a Stockholm Case Series 1996 to 1999

https://doi.org/10.1016/j.wneu.2012.03.032Get rights and content

Objective

We sought to (1) describe psychological, physical, and cognitive functions in patients 10 years after intracranial aneurysm rupture and (2) identify any differences in outcome variables between age groups, gender or aneurysm locations.

Methods

A consecutive sample of patients (n = 217) treated for intracranial aneurysm rupture at a neurosurgical clinic in Stockholm, Sweden, were followed-up in a cross-sectional design 10.1 years after the onset with questionnaires and telephone interviews. The outcome measures were psychological functions in terms of symptoms of anxiety or depression and physical and cognitive functions.

Results

Compared with the reference groups, the aneurysm patients scored greater levels of anxiety and depression than normal values. Patients with aneurysm rupture in the posterior circulation scored significantly more problems with anxiety and depression. Only 2.8% of the patients scored for severe physical disability. On a group level, cognition was lower than normal population levels; 21.7% of respondents scored below the cut-off value, indicating cognitive impairments.

Conclusions

Ten years after aneurysm rupture the majority of patients seem to be well-functioning physically, whereas the psychological and cognitive functions are affected. A screening of the mental health of these patients in connection to radiological follow-up might be helpful to identify which patients need further referral to psychiatric treatment for anxiety and depression disorders.

Introduction

Health problems after aneurysmal subarachnoid hemorrhage (SAH) are common. Up to 32% of patients have been reported to be affected by anxiety 2 to 4 years after the rupture (29). Symptoms of depression have been reported in up to 36% of patients 1 to 6 years after rupture (3). In a meta-analysis, Nieuwkamp et al. (20) have shown that on average 19% of survivors of aneurysmal SAH become so disabled that they become dependent on others for their daily life, but, in contrast, Carter et al. (3) found that only 3% of patients were dependent 1 to 6 years after SAH. Sleep-wake disorders (SWD) are common after stroke, in the forms of increased sleep needs, insomnia, or excessive daytime sleepiness. SWDs have previously been reported in 34% of cases 1 year after SAH (25). In comparison with normative values, and in case-control studies, patients with SAH score significantly lower on cognition tests (8, 18). It has been reported that majority of patients with SAH are impaired in some aspects of cognitive capacity (12).

The severity of the bleeding has a major impact on outcome after intracranial aneurysm rupture (2). However, other factors have impact on outcome, including the following: ruptured aneurysms in the posterior circulation of the brain are associated with a greater risk of death before hospital admission (10), worse neurological grade at admission (24), and unfavorable outcome 3 months after SAH (15). Older age has been found to be a prognostic factor for unfavorable neurological outcome both at 3 months after SAH (21) and 12 months after the rupture (19). Poor neurological outcome at hospital discharge has been found to be more unfavorable in men (9).

It has been proposed that the location of the aneurysm may influence cognitive outcome, although with inconsistent results. Hutter et al. (13) found that patients with ruptured left-sided middle cerebral artery (MCA) aneurysms had significantly more problems in cognition compared with those patients with right-sided ones. However, Haug et al. (7) found somewhat-better cognitive performance for MCA aneurysms compared with anterior communicating artery (ACoA) aneurysms, explained by that a SAH from an ACoA aneurysm rupture causes damage to the frontal lobes.

Many of the functional problems reported by patients with SAH seem to be ongoing several years after the rupture, but long-term studies on perceived health for these patients are scarce. Therefore, the primary objectives of our study were to (1) describe physical, psychological, and cognitive functions 10 years after intracranial aneurysm rupture and (2) to identify any differences in outcome variables between age-groups, gender, or aneurysm locations.

Section snippets

Methods

A cross-sectional survey design was used, and the study and was approved by the regional board for ethics of research involving humans. Through clinic patient registers we retrospectively identified all consecutive patients diagnosed with acute intracranial aneurysm rupture who were admitted to a neurosurgical clinic in Stockholm between January 1, 1996, and December 31, 1999.

Since 1990, the clinic has used a clinical pathway protocol for ruptured aneurysms, including early referral,

Results

During the inclusion period for this study, 468 patients were admitted to the neurosurgical clinic, of which 273 were eligible for this study, and 217 participated (79.5%). The mean follow-up time was 10.1 years after rupture (range, 8.8-12.0 years), and participants' mean age at follow-up was 60.7 years (range, 23.6-90.1 years). Figure 1 shows a flow diagram of participants and data collection.

There were no significant differences between the results for nonresponders and patients who refused

Discussion

Studies addressing patient reported outcomes on a long-term basis after intracranial aneurysm rupture are scarce. To the best of our knowledge, this is the first published Scandinavian study on patient-reported outcomes, including clipped and endovascularly treated patients, a decade after the onset with a large sample of patients (n = 217). Two Dutch long-term studies have addressed patient reported outcomes; Wermer et al. (30) assessed psychosocial consequences in aneurysmal SAH in mean 8.9

Conclusion and Clinical Implications

Ten years after intracranial aneurysm rupture, patients experience greater levels of anxiety, more symptoms of depression, and lower cognitive function compared with reference populations. Patients with ruptured aneurysms in the posterior circulation of the brain rate significantly greater anxiety and symptoms of depression than patients with aneurysms in the anterior circulation. A small proportion of patients experience physical disabilities; however, the majority of patients manage their

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    Conflict of interest statement: This study was supported by grants from the Center for Health Care Sciences, the Capio Research foundation, The Red Cross University College in Stockholm, and the Karolinska Institutet Foundations. The funding organizations had no role in the design and conduct of the study; collection, management, and analysis of the data; or preparation, review, and the decision to submit the paper for publication.

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