Tonje Haug Nordenmark, Tanja Karic, Cecilie Røe, Wilhelm Sorteberg and Angelika Sorteberg
Although many patients recover to a good functional outcome after aneurysmal subarachnoid hemorrhage (aSAH), residual symptoms are very common and may have a large impact on the patient’s daily life. The particular cluster of residual symptoms after aSAH has not previously been described in detail and there is no validated questionnaire that covers the typical problems reported after aSAH. Many of the symptoms are similar to post-concussion syndrome, which often is evaluated with the Rivermead Post-Concussion Symptoms Questionnaire (RPQ). In the present study, the authors therefore performed an exploratory use of the RPQ as a template to describe post-aSAH syndrome.
The RPQ was administered to 128 patients in the chronic phase after aSAH along with a battery of quality-of-life questionnaires. The patients also underwent a medical examination besides cognitive and physical testing. Based on their RPQ scores, patients were dichotomized into a “syndrome” group or “recovery” group.
A post-aSAH syndrome was seen in 33% of the patients and their symptom burden on all RPQ subscales was significantly higher than that of patients who had recovered on all RPQ subscales. The symptom cluster consisted mainly of fatigue, cognitive problems, and emotional problems. Physical problems were less frequently reported. Patients with post-aSAH syndrome scored significantly worse on mobility and pain scores, as well as on quality-of-life questionnaires. They also had significantly poorer scores on neuropsychological tests of verbal learning, verbal short- and long-term memory, psychomotor speed, and executive functions. Whereas 36% of the patients in the recovery group were able to return to their premorbid occupational status, this was true for only 1 patient in the syndrome group.
Approximately one-third of aSAH patients develop a post-aSAH syndrome. These patients struggle with fatigue and cognitive and emotional problems. Patients with post-aSAH syndrome report more pain and reduced quality of life compared to patients without this cluster of residual symptoms and have larger cognitive deficits. In this sample, patients with post-aSAH syndrome were almost invariably excluded from return to work. The RPQ is a simple questionnaire covering the specter of residual symptoms after aSAH. Being able to acknowledge these patients’ complaints as a defined syndrome using the RPQ should help patients to accept and cope, thereby alleviating possible secondary distress produced.
Anne-Berit Fjelstad, Jorunn Hommelstad and Angelika Sorteberg
The purpose of this study was to determine the frequency of infection and to identify risk factors for infection in connection with the implantation of an intrathecal baclofen (ITB) pump.
This retrospective study included all pediatric and adult patients who received ITB at Rikshospitalet during the years 1999–2005. A database was created that included the following variables: patient age, sex, weight, diagnosis, surgical procedure performed, presence of a percutaneous endoscopic gastrostomy (PEG) tube, urinary as well as fecal incontinence, anesthetist's classification of patient status (American Society of Anesthesiologists grade), timing of antibiotics administration, surgeon, assisting nurse, and surgical procedure time. Moreover, the mode of intrathecal screening trial (transcutaneous vs subcutaneous catheter insertion) and any complications were registered. The authors differentiated between deep and superficial infection, and they registered the causative agent.
A total of 163 patients received ITB; of these, 91 were pediatric patients (median age 10 years), and 72 were adults (median age 44 years). A total of 408 surgical procedures were performed. No infections occurred in direct relation to the screening trials. When a pump was implanted subsequent to a screening trial with transcutaneous catheter insertion, the rate of infection was 9% in the pediatric patients. The corresponding infection rate for pumps implanted after a screening trial with a subcutaneous distal catheter (Albright method) was 12%. This difference was not significant. There was a significantly higher incidence of deep infections following pump implantation in the pediatric group (p = 0.028) than in the adult group. The presence of a PEG tube increased the incidence of infection (p = 0.008) and may be one of the main reasons for a higher frequency of infections in children. When the patient suffered urinary and/or fecal incontinence, there was a higher chance of infection (p = 0.021). The surgical time was significantly longer in the pediatric group than in adults; however, the length of the surgical procedure had no impact on the occurrence of infection. The most common causative agent was Staphylococcus aureus; this microbe was responsible for 69% of deep infections. Also, 69% of deep infections occurred within 1 month after surgery.
The rate of infection is significantly higher in children undergoing ITB pump implantation than it is in adults. Screening trials applying the Albright method fail to reduce the frequency of infection subsequent to pump implantation. The presence of a PEG tube has the greatest significance as a predictor of infection.
Tanja Karic, Cecilie Røe, Tonje Haug Nordenmark, Frank Becker, Wilhelm Sorteberg and Angelika Sorteberg
Early rehabilitation is effective in an array of acute neurological disorders but it is not established as part of treatment guidelines after aneurysmal subarachnoid hemorrhage (aSAH). This may in part be due to the fear of aggravating the development of cerebral vasospasm, which is the most feared complication of aSAH. The aim of this study was to evaluate the effect of early rehabilitation and mobilization on complications during the acute phase and within 90 days after aSAH.
