Peer-Review ReportCognitive, Physical, and Psychological Status After Intracranial Aneurysm Rupture: A Cross-Sectional Study of a Stockholm Case Series 1996 to 1999
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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Incidence and Prediction of Chronic Depression Following Aneurysmal Subarachnoid Hemorrhage: A Single-Center 17-Year Experience
2023, World NeurosurgeryCitation Excerpt :The frequency of depression in their review ranged from 0% to 62% with a weighted proportion of 28.1%. Our study was also similar to previous studies in that age and biological sex were not associated with depression after SAH.14,16-18 Features and complications of SAH, such as vasospasm and type of aneurysm, have rarely been explored for an association with depression, with the exception of one study suggesting that infarction after SAH may be related to depression.19
Psychological distress after subarachnoid haemorrhage: A systematic review and meta-analysis
2021, Journal of Psychosomatic ResearchCitation Excerpt :Therefore, the initial, acute neuroinflammatory response in SAH may be a significant predisposing factor to psychological distress as inflammatory cytokines can signal the brain to cause neurotransmitter disturbances, hypothalamic-pituitary-adrenal axis dysfunction, and neuroplasticity changes which can affect mood and behaviour [104]. Therefore, SAH acting as both a physiological and a psychological trauma predisposes individuals to both short- and long-term psychological distress [12–15]. Although there is a large literature reporting the prevalence of psychological distress, studies have produced disparate findings and little consensus.
Anxiety after subarachnoid hemorrhage: A systematic review and meta-analysis: Anxiety in subarachnoid hemorrhage
2021, Journal of Affective Disorders ReportsCitation Excerpt :Two studies (n = 158) examined the relationship between neurological outcomes and anxiety: one reported that low perceived recovery was associated with significantly higher levels of anxiety (von Vogelsang et al., 2015), whereas the other found no association between neurological outcomes and anxiety (Morris et al., 2004). Two studies (n = 305) that considered the locations of aneurysms reported higher anxiety among those with ruptured posterior circulation aneurysms than anterior circulation aneurysms (von Vogelsang et al., 2013, von Vogelsang et al., 2015). The presence of unsecured aneurysm was not related to anxiety (von Vogelsang et al., 2015).
Does the Time Trade-Off Method Reflect Health-Related Quality of Life? A Mixed-Methods Analysis of Preference Measures 10 Years After Aneurysmal Subarachnoid Hemorrhage
2019, World NeurosurgeryCitation Excerpt :The sample consisted of a 10-year follow-up of patients with aSAH, eligible if treated at a Swedish neurosurgery clinic in Stockholm during 1996–1999 and able to communicate in Swedish. The results presented are part of a larger study; epidemiology data and patient-reported health outcomes are described elsewhere.17-19 EQ-5D-3L is a generic HRQoL instrument and consists of 2 parts.
Patients Experience High Levels of Anxiety 2 Years Following Aneurysmal Subarachnoid Hemorrhage
2015, World NeurosurgeryCitation Excerpt :Somewhat surprisingly, we found no significant differences in the levels of anxiety between patient with secured aneurysms and patient with lesions that remained unsecured. This is similar to findings in previous studies (40, 41, 50). One possible explanation for this is that respondents, over time, to some degree, adapt living with the risk of aneurysm rupture (39).
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.