| 书目名称 | Neuropsychological Sequelae of Subarachnoid Hemorrhage and its Treatment | | 编辑 | B. O. Hütter | | 视频video | | | 概述 | The quality of life after SAH is becoming more and more important.Provides a broad survey of the neuropsychological consequences.The author gives special attention to psychological trauma | | 图书封面 |  | | 描述 | The data about different aneurysm locations given in the present work clearly demonstrate that the quality and the severity of the neuropsycho logical impairments after subarachnoid hemorrhage are in particular dependent on the anatomical location and extent of the bleeding. In addition, the sometimes inevitable temporary clipping of perforating vessels seems to play a significant role with respect to later neuropsychological disturbances. Since modern aneurysm surgery is performed in the acute phase shortly after the hemorrhage, the findings reported in the present work are, according to my opinion, of particular relevance. In the light of the present intensive discussion about the indication for microneurosurgical clipping or neuroradiological interventional coiling of intracranial aneurysms, the results given here in by B. O. Hutter can be regarded as an argument for the surgical intervention, in particular because the extravasated blood can only be cleared by surgery. Therefore, this book may be an inspiration for the neurosurgical reader for a closer collaboration with psychologically trained scientists. This is important for all intracranial processes and not only for the to | | 出版日期 | Book 2000 | | 关键词 | Aneurysm; Bleeding; Depression; Neuropsychology; Outcome; Rehabilitation; SAH; Syndrom; Trauma; diagnostics; i | | 版次 | 1 | | doi | https://doi.org/10.1007/978-3-7091-6327-6 | | isbn_softcover | 978-3-211-83442-8 | | isbn_ebook | 978-3-7091-6327-6 | | copyright | Springer-Verlag Wien 2000 |
| 1 |
Front Matter |
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Abstract
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| 2 |
,Introduction, |
B. O. Hütter |
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Abstract
The first description of intracranial aneurysms dates back to the 17th century (Wiseman, 1676). However, two further centuries went by until Hodgson (1815) and later Bramwell (1886) recognized the extravasation of blood under the arachnoid of the brain as the consequence of the rupture of an intracranial aneurysm and named this form of hemorrhage “subarachnoid hemorrhage” (SAH). Until the beginning of the 20th century, a specific and systematic treatment of ruptured intracranial aneurysms was not possible because of the lack of adequate diagnostics (Beadles, 1907; Keen, 1890). The surgical treatment of ruptured intracranial aneurysms developed very slowly and was, despite all efforts, associated with a considerable mortality and morbidity. However, an enormous progress in neurosurgical treatment methods within the last 30 years has led to a considerable improvement of the prognosis. The introduction of the operating microscope, the concept of early surgery within 72 hours of the bleeding, specialized intensive care units, the calcium antagonist nimodipine and a highly differentiated pre-and post-operative management have contributed essentially to this advance (Hütter et al, 1999;
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| 3 |
,Clinical Appearance, Pathology and Diagnostics of Subarachnoid Hemorrhage (SAH), |
B. O. Hütter |
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Abstract
Spontaneous subarachnoid hemorrhage is a hemorrhage into the subarachnoid space between the arachnoid layer and the cortical surface of the brain. The subarachnoid space comprises essentially the basal cisterns, the interhemispherical fissure and the Sylvian fissure (Yasargil, 1984). The incidence of SAH lies between 0.06 and 0.08/1000 persons/year (Linn et al., 1996). There are considerable regional differences with a particularly high incidence in Finland of 0.21/1000 persons/year (Linn et al., 1996). Women are affected approximately 1.6 times more often than men (Linn et al, 1996). Smoking, arterial hypertension and alcohol ingestion of more than 150 g per week increase the risk to sustain an SAH (Teunissen et al., 1996; Taylor et al., 1995). According to an epidemiological study on the incidence of cerebrovascular disease in the community of Oxford and surroundings, the most common primary manifestation in a time span of four years was cerebrovascular occlusive disease with 81%, followed by intracerebral hemorrhage (10%) and subarachnoid hemorrhage with an incidence of 5%, as well as 5% unclear cases (Bamford et al., 1990). In so far, SAH represents a much more infrequent illne
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| 4 |
,Therapy of SAH, |
B. O. Hütter |
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Abstract
