Cognitive Functioning and Health Related Quality of Life after Treatment of Intracranial
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AbstractCognitive Functioning and Health Related Quality of Life after Treatment of Intracranial Aneurysms Background: Each year between 8 and 10 per 100 000 people in Norway will suffer an aneurysmal subarachnoid hemorrhage (SAH). Cognitive dysfunction is the most common form of neurological impairment after an aneurysmal SAH with as many as 65% experiencing changes in cognitive functioning as a result of their aneurysmal SAH. In addition a large percentage of patients also experience changes in their daily functioning through reduced Health Related Quality of Life (HRQOL) and inability to return to work. A number of studies have focused on determining the medical causes of these changes in cognitive and HRQOL but so far no consensus have been reached. Aims: The specific aims of the present study were: 1) to explore the time-course of improvement in cognitive dysfunctions the first year after an aneurysmal SAH, 2) to investigate whether an aneurysmal SAH cause a global or focal damage, with special emphasis on the effect of Anterior Communicating Artery (ACoA) aneurysms on frontal lobe functioning, 3) to evaluate the effect of surgery of unruptured intracranial aneurysms (UIAs) compared to ruptured intracranial aneurysms on cognitive function and HRQOL, 4) to explore the cognitive functioning and HRQOL in patients in clinical condition Hunt & Hess grade V after aneurysmal SAH. Material and methods: All patients included in the studies were treated for either an aneurysmal SAH or an UIA at the Department of Neurosurgery at Rikshospitalet University Hospital from January 1st 2002 to June 30th 2007. In study I, 32 patients in clinical condition Hunt & Hess grade I-V were included. In study II, 24 patients in clinical condition Hunt & Hess grade I-III with ruptured ACoA aneurysm or 22 patients in clinical condition Hunt & Hess grade I-III with a ruptured MCA aneurysm were included. In study III, 15 patients with unruptured MCA aneurysm and 22 patients with ruptured MCA aneurysms in clinical condition Hunt & Hess grade I-III were included and finally in Study IV, 26 patients in clinical condition Hunt & Hess grad V aneurysmal SAH were included. Data was collected on medical status using CT/MR, patient journals and clinical interviews by neurosurgeons at 3 and 12 months post aneurysmal SAH/surgery for UIAs. Patients also had a clinical psychological interview. They were tested using a comprehensive neuropsychological test battery and they answered two HRQOL questionnaires (SF-36 & GHQ-30). In Study I, patients were tested neuropsychologically at 3, 6 and12 months after SAH. In Study II, patients were tested neuropsychologically at 12 months. In study III, the UIA patients were tested neuropsychologically pre-operatively, as well as 3 and 12 months post-surgery, while the aneurysmal SAH MCA patients were tested neuropsychologically 3 and 12 months post-aneurysmal SAH. Finally, in Study IV patients were tested neuropsychologically 12 months after their aneurysmal SAH. Statistical comparisons on medical, neuropsychological and HRQOL data were conducted using non-parametric statistical analysis (Mann-Whitney). In addition effect sizes were calculated using Cohens’D. Raw scores for each neuropsychological test were converted into scaled scores based on published norms for each test and then converted to z-scores for easier comparison. Results: We found mild to moderate cognitive deficits in patients in a good outcome (Glasgow Outcome Scale 4-5), with the largest deficits on motor speed and memory function, but close to normal intellectual functioning. Motor functioning seemed to improve rapidly in the first 6 months post-aneurysmal SAH while verbal memory first improved between 6 and 12 months after aneurysmal SAH. Clinical and radiological parameters reflecting the bleed and patient management could be linked to neuropsychological outcome. Our data indicated that an aneursymal SAH cause a global damage, but focal damage could be seen in some cases. For example, we suggested that ACoA patients with medial frontal damage had problems with initiation of problem solving behavior. Elective surgery of unruptured intracranial aneurysm did not cause any substantial permanent cognitive dysfunctions, but had a significant effect on the patients HRQOL. Finally, among patients in clinical condition Hunt & Hess grade V after aneurysmal SAH lower age, higher education and no hydrocephalus in the acute stages had better cognitive outcome. Conclusions: This study showed that many patients with ruptured intracranial aneurysms have cognitive deficits and problems with HRQOL as a result of their aneurysmal SAH. The cognitive deficits improved over time although not always to the pre-morbid level. The cognitive problems were most likely caused by the bleed itself rather than the treatment of the ruptured aneurysm. A focus on cognitive and HRQOL problems in the follow-up of aneurysmal SAH patients is essential and neuropsychological testing should be an integrated part of the treatment of aneurysmal SAH patients.
LIST OF PAPERS
I. Haug T, Sorteberg A, Sorteberg W, Lindegaard K-F, Lundar T, Finset A. Cognitive outcome after aneurysmal subarachnoid hemorrhage: Time-course of cognitive recovery and Relationship to Clinical, Radiological and Management Parameters. Neurosurgery, 60(4), 649-657, 2007.
II. Haug T, Sorteberg A, Sorteberg W, Lindegaard K-F, Lundar T, Finset A. Cognitive functioning and Health Related Quality of Life after rupture of an aneurysm on the anterior communicating artery versus middle cerebral artery. Re-submitted Br J of Neurosurg December 2008.
III. Haug T, Sorteberg A, Sorteberg W, Lindegaard K-F, Lundar T, Finset A. Surgical repair of unruptured and ruptured middle cerebral artery aneurysms: Impact on cognitive functioning and Health Related Quality of Life. Neurosurgery. March 2009 In press.
IV. Haug T, Sorteberg A, Sorteberg W, Lindegaard K-F, Lundar T, Finset A. Cognitive functioning and Health Related Quality of Life one year after aneurysmal subarachnoid hemorrhage in patients in preoperative clinical condition Hunt & Hess grade V. Submitted, Neurosurgery December 2008.