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.     

Severe cognitive impairment in aneurysmal subarachnoid hemorrhage: Predictors and relationship to functional outcome

BackgroundCognitive impairment is common after aneurysmal subarachnoid hemorrhage (SAH). However, compared to predictors of functional outcome, meaningful predictors of cognitive impairment are lacking.ObjectiveOur goal was to assess which factors during hospitalization can predict severe cognitive impairment in SAH patients, especially those who might otherwise be expected to have good functional outcomes. We hypothesized that the degree of early brain injury (EBI), vasospasm, and delayed neurological deterioration (DND) would predict worse cognitive outcomes.MethodsWe retrospectively reviewed SAH patient records from 2013 to 2019 to collect baseline information, clinical markers of EBI (Fisher, Hunt–Hess, and Glasgow Coma scores), vasospasm, and DND. Cognitive outcome was assessed by Montreal Cognitive Assessment (MoCA) and functional outcomes by modified Rankin Scale (mRS) at hospital discharge. SAH patients were compared to non-neurologic hospitalized controls. Among SAH patients, logistic regression analysis was used to identify predictors of severe cognitive impairment defined as a MoCA score <22.ResultsWe screened 288 SAH and 80 control patients. Cognitive outcomes assessed via MoCA at discharge were available in 105 SAH patients. Most of these patients had good functional outcome at discharge with a mean mRS of 1.8±1.3. Approximately 56.2% of SAH patients had MoCA scores <22 compared to 28.7% of controls. Among SAH patients, modified Fisher scale was an independent predictor of cognitive impairment after adjustment for baseline differences (OR 1.638, p=0.043). MoCA score correlated inversely with mRS (r=−0.3299, p=0.0006); however, among those with good functional outcome (mRS 0–2), 48.7% still exhibited cognitive impairment.ConclusionsSevere cognitive impairment is highly prevalent after SAH, even among patients with good functional outcome. Higher modified Fisher scale on admission is an independent risk factor for severe cognitive impairment. Cognitive screening is warranted in all SAH patients, regardless of functional outcome.     

Short- and long-term outcomes in non-aneurysmal non-perimesencephalic subarachnoid hemorrhage

Objective: Our aim was to assess the short- and long-term prognosis in patients suffering from non-aneurysmal non-perimesencephalic SAH (Na-NPM-SAH).

Methods: Based on admission CT-scan, SAH was categorized as perimesencephalic (PM) or non-perimesencephalic (NPM). Based on digital subtraction angiography (DSA) results, patients were classified as normal DSA (Na-SAH) or aneurysmal SAH (aSAH). Between 1997 and 2010, 67 of 571 patients with non-traumatic SAH (11.7%) suffered from non-aneurysmal non-perimesencephalic SAH. Retrospective analyses of the 67 patients were undertaken, and compared with the aneurysmal SAH group. Long-term follow-up was assessed.

Results: The cohort consisted of 67 Na-NPM-SAH patients, mean age 54.8 years (range: 21–84), 56.7% male. Acute phase: 10.4% mortality and 3% rebleeding (two patients) during the acute phase. Long-term: extensive follow-up was possible in all except one of the survivors at discharge. Mortality was 6.6% during the 510 patient-years follow-up period (median follow-up time per patient, 8.95 years); rebleeding rate was 0–1.6%. An aneurysmal source was found in 13% of patients who underwent a second angiography. Aneurysmal SAH: 312 patients, with confirmed aneurysm by angiography. The mortality rate for Na-NPM-SAH during the acute phase was 10.4%, vs. 20% for aneurysmal SAH in the general database, p = 0.049.

Discussion: Na-NPM-SAH patients without an identifiable bleeding source on initial angiography might have a more benign short- and long-term prognosis than aneurysmal SAH patients. Our study confirms an important diagnostic advantage of a second arteriography. Still, despite the major concern of an undetected aneurysm, the long-term rebleeding rate was low in this subgroup of patients.     