In case of SAH due to an acutely ruptured intracranial aneurysm, there are two therapeutic goals: First, to prevent a rebleeding, and, secondly, to treat and to prevent the primary and secondary complications of the bleeding (Gilsbach, Poeck and Piscol, 1993). In case of SAH without a proven source of the bleeding, the emphasis is put on the renewed attempt to identify the source of the bleeding as well as on the treatment of the primary and secondary consequences of the bleeding. The time course is in many ways essential in aneurysmal SAH and determines therapeutic decisions. Maintenance of vital functions and vegetative stabilization of the patient is essential in the first few hours after SAH. In this phase, especially after severe bleedings, respiratory dysregulation and hypertensive crises, as the consequence of vegetative dysregulation, are particularly critical. Only in case of space-occupying hematomas with a rapidly progressive clouding of consciousness, an acute surgical removal of the hematoma is indicated. In approximately 25% of all patients, hydrocephalus with an additional impairment of cerebral perfusion caused by a blockade of the subarachnoid space due to the hemo
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| 5 |
,Special aspects of the pathology and therapy of SAH, |
B. O. Hütter |
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Abstract
The wide distribution of CCT scanners has led to a faster and more reliable diagnosis of SAH. Furthermore, the possibility arose to determine the amount of blood and its anatomical distribution exactly. Therefore, a variety of methods has been proposed to measure the amount of blood after aneurysm rupture based on CCT. Sano, Kanno and Shinomiya (1982) measured the density of a given point in the subarachnoid space in Hounsfield units. Other research groups recorded the thickness of the blood layers in the basal cisterns (Forssell et al., 1995; Gurusinghe and Richardson, 1984; Fisher, Kistler and Davis, 1980). While some scoring systems only quantified the amount of blood in the basal cistern (Hasan and Tanghe, 1992; Hijdra et al., 1990; Gurusinghe and Richardson, 1984), the CCT grading system by Fisher, Kistler and Davis (1980) also takes the presence of intracerebral hematoma and/or intraventricular blood into consideration. On the other hand, the Fisher CCT grading confounds the amount of subarachnoid blood and the presence of intracerebral and/or intraventricular hematoma. However, a separate listing would be more desirable.
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,Cerebral vasospasm after SAH, |
B. O. Hütter |
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Abstract
The introduction and worldwide application of the concept of early surgery after the rupture of an intracranial aneurysm as well as an improved intensive care management in the last two decades have contributed to a significant reduction of morbidity and mortality due to vasospasm. Fisher, Roberson and Ojemann (1977) found that 50% of 50 patients, who had survived SAH caused by aneurysm rupture, developed delayed neurological deficits as a consequence of vasospasm. In the Cooperative Study of Kassell et al. (1990a;b), 7.2% mortality and 6.3% permanent impairments were attributed to vasospasm. In the manifold literature on this topic, data on the incidence of vasospasm and the frequency of associated delayed ischemic deficits vary considerably. Various definitions of vasospasm and differences between the methods used to measure vasospasm are also responsible for the discrepancies.
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,Early surgery of patients grade IV or V after Hunt and Hess, |
B. O. Hütter |
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Abstract
Also at present, early surgery (within 72 hours) of ruptured aneurysms is not acknowledged without limitations by all neurosurgeons, although conservative treatment of patients initially in a bad clinical state (Hunt and Hess grade IV or V) exacts an additional unfavorable influence on morbidity and mortality in this patients group. A number of studies found a mortality of nearly 100% in the conservatively treated group of patients in an initial state corresponding to a Hunt and Hess grading of IV or V. These results led to the conclusion that, regarded in retrospect, approximately half of these patients could possibly have profited from early surgery, because they had died without early surgery of rebleeding or vasospasm (Bailes et al., 1990; Seifert, Trost and Stolke, 1990).
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,Neuropsychological sequelae of SAH, |
B. O. Hütter |
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Abstract
Due to the considerable changes that have evolved in aneurysm surgery and treatment of SAH since the seventies, also the neuropsychological studies completed before that time are not comparable to later investigations. It is sensible, therefore, to present and to discuss the former apart from the more recent studies, conducted since the late nineteen seventies. Based on the substantial differences between the individual clinical departments, it can neither be taken for granted, however, that in all studies published since the nineteen eighties, microneurosurgical methods have been used consistently, nor that the respective units are comparable in terms of surgical, pharmacological and intensive care management of SAH.
