Ruptured Isolated Aneurysm of a Coronal Branch of the Anterior Spinal Artery: Case Report and Discussion of Treatment Strategies.

BACKGROUND: Isolated spinal artery aneurysms are an extremely rare cause of subarachnoid hemorrhage. A limited number of case reports and case series have been reported in the literature. Treatment options include conservative management, surgical clipping/trapping, and endovascular procedures. Owing to the uncertain natural history of these lesions, there is no consensus about the optimal treatment. CASE DESCRIPTION: A 64-year-old man presented with subarachnoid hemorrhage from a ruptured anterior spinal artery aneurysm at the C1 level. Following initial conservative management, surgical treatment was proposed owing to an increase in lesion size at angiographic follow-up. A partially thrombosed aneurysm was found during surgery, suggesting that spontaneous resolution of the aneurysm was occurring. Despite initial worsening of neurological symptoms, the patient gradually recovered after rehabilitation. CONCLUSIONS: Treatment decisions for spinal aneurysms should be made on a case-by-case basis, the goal being to offer the patient the best option, while avoiding exposure to unnecessary invasive procedures. As spontaneous resolution of a spinal artery aneurysm is unpredictable, our case highlights the importance of performing a perioperative vascular study if surgery is planned.

Common Data Elements for Unruptured Intracranial Aneurysm and Subarachnoid Hemorrhage Clinical Research: Recommendations from the Working Group on Long-Term Therapies.

OBJECTIVES: The goal for the long-term therapies (LTT) working group (WG) of the Unruptured Intracranial Aneurysm (UIA) and Subarachnoid Hemorrhage (SAH) common data elements (CDEs) was to develop a comprehensive set of CDEs, data definitions, case report forms, and guidelines for use in UIA and SAH LTT clinical research, as part of a new joint effort between the National Institute of Neurological Disorders and Stroke (NINDS) and the National Library of Medicine of the US National Institutes of Health. These UIA and SAH CDEs will join other neurological disease-specific CDEs already developed and available for use by research investigators. METHODS: The eight LTT WG members comprised international UIA, and SAH experts reviewed existing NINDS CDEs and instruments, created new elements when needed, and provided recommendations for future LTT clinical research. The recommendations were compiled, internally reviewed by the all UIA and SAH WGs and steering committee members. The NINDS CDE team also reviewed the final version before posting the SAH Version 1.0 CDE recommendations on the NINDS CDE website. RESULTS: The NINDS UIA and SAH LTT CDEs and supporting documents are publicly available on the NINDS CDE ( https://www.commondataelements.ninds.nih.gov/#page=Default ) and NIH Repository ( https://cde.nlm.nih.gov/home ) websites. The subcommittee members discussed and reviewed various parameters, outcomes, and endpoints in UIA and SAH LTT studies. The following meetings with WG members, the LTT WG's recommendations are incorporated into the disease/injury-related events, assessments and examinations, and treatment/intervention data domains. CONCLUSIONS: Noting gaps in the literature regarding medication and rehabilitation parameters in UIA and SAH clinical studies, the current CDE recommendations aim to arouse interest to explore the impact of medication and rehabilitation treatments and therapies and encourage the convergence of LTT clinical study parameters to develop a harmonized standard.

Injury of optic radiation and visual field defect in a patient with aneurysmal subarachnoid hemorrhage: A case report.

RATIONALE: Little is known about optic radiation (OR) injury following aneurysmal subarachnoid hemorrhage (SAH). In the current study, we report on a patient who showed a visual field defect and injury of the OR following aneurysmal SAH, using diffusion tensor tractography (DTT). PATIENT CONCERNS: At 4 weeks from onset, when a 62-year old female started rehabilitation, she complained of a visual field defect. Peripheral field defects were detected on both eyes using the Humphrey visual field test. DIAGNOSES: The patient underwent aneurysm clipping for a ruptured aneurysm in the left posterior communicating artery and extraventricular drainage (the left prefrontal approach) for subarachnoid hemorrhage. She also underwent conservative management for intracerebral hemorrhage in the left internal capsule detected at 2 days after onset. INTERVENTIONS: DTT data were acquired at 4 weeks after onset OUTCOMES:: Regarding DTT parameters, fiber numbers of both ORs of the patient were decreased over 2 standard deviations of that of 7 age- and sex-matched normal subjects normal control subjects. However, the value of fractional anisotropy was similar to that of normal control subjects. On the configuration of the OR of the patient, both ORs were thinner than those of normal control subjects. LESSONS: Injury of the OR was demonstrated in a patient with a visual field defect following aneurysmal SAH, using DTT.

