Long-term cognitive deficits in patients with good outcomes after aneurysmal subarachnoid hemorrhage from anterior communicating artery

Aim

To evaluate long-term cognitive consequences of subarachnoid hemorrhage with good outcome and the opinion of patients and their relatives about these consequences.

Methods

The study included 10 patients surgically treated for subarachnoid hemorrhage due to the rupture of aneurysm of the anterior communicating artery 2 or more years earlier, and 10 age- and sex-matched healthy controls. The preoperative and postoperative course in the patients was uneventful. Clinical and psychosocial factors and cognitive status of the patients were assessed by use of checklists and neuropsychological tests for executive functions, attention, and memory, and event-related potential recordings (waves P3a and P3b) with tree-stimulus auditory oddball paradigm, which was also performed in healthy controls.

Results

The number of reported cognitive problems negatively correlated with the patients’ level of community integration (ρ range, -0.22 to -0.75). The average neuropsychological results ranged between the 12th and 46th percentile. Impaired results were found in 7 patients across different tests and were most frequent for visual memory, followed by verbal memory and executive functions. A clear decline in cognitive functioning was observed in 3 patients. Neither P3a nor P3b wave could be found in 3 patients. In comparison with controls, patients had significantly longer P3b wave latencies (364 vs 334 ms; Mann-Whitney U test, P = 0.025). We found statistically non-significant, but still prominent negative correlations between the sustained attention results and latencies of P3a (ρ = -0.58; P = 0.172) and P3b (ρ = -0.58; P = 0.172) waves.

Conclusion

Despite good outcome after subarachnoid hemorrhage, persistent cognitive consequences were still manifest, limiting the patients'' psychosocial functioning. The correlation between neuropsychological and neurophysiological measures indicated frontal lobe damage, which in some patients persisted for years after the hemorrhage.Aneurysmal subarachnoid hemorrhage leaves around 50% of the patients permanently disabled (1), with the same percentage unable ever to return to the same level of work they had had before the event (2). Cognitive dysfunction, a common consequence of aneurysmal subarachnoid hemorrhage (3), is present to various degrees even in patients with good outcomes and without neurological deficits (4), causing considerable distress not only to the patients themselves, but also to their families. The persistence of cognitive dysfunction can have a profound influence on the rehabilitation process and social and occupational reintegration of the patients.Patients may experience deficits in executive functions, memory, psychomotor speed, attention, visuospatial abilities, and other cognitive domains (3,5-7). The typical pattern is thought to be mild-to-moderate dysfunction across multiple cognitive domains (8,9), although some studies have confirmed only severe impairment in a subset of patients rather than mild-to-moderate impairment in most of them (3).Reports on different patterns of cognitive deficit, depending on the site of the aneurysm, are inconsistent (3,10). Different patterns may be present in patients with aneurysmal subarachnoid hemorrhage in identical locations (11). Earlier studies that explored cognitive deficits after subarachnoid hemorrhage from the anterior communicating artery (ACoA) described a special “ACoA syndrome”, characterized by amnesia, personality changes, and confabulation as the main symptoms (12-16), where damage to particular anterior cerebral structures was a suspected cause (14,15,17). However, other studies did not find specific deficits in ACoA patients, and a more diffuse pattern of brain damage was thought to be responsible for the deficits (9,18,19).Accurate cognitive assessment of patients after aneurysmal subarachnoid hemorrhage could improve treatment measures in the preoperative and postoperative periods and help in accurate guidance of rehabilitation. Previous studies have not simultaneously addressed patients’ and relatives’ views of cognitive deficits, their level of community integration, and the results of neuropsychological and neurophysiological tests. In this study, we explored long-term cognitive deficits in a small, selected group of patients with good outcome after subarachnoid hemorrhage due to the rupture of the anterior communicating artery aneurysm. Our aim was to determine whether long-term changes in brain functioning could be detected with a simple and objective method that could be of potential use at different time points after subarachnoid hemorrhage, and to determine if diminished cognitive capacities seen on neuropsychological test results were also reflected in neurophysiological measurements, since this could also provide some information regarding localization and the degree of brain damage.     