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,Basics of scientific research on the neuropsychological sequelae of subarachnoid hemorrhage, |
B. O. Hütter |
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Abstract
The fact that neurological criteria alone do not sufficiently assess the overall state of patients after SAH completely, gives rise to the necessity for a complementary neuropsychological investigation (Hütter and Gilsbach, 1993). Further aspects of the treatment result not to be neglected consist in the emotional state, psychosocial adjustment and competence in everyday life of the patients. A neuropsychological workup must, therefore, not be restricted to the application of cognitive performance tests, but should also cover these additional aspects of the state of the patient. Moreover, a number of studies was able to show that impairment in everyday life and occupational performance are only moderately associated with performance in tests of neuropsychological function (Hütter and Gilsbach, 1995a; Vilkki et al., 1990; Attenberry-Bennett et al., 1989; Chelune, Heaton and Lehman, 1986; Prigatano, 1986; McSweeny et al., 1985; Prigatano, Wright and Levin, 1984; Heaton and Pendleton, 1981). It is, therefore, essential that a thorough assessment of the persisting sequelae of SAH also includes the functional capacity of patients in daily life and their emotional condition.
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,The pattern of cognitive deficits in the chronic state after subarachnoid hemorrhage, |
B. O. Hütter |
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Abstract
In connection with the first attempts to exclude an intracranial aneurysm from circulation, already Goldflam (1923) found that SAH leads to specific neuropsychological and psychopathological symptoms, but not to an impairment of general intelligence. A report from Logue et al. (1968) stems from the early days of aneurysm surgery, even before the introduction of the operating microscope and modern intensive care management. Despite the oftentimes drastic consequences of surgery and the untreatable secondary complications, the authors found a normal level of intelligence in the surviving patients. Also in many later studies, substantial cognitive deficits in patients after SAH were found, but in all studies the average intelligence quotient (IQ) was in the normal range (Hütter, Gilsbach and Kreitschmann, 1995; Hütter and Gilsbach, 1993; Säveland et al., 1992; 1986; Ljunggren et al., 1985; Auer, Gallhofer and Auer, 1985; Sengupta, Chinu and Brierley, 1975). In a follow-up study by Sengupta, Chinu and Brierley (1975), as well as in a study by Auer, Gallhofer and Auer (1985), unremarkable IQ mean values were found in the Wechsler Intelligence Test in patients after aneurysm rupture. On
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,Neuropsychological effects of aneurysm location, |
B. O. Hütter |
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Abstract
For quite some time, the question of the existence of neuropsychological sequelae of the rupture of an intracranial aneurysm depending on its location has been discussed controversially among neuropsychologists (Hütter and Gilsbach, 1996a; 1992; DeLuca, 1993; 1992a;b; 1990; Irle et al., 1992a;b; DeLuca and Cicerone, 1991; Richardson, 1991; 1989; DeSantis, 1989; Larsson et al., 1989; Lindquist, 1975; Lindquist and Norlen, 1966). However, scientific interest has been focused mainly on the consequences of ruptured aneurysms of the ACoA. Therefore, only few investigations on the sequelae of ruptured aneurysms of other localization exist so far. Two different lines of thought can be found in the scientific literature on the question of the effects of aneurysm location. Some authors come to the opinion that there are specific neuropsychological consequences depending on aneurysm location (Irle et al., 1992a;b; Larsson et al., 1989; Lindquist, 1975; Lindquist and Norlen, 1966). Others again concur in the opinion that SAH leads to unspecific brain damage, that is for the greater part independent of the localization of the ruptured aneurysm (Hütter and Gilsbach, 1996a; 1992; Hiitter, Gilsba
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,Impairments in daily life after SAH, |
B. O. Hütter |
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Abstract
Contemporary social medicine differentiates three levels of effects of bodily illnesses: 1. “impairment” as the injured organ system, 2. “disability” as the resulting impaired function and 3. “handicap” as the individual psychosocial consequences (World Health Organization, 1980). Next to the level of neuropsychological impairments which should correspond to disability, the psychosocial impairments are to be mentioned on the handicap level. Although an illness such as SAH often leads to permanent disturbances of brain function, visible bodily impairments are rare. Therefore, it could be termed a “hidden” illness. The consequences of the illness cannot be observed directly by outsiders since no visible impairments or other abnormalities show in the outer appearance of the patient. Six months after the acute event only 20% of all patients exhibit deficits noticeable for outsiders such as pareses or mental impairments as severe aphasias (Gilsbach and Harders, 1989). Nevertheless, the patients are substantially handicapped in their daily functional capacity. Therefore, also in patients after SAH also questions about problems in daily life are of great importance. Based on the brain org
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,Psychological adjustment and depression after SAH, |
B. O. Hütter |
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Abstract
