Long-term cognitive deficits in patients after surgery on aneurysms of the anterior communicating artery.

259

191

Background-Cognitive dysfunction is a common and disabling sequela of subarachnoid hemorrhage (SAH). Although several clinical and radiographic findings have been implicated in the pathogenesis of cognitive dysfunction after SAH, few prospective studies have comprehensively and simultaneously evaluated these risk factors. Methods-Between July 1996 and March 2000, we prospectively evaluated 113 of 248 consecutively admitted nontraumatic SAH patients alive at 3 months with a comprehensive neuropsychological evaluation. Summary scores for 8 cognitive domains were calculated to express test performance relative to the entire study population. Clinical and radiographic variables associated with domain-specific cognitive dysfunction were identified with forward stepwise multiple regression, with control for the influence of demographic factors. Results-The study participants were younger (Pϭ0.005), less often white (Pϭ0.006), and had better 3-month modified Rankin scores (Pϭ0.001) than those who did not undergo neuropsychological testing. The proportion of subjects who scored in the impaired range (Ͼ2 SD below the normative mean) on each neuropsychological test ranged from 10% to 50%. Predictors of cognitive dysfunction in 2 or more domains in the multivariate analysis included global cerebral edema (4 domains), left-sided infarction (3 domains), and lack of a posterior circulation aneurysm (2 domains). Other variables consistently associated with cognitive dysfunction in the univariate analysis included admission Hunt-Hess grade Ͼ2 and thick SAH in the anterior interhemispheric and sylvian fissures. Conclusions-Global cerebral edema and left-sided infarction are important risk factors for cognitive dysfunction after SAH. Treatment strategies aimed at reducing neurological injury related to generalized brain swelling, infarction, and clot-related hemotoxicity hold the best promise for improving cognitive outcomes after SAH.

Section: Discussioncontrasting

confidence: 53%

Predictors of Cognitive Dysfunction After Subarachnoid Hemorrhage

Kreiter

Copeland

Bernardini

et al. 2002

259

191

“…4 -10 For example, a study found cognitive dysfunction in 83% of SAH survivors 3 to 5 years after hemorrhage. 4 The nature of the cognitive impairment depends on the site of the aneurysm, 5 but the most common impairments cited are aphasia, memory deterioration, and spatial deficits. 4,[7][8][9][10] Cognitive deficits associated with SAH result from the detrimental effect on the brain of the blood itself, 11 associated hydrocephalus, increased intracranial pressure, vasospasm and subsequent ischemia, or other complications.…”

mentioning

confidence: 99%

Craniotomy for Treatment of Unruptured Aneurysms Is Not Associated With Long-Term Cognitive Dysfunction

Tuffiash

Tamargo

Hillis

2003

Background and Purpose-Many studies have reported frequent cognitive deficits associated with subarachnoid hemorrhage (SAH) and aneurysm repair. One study found more severe cognitive deficits after clipping than coiling of aneurysms, raising the possibility that deficits are due to surgery instead of SAH itself. This possibility was directly addressed by evaluating the cognitive effects of surgery without SAH. The goal of this study was to identify changes in cognitive function associated with surgical clipping of unruptured intracerebral aneurysms. Methods-A consecutive series of 25 patients who underwent surgical clipping of Ն1 unruptured intracerebral aneurysm were tested within 1 week preoperatively and again postoperatively (before hospital discharge and at 3-month follow-up if they had deficits at discharge) on a neuropsychological battery. Different forms of each test were used preoperatively and postoperatively to reduce practice effects. Paired t tests were used to examine differences between preoperative and postoperative test scores across individuals. Results-On most tests, there was no significant change between preoperative and postoperative scores. A significant decline in accuracy before hospital discharge was found only in figure copying (PϽ0.04) and associative learning (PϽ0.01), and significant slowing was found on 1 test (PϽ0.01). Even on these tests, only 3 of 25 patients showed significant deterioration. All but 1 patient returned to baseline by the 3-month follow-up. Conclusions-We found no evidence of subtle cognitive deficits resulting from aneurysm clipping alone, suggesting that the common impairments after surgery for ruptured aneurysms are due to SAH itself, complications of SAH such as vasospasm or hydrocephalus, or perioperative stroke.

“…5 Controversy exists regarding the impact of anatomical location of the aneurysm on cognitive function after SAH. Early studies 21,[25][26][27] suggested patients with anterior communicating artery aneurysms are particularly susceptible to amnesia although recent reports 23,24,[27][28][29][30][31] failed to find a difference related to aneurysm location. Lack of standardized time of follow-up and small numbers of patients in some investigations potentially contributed to the differences.…”

Section: Discussionmentioning

confidence: 99%

Recovery of Cognitive Function After Surgery for Aneurysmal Subarachnoid Hemorrhage

Samra

Giordani

Caveney

et al. 2007

Background and Purpose-Abnormalities in neurocognitive function are common after surgery for aneurysmal subarachnoid hemorrhage, even among patients with good functional outcomes. The time course of neurocognitive recovery, along with the long-term effects of mild intraoperative hypothermia (33°C) and aneurysm location, is unknown. We determined these in a subset of subarachnoid hemorrhage patients enrolled in the Intraoperative Hypothermia for Aneurysm Surgery Trial (IHAST). Methods-We performed a longitudinal, multicenter, prospective, blinded study of adult IHAST patients with a Glasgow Outcome Scoreϭ1 or 2 (independent function), 3 months postsurgery and a matched control group (nϭ45). Subjects were tested with a 5-test cognitive function battery and standard neurological evaluations at 3, 9 and 15 months postsurgery. The primary outcome measure was a composite score on cognitive test performance. Results-There were 303 IHAST patients available for inclusion: 218 eligible, 185 enrolled (89 hypothermic, 96 normothermic). Significant cognitive improvement was noted from 3 to 9 (PϽ0.001) and 3 to 15 (PϽ0.001) months in both hypothermic and normothermic groups, even after adjusting for practice effects observed in the control group. No significant change was identified between 9 and 15 months. Neither mild hypothermia nor aneurysm location (anterior communicating artery versus others) had a significant effect on recovery over time or frequency of cognitive impairment. Compared with control group, the frequency of cognitive impairment (Z score ϽϪ1.96) in all patients at 3, 9 and 15 months was 36%, 26% and 23%, respectively. Conclusions-In this population, cognitive improvement continued beyond 3 months, with a plateau between 9 and 15 months. This was not affected by the use of intraoperative hypothermia or anatomical location of aneurysm. (Stroke.