Recurrent giant invasive thoracolumbar schwannoma

Giant invasive spinal schwannoma is a new term proposed by Sridhar in 2001 for a particularly aggressive type of benign spinal schwannoma. Only a few cases have been published, the majority of these located in the lumbosacral spine, two in the thoracic and only one in the cervical spine. A rare case of such a tumor is presented. The tumor predominantly occupied level L1 and partially levels T12 and L2, and recurred 13 years after the first seemingly radical excision of a benign melanotic schwannoma. The highly vascularized tumor was radically excised using the dorsal approach, and a Sokon transpeduncular fixation was performed. Carter's lateral thoraco-abdominal access allowed the retroperitoneal and intravertebral expansions of the tumor to be removed and L1 corpectomy to be accomplished. Ventral vertebral stabilization was achieved with a titanium cage. After the operation, the pain in the patient's left leg subsided. Three years after the management, he is still pain-free, able to walk freely and to resume his usual daily activities.     

Accidental poisoning with autumn crocus

We describe a case of a 43-yr-old female with severe multiorgan injury after accidental poisoning with Colchicum autumnale, which was mistaken for wild garlic (Allium ursinum). Both plants grow on damp meadows and can be confused in the spring when both plants have leaves but no blossoms. The autumn crocus contains colchicine, which inhibits cellular division. Treatment consisted of supportive care, antibiotic therapy, and granulocyte-directed growth factor. The patient was discharged from the hospital after three weeks. Three years after recovery from the acute poisoning, the patient continued to complain of muscle weakness and intermittent episodes of hair loss.     

Monitoring mixed venous oxygen saturation in patients with obstructive shock after massive pulmonary embolism

BACKGROUND: Patients with massive pulmonary embolism and obstructive shock usually require hemodynamic stabilization and thrombolysis. Little is known about the optimal and proper use of volume infusion and vasoactive drugs, or about the titration of thrombolytic agents in patients with relative contraindication for such treatment. The aim of the study was to find the most rapidly changing hemodynamic variable to monitor and optimize the treatment of patients with obstructive shock following massive pulmonary embolism. PATIENTS AND METHODS: Ten consecutive patients hospitalized in the medical intensive care unit in the community General Hospital with obstructive shock following massive pulmonary embolism were included in the prospective observational study. Heart rate, systolic arterial pressure, central venous pressure, mean pulmonary-artery pressure, cardiac index, total pulmonary vascular-resistance index, mixed venous oxygen saturation, and urine output were measured on admission and at 1, 2, 3, 4, 8, 12, and 16 hours. Patients were treated with urokinase through the distal port of a pulmonary-artery catheter. RESULTS: At 1 hour, mixed venous oxygen saturation, systolic arterial pressure and cardiac index were higher than their admission values (31+/-10 vs. 49+/-12%, p<0.0001; 86+/-12 vs. 105+/-17 mmHg, p<0.01; 1.5+/-0.4 vs. 1.9+/-0.7 L/min/m2, p<0.05; respectively), whereas heart rate, central venous pressure, mean pulmonary-artery pressure and urine output remained unchanged. Total pulmonary vascular-resistance index was lower than at admission (29+/-10 vs. 21+/-12 mmHg/L/min/m2, p<0.05). The relative change of mixed venous oxygen saturation at hour 1 was higher than the relative changes of all other studied variables (p<0.05). Serum lactate on admission and at 12 hours correlated to mixed venous oxygen saturation (r=-0.855, p<0.001). CONCLUSION: In obstructive shock after massive pulmonary embolism, mixed venous oxygen saturation changes more rapidly than other standard hemodynamic variables.     

Classification of Hot-Rolled Plates Using the Mahalanobis Distance of NMIs in Ti-Stabilized Austenitic Stainless-Steel Produced by Secondary Metallurgy

Three charges of scrap-based, Ti-stabilized, Cr-Ni-Mo austenitic stainless steel in the form of hot-rolled steel plates were characterized. Based on automated metallographic analyses of representative microstructures, a quality characterization in terms of cleanliness of the hot-rolled steel plates was performed. Elevated contents of impurities, especially Pb, Bi, and oxygen, which affect the hot workability of stainless steels, were detected. The recycled FeTi-cored wire was the main source of the elevated levels of impurities detected in the hot-rolled, Ti-stabilized, stainless-steel plates. Related to this, elevated levels of nonmetallic inclusions (NMIs) and segregations were formed. The three charges were classified based on calculations of the Mahalanobis distance (MD) between the inclusions. The charge with the smallest number of nonmetallic inclusions was set as the reference class. The selection of outlier inclusions based on their MDs and their back-representation into ternary diagrams gave relevant metallurgical information about the abnormalities. The advantage of this technique is that the calculations of the MD and the threshold can be fully automated.     