Early Prognostication of 1-Year Outcome After Subarachnoid Hemorrhage: The FRESH Score Validation

Background and Aim: The FRESH score is a tool to prognosticate long-term outcomes after spontaneous subarachnoid hemorrhage (SAH). Here, for the first time, we aimed to externally validate the disability part of FRESH using its original four score variables. Methods: A total of 107 patients with SAH were prospectively enrolled in the Yale Acute Brain Injury Biorepository between September 2014 and January 2018. 12-month functional outcome was recorded prospectively by trained study investigators using the modified Rankin Scale (mRS). FRESH-scores were calculated retrospectively using the original score variables. We used R² statistics to assess goodness of fit, and the area under the receiver operating characteristic curve (AUC) to assess ability of the score to discriminate between favorable and unfavorable (defined as mRS 4-6) outcome. Results: We identified 86 patients with SAH with complete 1-year follow-up data. Mean age was 60 years, 60% were women. An aneurysmal bleeding source was found in 71% of patients. 80% underwent aneurysm coiling, and 5% clipping. Sixteen percent of patients were considered high grade on admission (Hunt&Hess score 4 or 5). Discrimination of the FRESH score between favorable and unfavorable outcome was high (AUC 90.8%, confidence interval 81.9%-96.5%). Nagelkerke's (.54) and Cox&Snell's R² (.35) indicated satisfactory fit. Exclusion of patients without aneurysmal etiology of SAH did not significantly alter model performance. Conclusions: FRESH, a prognostication score of long-term outcomes in patients with SAH showed excellent score performance in this external validation. FRESH may guide the efficient use of hospital resources, family discussions, and stratification of patients in future randomized controlled trials.     

‘Quality of life at 90 days after stroke and its correlation to activities of daily living’: A prospective cohort study

BackgroundThe main goal of stroke rehabilitation is to improve the health-related quality of life (HRQoL). In developed countries, several studies evaluating the HRQoL among stroke survivors have been conducted. In India, HRQoL related to stroke as an important health care issue has not received sufficient attention. The study was conducted to encourage the professionals to use stroke-specific HRQoL scales in clinical practice as one of the measures of stroke outcome.ObjectivesTo study the correlation between activities of daily living (ADLs) and HRQoL at 90 days following an acute stroke.MethodsIn this prospective study, functional independence of patients admitted with stroke were measured using Barthel Index (BI). At 90 days post-stroke patients were assessed using two questionnaires.ResultsSignificant improvement in BI total and domains scores at 90 days (p < .001) were seen. At follow-up, Stroke Specific Quality of Life Scale-12 (SS-QoL-12) score for 59 patients was 48 (high QoL). Individuals scored lowest for psychosocial subscale of HRQoL compared to physical subscale. All items and the total score of the BI showed a significant positive partial correlation (p< .001) with the HRQoL total score. The self-care domain of BI showed the highest correlation with QoL total score at 0.88.ConclusionsPatient dependent in ADL constantly scored less in all QoL domains. The psychosocial QoL was found to be most affected even in the presence of complete functional independence paving way for further studies on factors that impact psychosocial QoL of stroke survivors.     

Association between clinician reported outcome and patient reported outcome measures one year after stroke

ObjectivesPatient reported outcome measures (PROM) are increasingly important in the evaluation of care. In this study we evaluate patient PROM in stroke patients and the association with clinical reported outcomes.Materials and methodsOf 3706 first-ever stroke patients, 1861 were discharged home and invited to fill out PROM at discharge, 90 days and one-year after stroke. PROM include mental and physical health and patients’ self-reported functionals status, all available via International Consortium for Health Outcomes Measurement. Clinician reported measures as NIHSS, Barthel index were collected during hospital admission and modified Rankin Scale (mRS) 90 days after stroke. PROM compliance was evaluated. Clinician reported measures were related to PROM.Results844 (45%) of the invited stroke patients filled out PROM. In general, those patients were younger and less severely affected (higher Barthel index and lower mRS). Compliance after enrolment is about 75%. Barthel index and mRS correlated with all PROM at 90 days and one-year. In age and gender adjusted multiple regression analysis, mRS was a consistent predictor for all PROM subsets, and Barthel index holds predictive value for physical health and patients’ self-reported functional status.ConclusionsParticipation rate to fill out PROM is only 45% among stroke patients who were discharged home, and compliance rate is around 75% up one-year follow-up. PROM associated with the clinician reported functional outcome measures Barthel index, and mRS score. Low mRS score is a consistent predictor of better PROM at one year. We propose to use mRS in stroke care evaluation, until PROM participation improves.     