Impact of early mobilization and rehabilitation on global functional outcome one year after aneurysmal subarachnoid hemorrhage.

OBJECTIVE: To assess the impact of early mobilization and rehabilitation on global functional outcome one year after aneurysmal subarachnoid haemorrhage. METHODS: Prospective, controlled, interventional study comprising patients managed in the neuro-intermediate ward following repair of a ruptured intracranial aneurysm. Patients in the Control group (n = 76) received standard treatment, whereas those in the Early Rehab group (n = 92) in addition underwent early mobilization and rehabilitation. Demographic, clinical and intervention data were registered. Global functional outcome was assessed using the modified Rankin Scale and the Glasgow Outcome Scale Extended. RESULTS: The 2 groups were similar in their demographic and clinical characteristics. Early Rehab group patients were mobilized more quickly (p < 0.001), median 1.4 days (range 0-23 days) after aneurysm repair. After 1 year, 47% of the patients had made a good recovery, whereas 6.5% had died. Regression analysis did not reveal any significant effect of early rehabilitation on functional outcome. However, in poor-grade patients, early rehabilitation more than doubled the chance of a favourable outcome (adjusted odds ratio = 2.33; confidence interval 1.04-5.2, p = 0.039). CONCLUSION: Early mobilization and rehabilitation probably increases the chance of a good functional outcome in poor-grade aneurysmal subarachnoid haemorrhage patients.

Health-Related Quality-of-Life Outcomes: Comparing Patients With Aneurysmal and Nonaneurysmal Subarachnoid Hemorrhage.

Subarachnoid hemorrhage (SAH) is divided into two major types (aneurysmal [ASAH] and nonaneurysmal [NASAH]) because, in approximately 15% of the patients who experience SAH, no source of hemorrhage can be identified. Anecdotal evidence and contradictory research suggest that patients with NASAH experience some of the same health-related quality of life (HRQOL) issues as patients with ASAH. This quantitative survey design study compared 1-3 years after hemorrhage the HRQOL in patients who had experienced an NASAH with those who had experienced an ASAH. This is the first U.S. study to specifically investigate HRQOL in NASAH and the second to compare HRQOL outcomes between patients with ASAH and NASAH. These study results corroborate those of the first-that the two groups are much more similar than different. It confirms that the impact on employment for both hemorrhage groups is significant, and it also finds an even greater inability to return to work for the patients with NASAH. Physical symptom complaints were more common in the group with NASAH, whereas the group with ASAH experienced more emotional symptoms. Both groups had low levels of posttraumatic stress disorder (PTSD), with those levels not differing significantly between groups. However, PTSD and social support were shown to impact HRQOL for both groups. The authors recommend that clinicians assess all patients with SAH for PTSD and institute treatment early. This may include offering psychological services or social work early in the hospital course. Further research and policy changes are needed to assist in interventions that improve vocational reintegration after SAH. Patients with NASAH should no longer be described as having experienced a "benign hemorrhage." They have had a life-changing hemorrhage that may forever change their lives and impact their HRQOL.

A discussion of the optimal treatment of intracranial aneurysm rupture in elderly patients.

