The mortality rate has recently been reduced to only a small percentage of patients selected for early aneurysm surgery. Despite recovery without neurological deficits, however, a diffuse encephalopathy may remain, with emotional and psychological sequelae that will interfere with rehabilitation and social reintegration. The present study evaluates quality of life, degree of cognitive dysfunction, and adjustment of patients with a satisfactory neurological recovery after aneurysm operation in the acute stage following a major subarachnoid hemorrhage (SAH). Of 118 patients with a good neurological recovery, 40 patients were randomly sampled for a cross-sectional study and subjected to a questionnaire relating to their symptoms, a clinical interview, and a comprehensive neuropsychological investigation. The time interval between SAH and assessment varied between 14 months and 7 years, averaging 3 1/2 years. By means of standardized psychometric testing of intellectual capacity, memory functions, visuo-spatial abilities, perceptual speed and accuracy, and concept formation, degrees of cognitive impairment ranging from slight to severe dysfunction were identified. The results suggest that these disturbances may be permanent. The degree of impairment appeared to correlate with the patients' age. Interview data revealed substantial post-hemorrhagic maladjustment with respect to vitality, social management, self-assertion, emotional control, temperament, mood, and cognitive abilities. These findings were considerably at variance with the symptoms reported. It is stressed that, in the absence of gross neurological deficits, vital information on post-hemorrhage adjustment and impairment may easily be overlooked due to psychological defensive measures. It remains an open question whether post-SAH encephalopathy is enhanced by surgery performed in the acute stage.

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Seventy-eight individuals among a population of 1.46 million suffered aneurysmal subarachnoid hemorrhage (SAH) during 1983. Within 24 hours after the bleed, 32 of the 78 patients were in Hunt and Hess neurological Grades I to II, 13 were in Grade III, 21 were in Grades IV to V, and 12 were dead on admission to a hospital or forensic department. When the amount of blood visualized on computerized tomography (CT) scanning was integrated with the Hunt and Hess neurological classification in order to improve prediction of prognosis, only 16 patients were considered to have a good prognosis (CT-modified Grades I to II), 21 had a less favorable prognosis (CT-modified Grade III), and 29 had a poor prognosis (CT-modified Grades IV to V). Assessment at 1 year revealed that only 32 patients (41%) had a good physical recovery. The physical morbidity rate was 22%, and the overall mortality rate was 37%. Twenty-six individuals with a good neurological outcome and five with a fair outcome also underwent reexamination 1 year or more post-SAH, which included a comprehensive evaluation of the quality of life, assessment of cognitive dysfunction, and determination of general adjustment. Five of the patients with a good neurological outcome and all five with a fair outcome (four of whom had had a poor prognosis in the acute stage) showed severe psychosocial and cognitive incapacitation. When functional morbidity, based upon persistent severe cognitive and psychosocial impairment, was included in the outcome assessment, only 33% of the total series was considered to have a favorable outcome. Approximately 60% of the initially good-risk patients (Grades I and II) showed a good physical outcome without concomitant indications of severe cognitive dysfunction and/or psychosocial impairment. Among the good-risk patients with a CT-modified grade, the figure was 70%. It is suggested that in any outcome grading system, persistent cognitive and psychosocial disturbances be taken into account.

SUMMARY1. In albino rats the botulinum poisoned gastrocnemius muscle was supplied with an accessory motor nerve in order to investigate whether muscle fibres with structurally intact but non-transmitting synapses would accept additional innervation. As a control similar operations were made in unpoisoned rats.2. One to three months after nerve implantation the muscles were examined histologically for the presence of a new end-plate zone. In botulinum treated muscles 1662 + 165 (mean + S.D.) of new end-plates were found. In the control animals only a few (90 + 13) were observed in the immediate vicinity of the implanted nerve trunk.3. Following recovery from the paralysing action of botulinum toxin electrical stimulation of both the implanted and the original motor nerve evoked strong mechanical twitches in the gastrocnemius muscle.4. When the nerves were stimulated simultaneously little or no summation of tension occurred, indicating that presumably many of the muscle fibres with new end-plates also had functionally intact junctions from the original nerve. The presence of two end-plates in a muscle fibre was confirmed in a few experiments on single curarized fibres by intracellular recording of end-plate potentials on stimulation of each nerve.

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