Long-term outcomes,including the survival rate and period to death,in patients over 80 years old after ruptured cerebral aneurysm clipping

ObjectiveThis study aimed to identify the long-term outcomes, including the survival rate, period to death, causes of death, and predictors of poor outcomes, in patients aged over 80 years who underwent surgical clipping for a ruptured anterior circulation aneurysm.Materials and MethodsIn this retrospective observational study, the medical records of patients from April 1, 1994, to June 30, 2019, were evaluated. All patients underwent surgical clipping within 72 h of subarachnoid hemorrhage (SAH) onset. Information on the patient, SAH, and outcomes were collected.ResultsThe mean hospitalization and long-term follow-up periods for all patients were 54.5 days and 53.3 months, respectively. The period to death was significantly shorter in patients with modified Rankin scale (mRS) of 4–5 than for those with an mRS of 0–3 at discharge (p=0.001). The Kaplan–Meier method using the log-rank test demonstrated that patients with an mRS of 4–5 at discharge had a significantly lower survival rate compared to those with an mRS of 0–3 at discharge (p<0.05). Univariate analysis revealed that the proportion of patients with Hunt and Hess grade and presence of surgical complications were significantly larger in the group with an mRS of 4–5 than in that with an mRS of 0–3 at discharge (p=0.0013 and 0.011, respectively). Multivariate analysis demonstrated that presence of surgical complications was the only independent predictor of poor outcomes (p=0.043, odds ratio [OR] 7.937, 95% confidence interval [CI] 1.061–59.38). The Kaplan-Meier method using the log-rank test demonstrated that patients with surgical complications had a significantly lower survival rate compared to those with no surgical complications (p<0.05).ConclusionsEspecially in patients aged over 80 years, those with H-H grade 2 and a good clinical condition can be candidates for surgical clipping, whereas avoiding surgical complications is essential for achieving good outcomes.     

Clinical Characteristics and Treatment Outcomes of De Novo Nonconvulsive Status Epilepticus: A Retrospective Study

Background and PurposeNonconvulsive status epilepticus (NCSE) is challenging to diagnose. This study aimed to describe and classify the clinical features and electroencephalography (EEG) findings of patients with de novo NCSE and to correlate them with clinical outcomes.MethodsWe retrospectively reviewed the medical and EEG records of patients admitted to our institution with altered mentation and EEG abnormalities from January 1, 2013 to December 31, 2018. We evaluated premorbid modified Rankin Scale (mRS) scores, underlying disorders, precipitating factors, clinical manifestations, laboratory tests, and outcomes after a 3-month follow-up. Patients who met the Salzburg Consensus Criteria for NCSE were categorized into good-outcome and poor-outcome groups. A good outcome was defined as 1) clinical and electrographic seizures ceasing after treatment, and 2) an mRS score of ≤2 or remaining unchanged during the 3-month follow-up. A poor outcome was defined as 1) death, 2) seizures continuing despite treatment, or 3) a follow-up mRS score of ≥3 in a patient with a premorbid mRS score of ≤2, or a follow-up mRS score that increased in a patient with a premorbid mRS score of ≥3.ResultsThe 48 included patients comprised 37 categorized into the good-outcome group and 11 into the poor-outcome group. The presence of acute metabolic disturbances was significantly correlated with poor outcome (p=0.036), while the other analyzed variables were not significantly correlated with outcomes.ConclusionsAcute metabolic disturbances in NCSE are associated with poor outcomes. Adequate treatment of underlying reversible disorders alongside controlling seizures is critical for patients with NCSE.     