This was a prospective, interventional study that included patients with aSAH at the neuro-intermediate ward after aneurysm repair. The control group received standard treatment, whereas the early rehab group underwent early rehabilitation and mobilization in addition to standard treatment. Clinical and radiological characteristics of patients with aSAH, progression in mobilization, and treatment variables were registered. The frequency and severity of cerebral vasospasm, cerebral infarction acquired in conjunction with the aSAH, and acute and chronic hydrocephalus, as well as pulmonary and thromboembolic complications, were compared between the 2 groups.
Clinical and radiological characteristics of patients with aSAH were similar between the groups. The early rehab group was mobilized beginning on the first day after aneurysm repair. The significantly quicker and higher degree of mobilization in the early rehab group did not increase complications. Clinical cerebral vasospasm was not as frequent in the early rehab group and it also tended to be less severe. Each step of mobilization achieved during the first 4 days after aneurysm repair reduced the risk of severe vasospasm by 30%. Acute and chronic hydrocephalus were similar in both groups, but there was a tendency toward earlier shunt implantation among patients in the control group. Pulmonary infections, thromboembolic events, and death before discharge or within 90 days after the ictus were similar between the 2 groups.
Early rehabilitation of patients after aSAH is safe and feasible. The earlier and higher degree of mobilization does not increase neurosurgical complications. Rather, the frequency and severity of cerebral vasospasm following aSAH are alleviated and are not aggravated by early rehabilitation.
Clinical trial registration no.: NCT01656317 (www.clinicaltrials.gov).
Per Kristian Eide, Angelika Sorteberg, Gunnar Bentsen, Pål Bache Marthinsen, Audun Stubhaug and Wilhelm Sorteberg
Indices of cerebrovascular pressure reactivity (CPR) represent surrogate markers of cerebral autoregulation. Given that intracranial pressure (ICP) wave amplitude–guided management, as compared with static ICP-guided management, improves outcome following aneurysmal subarachnoid hemorrhage (SAH), indices of CPR derived from pressure wave amplitudes should be further explored. This study was undertaken to investigate the value of CPR indices derived from static ICP–arterial blood pressure (ABP) values (pressure reactivity index [PRx]) versus ICP-ABP wave amplitudes (ICP-ABP wave amplitude correlation [IAAC]) in relation to the early clinical state and 12-month outcome in patients with aneurysmal SAH.
The authors conducted a single-center clinical trial enrolling patients with aneurysmal SAH. The CPR indices of PRx and IAAC of Week 1 after hemorrhage were related to the early clinical state (Glasgow Coma Scale [GCS] score) and 12-month outcome (modified Rankin Scale score).
Ninety-four patients were included in the study. The IAAC, but not the PRx, increased with decreasing GCS score; that is, the higher the IAAC, the worse the clinical state. The PRx could differentiate between survivors and nonsurvivors only, whereas the IAAC clearly distinguished the groups “independent,” “dependent,” and “dead.” In patients with an average IAAC ≥ 0.2, mortality was approximately 3-fold higher than in those with an IAAC < 0.2.
The IAAC, which is based on single ICP-ABP wave identification, relates significantly to the early clinical state and 12-month outcome following aneurysmal SAH. Impaired cerebrovascular pressure regulation during the 1st week after a bleed relates to a worse outcome. Clinical trial registration no.: NCT00248690.
Torstein R. Meling, Angelika Sorteberg, Søren J. Bakke, Haldor Slettebø, Juha Hernesniemi and Wilhelm Sorteberg
The object of this study was to evaluate cases of subarachnoid hemorrhage (SAH) from ruptured blood blister–like aneurysms (BBAs) of the internal carotid artery (ICA) trunk.
The authors performed a single-center, retrospective study. Data analyzed were patient age, sex, Hunt and Hess grade, Fisher grade, time from SAH to hospitalization, aneurysm size and location, collateral capacity of the circle of Willis, time from hospitalization to aneurysm repair, type of aneurysm repair, complications, and Glasgow Outcome Scale (GOS) score at follow-up.
A total of 211 patients suffered SAH from ICA aneurysms. Of these, 14 patients (6.6%) had ICA trunk BBAs; 6 men and 8 women. The median age was 47.8 years (range 29.9–67.7 years). The Hunt and Hess grade was IV or V in 7 cases, and SAH was Fisher Grade 3 + 4 in 6. All aneurysms were small (< 1 cm), without relation to vessel bifurcations, and usually located anteromedially on the ICA trunk. Three patients were treated with coil placement and 11 with clip placement. Of the 7 patients in whom the ICA was preserved, only 1 had poor outcome (GOS Score 2). In contrast, cerebral infarcts developed in all patients treated with ICA sacrifice, directly postoperatively in 2 and after delay in 5. Six patients died, 1 survived in poor condition (GOS Score 3; p < 0.001).
Internal carotid BBAs are rare, small, and difficult to treat endovascularly, with only 2 of 14 patients successfully treated with coil placement. The BBAs rupture easily during surgery (ruptured in 6 of 11 surgical cases). Intraoperative aneurysm rupture invariably led to ICA trap ligation. Sacrifice of the ICA within 48 hours of an SAH led to very poor outcome, even in patients with adequate collateral capacity on preoperative angiograms, probably because of vasospasm-induced compromise of the cerebral collaterals.