In the chronic state after SAH, increased irritability, changes of personality, loss of interests and initiative, social problems and emotional disturbances frequently persist (Hütter, 1998; Ogden, Utley and Mee, 1997; Hütter, Gilsbach and Kreitschmann, 1995; Säveland et al., 1992; 1986; Stegen and Freckmann, 1991; Maurice-Williams et al., 1991; Vilkki et al., 1990; Sonesson et al., 1989; 1987; Bornstein et al., 1987; Ljunggren et al., 1985). These psychological disturbances and subjective complaints are also present when the degree of neurological and/or cognitive impairments is relatively mild (Hütter, 1998; Hütter, Gilsbach and Kreitschmann, 1995; Stegen and Freckmann, 1991; Vilkki et al., 1990; Ljunggren et al., 1985). Ropper and Zervas (1984) investigated a series of 112 consecutive cases after aneurysm rupture presenting with a good neurological recovery and detected in 25% of their patients, substantial emotional disturbances. Ljunggren et al. (1985) reported that 25% of their SAH patients with a good neurological result (GOS = I) complained of emotional problems in a clinical interview. Säveland et al. (1986) determined that of 21 patients after SAH and aneurysm rupture 5 (
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| 14 |
,Ability to Work and Professional Performance Capacity in Patients after SAH, |
B. O. Hütter |
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Abstract
Next to the severity of neurological impairment, the extent of occupational reintegration and performance capacity is a further criterion often used to assess permanent sequelae of the illness and treatment success in patients after SAH. However, this criterion is subject to several limitations that impair the reliability and power of such information. Changes or regional differences of the labor market may lead to the situation that occupational reintegration of the patient is not successful although his/her functional impairments are relatively slight. Moreover, it is well known that patients with a higher level of education are more likely to return to their old profession despite considerable impairments than patients with a lower level of education. Comparable correlations should also hold true for the factors social status and professional status. Furthermore, this criterion is not applicable to housewives who still constitute a large number of the female patients, which further limits its usefulness. Lastly, the reliability of specifications on occupational reintegration remains doubtful since they are also dependent on the investigator. Additionally, it would have to be exp
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,Neurobehavioral sequelae of SAH without a proven source of the bleeding in comparison to the sequel |
B. O. Hütter |
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Abstract
In 15–22% of all cases of non-traumatic spontaneous SAH a source of the bleeding cannot be identified even after repeated angiography (Cioffi et al., 1989; Alexander, Dias and Uttley, 1986; Spallone et al., 1986; Brismar and Sundbârg, 1985; Eskesen et al., 1984; Nishioka et al, 1984). Ferbert, Hubo and Biniek (1992) found in 38 of 91 patients after spontaneous nontraumatic SAH without a proven source of the bleeding (NA-SAH) a preponderant or exclusive distribution of blood in the prepontine and/or interpeduncular cistern. Ruelle et al. (1985) reported on an essentially more favorable course in 49 NA-SAH patients in comparison to patients after aneurysm rupture. Clinically relevant, angiographically proven vasospasm only occurred in 24.5% of the NA-SAH patients. Upon discharge only one patient presented with a hemiparesis and an aphasia (Ruelle et al., 1985). At follow-up 1–15 (median 8) years later, 94% of the patients were able to work to the same extent as before the hemorrhage.
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,Neuropsychological sequelae of aneurysm surgery, |
B. O. Hütter |
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Abstract
At present only few studies on the direct neuropsychological sequelae of operative measures and events in aneurysm surgery have been published. This shortcoming is all the more serious before the background that an increasing number of authors recently found no significant influence of different aneurysm locations on neuropsychological test performance (Hiitter and Gilsbach, 1996a; 1995a; 1992; Hiitter, Gilsbach and Kreitsch-mann, 1995; Tidswell et al., 1995; Satzger et al., 1995; Ogden, Mee and Henning, 1993a; DeLuca, 1993; 1992a;b; Richardson, 1991; 1989; DeLuca and Cicerone, 1991; Vilkki et al., 1989). Therefore, the surgical exclusion of a ruptured intracranial aneurysm as a possible cause of the observed neuropsychological abnormalities moves further into the foreground. Evidence for a potentially damaging effect of aneurysm surgery even under microneurosurgical conditions is provided by the study of Hornyak, Gilsbach and Harders (1991), who found that of the 23 patients in their consecutive series exhibiting postoperative infarcts, these could be attributed in 19 (83%) patients most probably to the surgical intervention. Prolonged temporary clipping as well as inadvertent dam
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,Neurobehavioral sequelae of the anatomical bleeding pattern, |
B. O. Hütter |
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Abstract
Several authors stress the great prognostic relevance of the presence of intraventricular and/or intracerebral blood for the neurological result after SAH, even if the amount of further subarachnoid blood is small (Gerber et al., 1993; Auer, Schneider and Auer, 1986; Adams, Kassell and Torner, 1985; Gurusinghe and Richardson, 1984; Fisher, Kistler and Davis, 1980). From a neuropsychological point of view, Odgen, Mee and Henning (1993a) reported that SAH patients with intracerebral hemorrhage exhibited a significantly worse memory performance 10 weeks after the acute event which persisted at follow-up 12 months later. However, Tidswell et al. (1995) could not find any correlation between the bleeding pattern on CCT and the cognitive deficits of the patients. It does not become clear from the study of Tidswell et al. (1995) according to which criteria the CCT scans had been evaluated and which aspects of the bleeding pattern were investigated by the authors.