Excessive release of endogenous neuropeptide Y into cerebrospinal fluid after treatment of spontaneous subarachnoid haemorrhage and its possible impact on self-reported neuropsychological performance – results of a prospective clinical pilot study on good-grade patients

ABSTRACT

Objectives: Neuropsychological dysfunction after treatment of spontaneous subarachnoid haemorrhage (sSAH) is common but underreported. The vasoconstrictor neuropeptide Y (NPY) is excessively released after sSAH and in psychiatric disorders. We prospectively analysed the treatment-specific differences in the secretion of endogenous cerebrospinal fluid (CSF) NPY during the acute stage after sSAH and its impact on cognitive processing.

Methods: A total of 26 consecutive patients (f:m = 13:8; mean age 50.6 years) with good-grade sSAH were enrolled (drop out n = 5): n = 9 underwent endovascular aneurysm occlusion, n = 6 microsurgery, and n = 6 patients with perimesencephalic SAH received standardized intensive medical care. Ventricular CSF was drawn daily from day 1–10. CSF NPY levels were determined with competitive enzyme immunoassay. All patients underwent neuropsychological self-report assessment [36-Item Short Form Health Survey (SF-36) and ICD-10-Symptom-Rating questionnaire (ISR)] after the onset of sSAH (day 11–35; t₁) and at the 6-month follow-up (t₂).

Results: At t₁, increased mean levels of NPY in CSF significantly correlated with impaired performance in most ISR scores (ISR total p = .018, depression p = .035, anxiety p = .008, nutrition disorder p = .047, supplementary items p = .038) and in several psychological SF-36 items (vitality p = .019, general mental health p = .001, mental component summary p = .025).

Discussion: To the best of our knowledge, this study is the first to correlate the levels of endogenous NPY in supratentorial CSF with cognitive outcome in good-grade sSAH patients. Excessive NPY release into CSF may have a short-term influence on the pathogenesis of neuropsychological deficits. The impact of cerebrovascular manipulation on NPY release has to be further elucidated.

Abbreviations: ANOVA: analysis of variance; aSAH: aneurysmal subarachnoid haemorrhage; AUC: area under the curve; CBF: cerebral blood flow; CSF: cerebrospinal fluid; CT (scan): computed tomography (scan); CV: cerebral vasospasm; DIND: delayed ischemic neurological deficit; DSA: digital subtraction angiography; EIA: enzyme immunoassay; EV: endovascular aneurysm occlusion; EVD: external ventricular drainage; FU: 6-month follow-up; GCS: Glasgow Coma Scale; Ghp: general health perceptions; GOS: Glasgow Outcome Scale; h: hour/s; HH: Hunt and Hess; ICU: intensive care unit; ISR: ICD-10-Symptom-Rating questionnaire; MCS: mental component summary; Mhi: general mental health; min: minute/s; min-max: minimum – maximum; ml: millilitre; mRS: modified Ranking Scale; MS: microsurgical clipping, microsurgical aneurysm occlusion; ng: nanograms; no. [n]: number; NPY: Neuropeptide Y; p: p value; Pain: bodily pain; PCS: physical component summary; Pfi: physical functioning; pSAH: perimesencephalic subarachnoid haemorrhage; PTSD: posttraumatic stress disorder; QoL: quality of life; Rawhtran: health transition item; Rolem: role limitations because of emotional problems; Rolph: role limitations due to physical health problems; SAH: subarachnoid haemorrhage; SD: standard deviation; SF-36: 36-Item Short Form Health Survey; Social: social functioning; sSAH: spontaneous subarachnoid haemorrhage; TCD: trans-cranial Doppler ultrasound; (test) t₁: test in the sub-acute phase after the onset of bleeding (between day 11 and 35 after subarachnoid haemorrhage); (test) t₂: test in the short-term (chronic phase) after treatment at 6-month follow-up; test t₁ - t₂: intergroup development from t₁ to t₂; Vital: vitality; vs: versus.     