Statistical Modelling of the Fatigue Bending Strength of Norway Spruce Wood

When wood is used as a structural material, the fact that it is a highly inhomogeneous material, which significantly affects its static and fatigue properties, presents a major challenge to engineers. In this paper, a novel approach to modelling the fatigue-life properties of wood is presented. In the model, the common inverse-power-law relationship between the structural amplitude loads and the corresponding number of load cycles to failure is augmented with the influence of the wood’s mass density, the loading direction and the processing lot. The model is based on the two-parametric conditional Weibull’s probability density function with a constant shape parameter and a scale parameter that is a function of the previously mentioned parameters. The proposed approach was validated using the example of experimental static and fatigue-strength data from spruce beams. It turned out that the newly presented model is capable of adequately replicating the spruce’s S-N curves with a scatter, despite the relatively scarce amount of experimental data, which came from different production lots that were loaded in different directions and had a significant variation in density. Based on the experimental data, the statistical model predicts that the lower density wood has better fatigue strength.     

Helical High-Resolution Volume-Rendered 3-Dimensional Computer Tomography Angiography in the Detection of Intracranial Aneurysms

BACKGROUND AND PURPOSE: This study was carried out to determine whether high-resolution 3-dimensional prospective-volume-rendered computed tomographic (CT) angiography can replace conventional intra-arterial digital subtractional angiography in the diagnostic evaluation of patients with an acute subarachnoid hemorrhage (SAH) due to ruptured intracranial aneurysm. METHODS: Both techniques were performed in 30 consecutive patients within 2 to 12 hours after their admission to the hospital. RESULTS: In this group of 30 patients, CT angiography with 3-dimensional volume-rendered reconstruction detected 31 aneurysms in 25 patients. Two aneurysms were missed on CT angiography. Conventional angiography detected 33 aneurysms in 27 patients. The authors considered angiograms in 3 patients presenting with SAH as normal. In all cases where an aneurysm was detected on CT angiography, the finding was confirmed by conventional angiography. CONCLUSIONS: CT angiography with 3-dimensional post-processing is a sensitive, noninvasive method that provides a 3-dimensional view of intracranial vessels and the aneurysm. It is also very useful in planning either surgical or endovascular treatment.     

Correspondence between the time course of cerebral vasospasm and the level of cerebral dopamine-beta-hydroxylase in rabbits

The aim of the study was to explore whether the biphasic time course of the vasospastic response following experimental subarachnoid hemorrhage is associated with any concomitant changes in the amount of cerebral dopamine beta-hydroxylase in the noradrenergic central nervous system. A single-hemorrhage animal model was used. Rabbits were sacrificed from day 1 to day 8 after subarachnoid hemorrhage. Intimal corrugation of the basilar artery and the amount of cerebral dopamine beta-hydroxylase in the hypothalamus and brain stem were measured each day. Vasospastic changes occurred in the biphasic manner following subarachnoid hemorrhage. More profound vasospastic corrugation occurred in the acute phase, followed by a slightly less intense corrugation in the chronic phase (between days 5 and 8 after the subarachnoid hemorrhage). Simultaneously, a clear concomitant biphasic time course developed in the form of an increased amount of dopamine-beta-hydroxylase in the noradrenergic nervous system of the rabbit hypothalamus and brain stem during the acute and chronic phases after the subarachnoid hemorrhage. Statistically significant correlation between basilar artery corrugation and the amount of dopamine beta-hydroxylase was found. These results suggest the possible role of the central sympathetic system in the pathogenesis of vasospasm. At the same time, this study demonstrates the chronological similarity of the vasospastic development after subarachnoid hemorrhage in the animal experimental model with the human time course of vasospasm.