This study aimed to find an optimal treatment for intracranial aneurysm rupture in elderly patients. We adopted endovascular embolization and combined it with mini-invasive aspiration, vascular stenosis stenting, and rehabilitation training to treat 13 elderly patients with intracranial aneurysm rupture. When the 13 patients were discharged and evaluated by the Glasgow Outcome Score (GOS), 7 patients were grade 5, 4 patients were grade 4, and 2 patients were grade 2. We found that a combination of endovascular embolization with mini-invasive aspiration and vascular stenosis stenting allowed us to adapt this treatment to various types of aneurysms. Our approach is especially suitable for elderly patients, because it reduces the occurrence of complications, improves patient prognoses, shortens the duration of hospitalization, and improves the quality of life.

Recovery and quality of life in patients with ruptured cerebral aneurysms.

PURPOSE: Subarachnoid hemorrhage (SAH) secondary to ruptured cerebral aneurysm is a common and frequently devastating condition with a high mortality and morbidity among survivors. The purpose of this study was to conduct a long-term follow-up of SAH patients, assess the changes in functional outcomes, describe quality of life (QOL), and determine its predictors 3.6 years after the hemorrhage. DESIGN: The study design is an exploratory, descriptive correlational design. METHODS: Results were collected from a sample of 113 SAH survivors treated in our institution over a 2-year period (January 2006 until December 2007). We collected data on early and long-term functional outcomes and compared the differences. The health-related QOL was measured using the Polish version of The Short Form - 36 Health Survey Questionnaire (SF-36v2). Multivariable logistic regression was derived to define independent predictors of the QOL. FINDINGS: The mean follow-up time was 3.6 years. Sixty-six percent of patients had improvement in functional outcomes and among previously employed people 56% returned to work. QOL deteriorated in 24% of patients with the most affected dimension of Physical Role. Factors that predict good QOL are male gender, younger age, good economic/professional status, lack of physical handicaps, rehabilitation in a professional center, subjective improvement in health status, and absence of headaches or physical decline. CONCLUSIONS AND CLINICAL RELEVANCE: Recovery process in SAH patients is dynamic and progresses over time. Since physical handicaps and low economic status significantly reduce the quality of life, an effort should be made to provide intensive rehabilitation and to encourage SAH survivors to return to work.

Outcomes for clip ligation and hematoma evacuation associated with 102 patients with ruptured middle cerebral artery aneurysms.

OBJECTIVE: Few studies have investigated the implications of intracerebral hematoma (ICH) due to rupture of a middle cerebral artery (MCA) aneurysm and patient outcomes. We hypothesized that patients with Hunt-Hess (HH) grade IV-V may not benefit from aggressive measures. METHODS: A prospectively acquired aneurysm database was examined. We found 144 patients who harbored a ruptured MCA aneurysm and suffered from ICH or intrasylvian hematoma with or without subarachnoid hemorrhage. The mean age of our patients was 52.5 years (range, 10-82 years) with 87 women and 57 men. Of these, 122 (84.7%) underwent a combination of interventions, including clip ligation, hematoma evacuation, and/or endosaccular coiling; most patients underwent clip ligation at the same time as their hematoma was evacuated. The discharge information was not available for two patients. We examined significant associations among presenting details (e.g., age, sex, admission HH grade) and patients' final outcome. RESULTS: The total in-hospital mortality rate was 49% (70 of 142 patients); 42% (51 of 120) for the patients who underwent an intervention and 86.4% (19 of 22) for those who did not undergo any intervention. Among our patients, approximately 52% with an admission HH grade of IV/V died in-hospital after surgery, whereas 21% with admission HH grade of I-III expired during the same time. In the patient cohort with presenting with HH grade IV and V, 4% (3 of 76) demonstrated Glasgow outcome scale 4-5 at discharge, whereas 15% (12 of 78) displayed Glasgow outcome scale 4-5 at 6-month follow-up. Age and sex did not affect outcome. CONCLUSIONS: Aggressive clip ligation and hematoma evacuation remains a reasonable option for patients suffering from an ICH associated with a ruptured MCA aneurysm. Admission HH grade is the primary prognostic factor for outcome among this patient population as more than half of patients with HH grade IV and V expired during their hospitalization despite aggressive treatment of their hematoma and aneurysm. Long-term functional outcome was poor in up to 85% of surviving patients with HH grade IV-V. It may be beneficial to discuss these prognostic factors with the family before implementing aggressive measures.