Depressive symptoms and quality of life after thrombolysis in stroke: the TEMPiS study

Intravenous thrombolysis leads to a reduction of post-stroke disability. No data exist about whether depression and poor quality of life (QoL) remain relevant problems in patients with good functional outcome. We assessed mood and QoL at 3 and 6 months after stroke in consecutive patients who received intravenous thrombolysis in stroke centers and telemedicine hospitals within the TEMPiS network. The Beck Depression Inventory (BDI) was used with BDI ≥18 indicating clinically relevant depressive symptoms. Stroke specific quality of life (SSQOL) was used for QoL assessment with the definition of SSQOL total score <60% for poor QoL. Associations of BDI and SSQOL with baseline parameters and modified Rankin scale (mRS) in follow-up were analyzed. In patients with known mRS 0–4 at 3 months (N = 213), BDI was available in 74% and SSQOL in 77%. At 3 and 6 months, 23 and 18% of patients had clinically relevant depressive symptoms; 25 and 24% reported a poor QoL. The mRS at 3 months correlated with BDI (r = 0.43, p < 0.01) and SSQOL (r = −0.75, p < 0.01). BDI ≥18 was observed in 11% of patients with mRS 0–1 and 16% in mRS 0–2. Severe stroke (NIHSS ≥12) at admission (OR 1.23, 0.57–2.66; p = 0.57) was not predictive for depressive symptoms but for poor QoL (OR 2.77, 95%CI 1.34–5.74). Depressive symptoms and impaired QoL are observed in a substantial proportion of stroke patients at 3 months after intravenous thrombolysis. Health professionals should be aware that thrombolysed patients may have relevant mood disorders despite good functional outcome.     

Cerebral venous thrombosis: an all or nothing disease?: Prognostic factors and long-term outcome

BACKGROUND: There is insufficient data on short- and especially long-term prognosis of cerebral venous thrombosis (CVT). METHODS: In 79 consecutive patients, we analyzed factors for acute death and functional outcome at hospital discharge and after 6 months as well as long-term prognosis >/=12 months. Neurological deficits were graded on the National Institute of Health Stroke Scale (NIHSS), functional outcome on the modified Rankin Scale (mRS). Primary outcome was defined as mRS >/= 3 at 6 months, secondary outcomes were death during hospital treatment and number as well as type of complications during follow-up >/=12 months after hospital discharge. Forty-two patients were recruited prospectively, 37 were identified by chart review. Information on outcome was based on neurological examinations at our outpatient clinic. RESULTS: Factors significantly related to acute death were age, the NIHSS on admission, more than two seizures despite antiepileptic treatment, venous infarct, and hemorrhagic transformation of the venous infarct. Primary outcome after 6 months in 74 patients was excellent with 73% of patients reaching a mRS 0-1, 4% a mRS of 2, and 23% a mRS 3-6, including 12 deaths in the acute stage of illness. Factors significantly related to a mRS >/= 3 at 6 months in a logistic regression analysis were age and items 1a-c of the NIHSS on admission related to consciousness. Fifty-eight surviving patients had a follow-up >/= 12 months (median: 31; mean: 52 +/- 61 months). Most frequent complication on long-term follow-up was epilepsy in nine patients and recurrent venous thrombosis in seven patients. CONCLUSIONS: When the acute stage of illness has been survived, CVT has a good prognosis unlike arterial ischemic stroke.     

Comparison of microsurgery and endovascular treatment on clinical outcome following poor-grade subarachnoid hemorrhage