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,Short-and long-term effects of disturbed CSF circulation after SAH, |
B. O. Hütter |
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Abstract
Despite the meanwhile routine use of CCT in patients with SAH, effects of disturbances of the circulation of cerebrospinal fluid (CSF) have rarely been investigated scientifically in patients after SAH. Vassilouthis and Richardson (1979) saw no clinical problem in ventricular enlargement after SAH. On the other hand, Menon, Weir and Overton (1981) observed a decreased cerebral blood flow (CBF) and a poorer clinical state in patients with ventricular enlargement in the acute state after SAH. Hydrocephalus in the acute stage after SAH seems to constitute a particularly unfavorable prognostic factor (Mohr et al., 1983). Van Gijn et al. (1985a) reported that in 30 of 34 patients with acute hydrocephalus after SAH a substantially deteriorated state of consciousness was observed. Hiitter, Gilsbach and Kreitschmann (1995) found that, one to four years after SAH according to the assessment of the life-companions, those patients who had developed hydrocephalus in the postacute clinical course and in whom shunt insertion had been performed were still significantly more impaired in daily life than the patients who had not developed hydrocephalus.
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,Health-related quality of life in patients who had been in Hunt and Hess grades IV or V on admissio |
B. O. Hütter |
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Abstract
Next to a substantial reduction of mortality and morbidity, the progress that has modified neurosurgical treatment of ruptured intracranial aneurysms considerably in the last years has led to increasingly frequent surgery on patients in Hunt and Hess grades IV or V on admission to the neurosurgical unit. In some centers, it is attempted to attain an exclusion of the ruptured aneurysm by early surgery in all patients in a Hunt and Hess grade IV or V with only few exceptions (Hütter et al., 1998; LeRoux et al., 1996b; Spetzger and Gilsbach, 1994; Seifert, Trost and Stolke, 1990; Bailes et al., 1990; Gilsbach et al., 1989; 1988b; Brandt et al, 1987). On the basis of the poor prognosis in this group of SAH patients the question arises in how far and under what conditions the patients surviving after maximal medical therapy show an acceptable quality of life in their later everyday life. Therefore, verification of the prognostic relevance of a number of clinical variables is important for the later quality of life. For this reason, at the Department of Neurosurgery of the University Hospital of the University of Technology (RWTH) Aachen, a prospective study was conducted with the intent
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,Vasospasm: a risk factor for neuropsychological impairments after SAH?, |
B. O. Hütter |
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Abstract
Richardson (1989) found a significantly unfavorable influence of severe angiographically proven postoperative vasospasm on memory performance in comparison to those patients with no or only slight vasospasm. In a retrospective study of 219 patients two to 14 years after SAH, Larsson et al. (1989) found no influence of angiographically proven vasospasm in the acute stage of the illness on later neuropsychological test performance in working memory (Larsson et al., 1989). On the other hand, Gade (1982) found that in amnesties angiographically proven vasospasm was present in the acute stage more frequently, while, in contrast, Teissier Du Cros and Lhermitte (1984) were not able to demonstrate such a connection. In the study of Stenhouse et al. (1991) the neuropsychological most impaired patients had most frequently been subject to severe angiographically proven vasospasm. This was for Stenhouse et al. (1991) the most important cause for the impairments of the patients even though a third of them also presented with hydrocephalus. Moreover, both secondary complications make it plausible that these patients must have sustained a particularly severe bleeding. Unfortunately, detailed data
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发表于 2025-3-21 16:27:33