Verbal memory capacity after treatment for ruptured intracranial aneurysm--the outcomes of three psychological tests: within a month, 1 year after and 5-7 years after treatment.

BACKGROUND: Verbal memory is an essential cognitive ability with scope for adequate treatment of information and for orientation in everyday life. Our study is centered on memory performance in the wake of treatment for ruptured intracranial aneurysm. METHODS: Three psychological tests were performed: (1) within a month of the neurosurgical intervention, (2) 1 year and (3) 5-7 years after the ruptured aneurysm treatment. Under comparison are the overall results of tests for verbal memory capacity in a cohort of patients (N = 59) and in the control group. RESULTS: Three post-treatment measurements revealed a persistent deficit of verbal memory. The cohort's average performance improved from -1.3 SD (standard deviation) below the average of the norm to -0.5 SD below the norm at the second test 1 year after treatment, while at the third test the deficit had worsened to -0.68 SD. Similarly, testing for long-term recovery at 5-7 years postoperatively showed the patients' performances to be 2/3 SD below the average of the general population. CONCLUSIONS: The results of the study imply the need for long-term rehabilitation of memory in this particular group of patients.

[Rehabilitation of patients following subarachnoid haemorrhage as a result of ruptured intracranial aneurysms]. / Rehabilitacja pacjentów po krwawieniu podpajeczynówkowym z peknietego tetniaka wewnatrzczaszkowego.

The aim of the present paper is to discuss how neuropsychological impairments affect the functioning of patients in the aftermath of aneurysmal SAH and to highlight the need for complex professional rehabilitation services for this group of patients. Following the acute stage of illness, when treatment efforts are focused on life-saving measures, a significant proportion of patients are left with long-term consequences of cerebral damage in the form of specific cognitive impairments or emotional changes. The resultant functional deficits require specialist treatment, but few patients have sufficient knowledge in this regard to allow them to seek help and the availability of specialist services is frequently restricted only to large centres of population. Patients and their families usually do not know where to turn in the face of a sudden, life-threatening illness, which changes their lives diametrically, still less, what kind of specialist help might be available to them. Bearing in mind the needs of patients and their families, there are but few centers offering cognitive therapy or other forms of psychotherapeutic intervention, that are funded under the auspices of the National Health Fund (NFZ). Furthermore, healthcare policies do not place high priority on employing adequately trained psychological therapists in neurosurgical or neurological departments, and the lack of effective cooperation between specialists from different disciplines places significant limitations on the effective rehabilitation of patients who have undergone SAH. In the following article we review the opportunities for effective rehabilitation in order to optimize the functioning of patients with brain damage following SAH.

Results of rehabilitation in patients after subarachnoid haemorrhage from ruptured intracranial aneurysm and after surgical treatment.

BACKGROUND AND PURPOSE: Non-traumatic, or spontaneous subarachnoid haemorrhage (SAH) is responsible for 5-7% of strokes. In Podkarpackie voivodeship, 217 patients were hospitalized in 2003 with spontaneous SAH. The aim of this study was to assess the relationship between the results of rehabilitation carried out in patients after surgical treatment of SAH estimated on the Brunnström, Barthel, and Rankin scales and patients' initial condition measured by means of the Hunt-Hess Scale. MATERIAL AND METHODS: The examined group consisted of 55 patients after surgically treated SAH (clipping). Severity of bleeding was graded with the Hunt-Hess Scale on admission to the neurosurgery ward. Patients' clinical status was assessed with the Barthel Index and Rankin and Brunnström scales on admission to a rehabilitation ward, and rehabilitation effects were assessed after 4 weeks of the rehabilitation period and after at least 6 months from the end of rehabilitation on the ward. RESULTS: The study did not reveal any significant correlation between severity of bleeding and the results of rehabilitation. No explicit advantage was observed in the process of treatment of patients with grade I or II grade according to the Hunt-Hess Scale in the later period. In each group of patients (grades I to IV) there were patients whose final condition improved evidently. CONCLUSIONS: No significant correlation was observed between the clinical status at the onset of the disease and clinical or functional status in early and late periods of rehabilitation.