Poor-grade (World Federation of Neurological Surgeons [WFNS] clinical grading scale grades IV and V) subarachnoid hemorrhage (SAH) is associated with significant morbidity and mortality. However, the correlation between the timing, modality of intervention (clipping or coiling) and the clinical outcome is not clear. This study aims to examine this correlation. Patients presenting with WFNS grades IV and V aneurysmal SAH between 1997 and 2008 to a single centre were studied. An aggressive policy of early intervention was followed, and the selection of endovascular versus microsurgical intervention was made according to angiographic rather than clinical features. Clinical outcomes were graded using the modified Rankin scale (mRS) at 6 month follow-up. One hundred and forty-three poor-grade patients (23.9% of all 598 aneurysmal SAH patients) were studied. Treatment was microsurgical in 83 (58.0%) and endovascular in 60 (42%) patients. Twenty patients (14.0%) were lost to follow-up. Good outcome (mRS 0-2) at 6 months was found in 45 microsurgical patients (63.3%) and 24 endovascular patients (46.1%). This trend towards better clinical outcomes in the microsurgical group was not statistically significant. With an aggressive early treatment policy more than half of the poor-grade SAH patients demonstrated a good clinical outcome. Microsurgery and endovascular treatment, when selected primarily according to angiographic features, were equally likely to achieve good outcome.     

High-Dose Simvastatin Is Effective in Preventing Cerebral Vasospasm after Aneurysmal Subarachnoid Hemorrhage: A Prospective Cohort Study in Korean Patients

ObjectiveThe goal of this study was to assess the effect of high-dose simvastatin on cerebral vasospasm and its clinical outcome after aneurysmal subarachnoid hemorrhage (SAH) in Korean patients.MethodsThis study was designed as a prospective observational cohort study. Its subjects were aneurysmal SAH patients who had undergone aneurysm clipping or coiling. They were assigned to 1 of 3 groups : the 20 mg, 40 mg, and 80 mg simvastatin groups. The primary end-point was the occurrence of symptomatic vasospasm. The clinical outcome was assessed with the modified Rankin Scale (mRS) score after 1 month and 3 months. The risk factors of the development of vasospasm were assessed by logistic regression analysis.ResultsNinety nine patients with aneurysmal SAH were treated and screened. They were sequentially assigned to the 20 mg (n=22), 40 mg (n=34), and 80 mg (n=31) simvastatin groups. Symptomatic vasospasm occurred in 36.4% of the 20 mg group, 8.8% of the 40 mg group, and 3.2% of the 80 mg group (p=0.003). The multiple logistic regression analysis showed that poor Hunt-Hess grades (OR=5.4 and 95% CI=1.09-26.62) and high-dose (80 mg) simvastatin (OR=0.09 and 95% CI=0.1-0.85) were independent factors of symptomatic vasospasm. The clinical outcomes did not show a significant difference among the three groups.ConclusionThis study demonstrated that 80 mg simvastatin treatment was effective in preventing cerebral vasospasm after aneurysmal SAH, but did not improve the clinical outcome in Korean patients.     

Treatment expectations influence the outcome of multidisciplinary rehabilitation treatment in patients with CFS

ObjectiveTo improve the effectiveness of treatment in patients with chronic fatigue syndrome it is worthwhile studying factors influencing outcomes. The aims of this study were (1) to assess the association of expectancy and credibility on treatment outcomes, and (2) to identify baseline variables associated with treatment expectancy and credibility.Methods122 patients were included in a randomized controlled trial of whom 60 received cognitive behavioural therapy (CBT) and 62 multidisciplinary rehabilitation treatment (MRT). Expectancy and credibility were measured with the credibility and expectancy questionnaire. Outcomes of treatment, fatigue, and quality of life (QoL), were measured at baseline and post-treatment. Multiple linear regressions were performed to analyse associations.ResultsIn explaining fatigue and the physical component of the QoL, the effect of expectancy was significant for MRT, whereas in CBT no such associations were found. The main effect of expectancy on the mental component of QoL was not significant. For credibility, the overall effect on fatigue and the physical component of QoL was not significant. In explaining the mental component of QoL, the interaction between treatment and credibility was significant. However, the effects within each group were not significant.In the regression model with expectancy as dependent variable, only treatment centre appeared significantly associated. In explaining credibility, treatment centre, treatment allocation and depression contributed significantly.ConclusionsFor clinical practice it seems important to check the expectations of the patient, since expectations influence the outcome after MRT.     

Endovascular treatment of blood blister-like aneurysms of internal carotid artery: Stent-assisted coiling and pipeline flow diversion

ObjectiveTo report the stent-assisted coil embolization and flow diversion treatments of blood-blister-like aneurysms based on the theory of acute dissection of the internal carotid artery.Patients and methodsFrom July 2016 through July 2020, 27 patients presenting with subarachnoid hemorrhage (SAH) due to rupture of internal carotid artery blood blister-like aneurysms were subjected to endovascular treatment with stent-assisted coiling or Pipeline flow diversion. Clinical outcomes were evaluated using modified Rankin Scale score (mRS).ResultsA proximal stenosis caused by angiopathology adjacent to aneurysms were found on internal carotid artery angiograms in all 27 cases. The angiopathology combining with the aneurysms implement that acute dissection of the supraclinoid segment of the internal carotid artery indicated the pathogenesis of blood blister-like aneurysm formation. All aneurysms were treated successfully with alleviation of the adjacent angiopathology after stenting on angiograms. During 1–12 months, mean 3.5 months, complete aneurysm obliteration without adjacent stenosis were found in 25(92.6%) patients. Two (7.4%) cases of recanalization were retreated with complete obliteration at 1 week and 3 months after initial treatment. Clinical mRS 0 and 1 outcomes were observed in 23(85.2%) patients, mRS 2 in 3(11.1%) patients and mRS 6 in 1(3.7%) not related to aneurysm treatment during follow-up.ConclusionsAcute focal dissection of supraclinoid segment of internal carotid artery underlies the development of blood blister-like aneurysm. Stent-assisted coiling and flow diversion treatments constitute appropriate treatment based on the arterial dissection pathology.     

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.     

Decompressive hemicraniectomy in ischaemic stroke

Background and purposeHemispheric ischaemic stroke complicated by oedema is associated with high mortality. The results of randomized studies showed that decompressive hemicraniectomy performed in this group of patients could be beneficial. First experiences with implementation of hemicraniectomy in patients with brain infarct in our stroke centre are presented.Material and methodsBetween August 2007 and July 2008, four patients with hemispheric brain infarcts complicated by malignant oedema underwent decompressive hemicraniectomy within 72 hours from symptoms onset. Stroke severity was assessed with the National Institutes of Health Stroke Scale (NIHSS). Clinical outcome was assessed 3, 6 and 12 months after the event using the modified Rankin scale (mRS).ResultsIn the first patient, the neurosurgical procedure included only decompressive hemicraniectomy, whereas in the other three duraplasty was performed additionally. The first patient died 23 days after the stroke onset due to acute respiratory failure. Another died at four months after the event, due to infectious complications. The remaining two patients presented severe functional disability 12 months after the procedure (mRS score 4).ConclusionsDecompressive surgery with duraplasty can be a life-saving procedure for patients with brain oedema. To our knowledge, the presented cases are among the first reported cases of hemispheric ischaemic stroke treated with decompressive hemicraniectomy in Poland. Extended follow-up with a larger group of patients is necessary to assess long-term outcome.     

Elevated C-reactive protein and white blood cell count at admission predict functional outcome after non-aneurysmal subarachnoid hemorrhage

Introduction

Patients with non-aneurysmal subarachnoid hemorrhage (SAH) are considered to have an overall benign course of disease compared to patients suffering from aneurysmal SAH. Nevertheless, a small but significant number of such patients might only achieve unfavorable outcome. Therefore, the purpose of the present study was to determine if routine laboratory markers of acute phase response are associated with unfavorable outcome in patients with non-aneurysmal SAH.

Methods

From 2006 to 2017, 154 patients suffering from non-aneurysmal SAH were admitted to our institution. Patients were stratified according to the distribution of cisternal blood into patients with perimesencephalic SAH (pSAH) versus non-perimesencephalic SAH (npSAH). C-reactive protein (CRP) and white blood cells (WBC) assessments were performed within 24 h of admission as part of routine laboratory workup. Outcome was assessed according to the modified Rankin Scale (mRS) after 6 months and stratified into favorable (mRS 0–2) vs. unfavorable (mRS 3–6).