Incidence of recurrent subarachnoid hemorrhage after clipping for ruptured intracranial aneurysms.

BACKGROUND AND PURPOSE: Because intracranial aneurysms develop during life, patients with subarachnoid hemorrhage (SAH) and successfully occluded aneurysms are at risk for a recurrence. We studied the incidence of and risk factors for recurrent SAH in patients who regained independence after SAH and in whom all aneurysms were occluded by means of clipping. METHODS: From a cohort of patients with SAH admitted between 1985 and 2001, we included those patients who were discharged home or to a rehabilitation facility. We interviewed these patients about new episodes of SAH. We retrieved all medical records and radiographs in case of reported recurrences. If patients had died, we retrieved the cause of death. We analyzed the incidence of and risk factors for recurrent SAH by Kaplan-Meier curves and Cox regression analysis. RESULTS: Of 752 patients with 6016 follow-up years (mean follow up 8.0 years), 18 had a recurrence. In the first 10 years after the initial SAH, the cumulative incidence of recurrent SAH was 3.2% (95% confidence interval [CI], 1.5% to 4.9%) and the incidence rate 286 of 100,000 patient-years (95% CI, 160 to 472 per 100,000). Risk factors were smoking (hazard ratio [HR], 6.5; 95% CI, 1.7 to 24.0), age (HR, 0.5 per 10 years; 95% CI, 0.3 to 0.8) and multiple aneurysms at the time of the initial SAH (HR, 5.5; 95% CI, 2.2 to 14.1). CONCLUSIONS: After SAH, the incidence of a recurrence within the first 10 years is 22 (12 to 38) times higher than expected in populations with comparable age and sex. Whether this increased risk justifies screening for recurrent aneurysms in patients with a history of SAH requires further study.

Self-awareness of traumatically brain injured patients in the acute inpatient rehabilitation setting.

The self-awareness of brain injured patients in an acute inpatient rehabilitation programme was measured using the Functional Self-Appraisal Scale (FSAS), which compares patient and staff ratings of patient performance on tasks relevant for acute rehabilitation and in a format that is easy to administer. There was a significant difference between patients' and staffs ratings near admission, consistent with previous findings in post-acute settings that brain injured patients tend to overestimate their abilities relative to other raters. Patient and staff ratings tended to converge at time of discharge, likely reflecting patients' improvements on rehabilitation tasks rather than increased self-awareness. The average difference between patients' and staffs ratings did not correlate with neuropsychological functioning on admission, supporting evidence that self-awareness early in the recovery process is a unique construct. Future research is outlined, including investigating the relationship of early levels of self-awareness following TBI to functional outcome.

[Learning disorders after ruptured aneurysms of the anterior communicating artery]. / Les déficits d'apprentissage après rupture des anévrysmes de l'artère communicante antérieure.

The aim of this study was to reevaluate short term and long term memory disorders after anterior communicating artery rupture, then to more specifically assess the importance and the role of forgetting, proactive and retroactive interferences, impaired memory for temporal order, attention disorders and dysexecutive syndrome, and finally MRI-defined brain lesions. Twenty one patients presenting with selective anterior brain injury, were assessed at the secondary and late post stroke phases. The short term memory analysis showed the digit span was reduced at the secondary stage, but that mean performances were preserved in the Peterson and Sternberg paradigms. Verbal and visuospatial learning in long term memory showed a severe deficit in free recall, chiefly serial, and associative recall. Recognition was mildly impaired at the secondary phase, and later normalized. A definite and lasting increase of proactive and retroactive interferences and an impairment in discriminating the temporal order of word presentations were observed. Amnesic impairment was relatively well correlated with forgetting, severity of interferences and temporal order amnesia, so as with disorders of attention and executive functions (Wisconsin Card Sorting Test). However, intrusions in free recall and false recognitions were not clearly related with the dysexecutive syndrome. The severity of amnesia was associated with lesions of the left anterior cingulate cortex, and of the corpus callosum. These results suggest that these patients mainly had a deficit in information retrieval, mostly compromising long term memory, but also to a lesser degree short term memory. Forgetting, interferences and the dysexecutive syndrome probably play an important role in the decline of mnemonic performance, but do not clearly explain intrusions in recall and errors in recognition.

Delayed traumatic cerebral aneurysm after brain injury.

Traumatic aneurysms (TAs) are an unusual etiology for late neurological deterioration after traumatic brain injury (TBI) and represent less than 1% of all cerebral aneurysms. TAs most often are diagnosed acutely but may be delayed in presentation. To increase awareness of this serious but treatable condition when diagnosed early, we report a delayed TA after a motor vehicle accident. The patient experienced a seizure on day 46 postinjury while in rehabilitation and demonstrated persistent lethargy and hemiparesis. Neuroimaging revealed a large, ruptured left pericallosal artery TA, which was surgically clipped. The patient completed his rehabilitation course and was eventually discharged home with family. Among TBIs, TAs are associated with penetrating injuries and skull base or anterior cranial fossa fractures. Associated mortality is high, especially if rupture has occurred. Although TAs are rare, the clinician should be vigilant in the at-risk patient.

[Indication of early surgery in elderly patients with ruptured intracranial aneurysms--the comparison between surgical and conservative therapy].

The purpose of this study was to investigate the indication of direct early surgery for elderly cases aged over 70 years with ruptured intracranial aneurysms. The result of early surgical treatment in 39 elderly cases was analyzed and was compared with that of conservative treatment in 39 elderly patients. According to the multiple logistic analysis, surgery was only significant factor influenced the outcome, however, Hunt & Kosnik grade (HKG), activity of daily life (ADL) before subarachnoid hemorrhage (SAH) and past history were related to the outcome. The outcome in the direct early surgical group statistically correlated (p < 0.05) with preoperative HKG, although the outcome in the conservative group did not correlate with HKG. The outcome in conservative group was miserable because of rerupture or poor preoperative neurological grade. The indication of direct early surgery for elderly cases with ruptured intracranial aneurysms should be considered as follows, HKG 1 to 3, ADL before SAH 1, no or minor past history and age under 84 since most elderly patient was 84 in our series. Direct early surgery in elderly patients seems to improve the outcome under these indications.

Management results attained by predominantly late surgery for intracranial aneurysms.

In contrast to previous studies conducted by various authors, who recommended early surgery for all patients admitted to the hospital within 72 hours of an aneurysmal subarachnoid hemorrhage, several more recent studies have declined to advise early surgery for the treatment of patients with impaired consciousness. In our series, early surgery was undertaken for patients who were rated at Grades 1 to 2 (Hunt and Hess) at admission and who did not exhibit any additional risk factors (e.g., evidence of incipient vasospasm, giant aneurysm, unfavorable aneurysm location, or a severe concomitant disease). Only three patients rated Grade 3 at admission with a favorable aneurysm location and shape underwent early surgery. The management results attained in this series (n = 131), in which the early surgery rate was 17%, have been analyzed. The management mortality rate of patients with aneurysmal subarachnoid hemorrhage was 13%, and it was 7.7% for patients admitted at Grades 1 to 3 on the Hunt and Hess scale. Good results (Glasgow Outcome Scale, 1 or 2) were attained in 75% of the entire study population, in 85% of patients admitted at Grades 1 to 3, and in 53% of those patients who were admitted at Grades 4 to 5 and who underwent late surgery after their condition had improved to Grades 1 to 3. At an average interval of 3 years after the operation, 83% of the patients discharged with Glasgow Outcome Scale ratings of 1 or 2 reported no significant restriction of their "stress resistance."(ABSTRACT TRUNCATED AT 250 WORDS)