Results

The multivariate regression analysis revealed “CRP?>?5 mg/l” (p?=?0.004, OR 143.7), “WBC count?>?12.1 G/l” (p?=?0.006, OR 47.8), “presence of IVH” (p?=?0.02, OR 13.5), “poor-grade SAH” (p?=?0.01, OR 45.2) and “presence of CVS” (p?=?0.003, OR 149.9) as independently associated with unfavorable outcome in patients with non-aneurysmal SAH.

Conclusion

Elevated C-reactive protein and WBC count at admission were associated with unfavorable outcome after non-aneurysmal SAH.

     

Functional movement disorders: successful treatment with a physical therapy rehabilitation protocol

BackgroundFunctional (“psychogenic”) gait and other movement disorders have proven very difficult to treat.ObjectivesDescribe the Mayo Clinic functional movement disorder motor-reprogramming protocol conducted in the Department of Physical Medicine and Rehabilitation (PMR), and assess short-term and long-term outcomes.DesignHistorical-cohort-study assessing non-randomized PMR intervention.SettingTertiary care center.PatientsInterventional group: 60 consecutive patients with a chronic functional movement disorder that underwent the PMR protocol between January 2005 and December 2008. Control group: age- and sex-matched patients with treatment-as-usual (n = 60).InterventionsAn outpatient, one-week intensive rehabilitation program based on the concept of motor-reprogramming following a comprehensive diagnostic neurological evaluation, including psychiatric/psychological assessment.Main outcome measuresImprovement of the movement disorder by the end of the week-long program (patient- and physician-rated), plus the long-term outcome (patient-rated).ResultsPatient demographics: median symptom duration, 17 months (range, 1–276); female predominance (76.7%); mean age 45 years (range, 17–79). Physician-rated outcomes after the one-week treatment program documented 73.5% were markedly improved, nearly normal or in remission, similar to the patient-ratings (68.8%). Long-term treatment outcomes (patient-rated; median follow-up, 25 months) revealed 60.4% were markedly improved or almost completely normal/in remission, compared to 21.9% of controls (p < 0.001).ConclusionsShort-term and long-term successful outcomes were documented in the treatment of patients with functional movement disorders by a rehabilitative, goal-oriented program with intense physical and occupational therapy. The rapid benefit, which was sustained in most patients, suggests substantial efficacy that should be further assessed in a prospective, controlled, clinical trial.     

Time from Onset of SIRS to Antibiotic Administration and Outcomes after Subarachnoid Hemorrhage

Introduction

The interval from presentation with systemic inflammatory response syndrome (SIRS) to the start of antibiotic administration affects mortality in patients with sepsis. However, patients with subarachnoid hemorrhage (SAH) often develop SIRS directly from their brain injury, making it a less useful indicator of infection. We therefore hypothesized that SIRS would not be a suitable trigger for antibiotics in this population.

Methods

We examined the time from the development of SIRS until antibiotic initiation and its relationship to long-term neurological outcomes in patients with nontraumatic SAH. Patients’ baseline characteristics, time of antibiotic administration, and hospital course were collected from retrospective chart review. The primary outcome, 6-month functional status, was prospectively determined using blinded, structured interviews incorporating the modified Rankin Scale (mRS).

Results

Sixty-six of 70 patients with SAH during the study period had 6-month follow-up and were included in this analysis. SIRS developed in 57 patients (86 %, 95 % CI 78–95 %). In ordinal logistic regression models controlling for age and illness severity, the time from SIRS onset until antibiotic initiation was not associated with 6-month mRS scores (OR per hour, 0.994; 95 % CI 0.987–1.001).

Conclusions

In this cohort of patients with SAH, time from SIRS onset until antibiotic administration was not related to functional outcomes. Our results indicate that SIRS is nonspecific in patients with SAH, and support the safety of withholding antibiotics in those who lack additional evidence of infection or hemodynamic deterioration.