Course of brain shift during microsurgical resection of supratentorial cerebral lesions: limits of conventional neuronavigation.

BACKGROUND: The authors have conducted a prospective study to evaluate the amount and course of brain shift during microsurgical removal of supratentorial cerebral lesions, and to assess factors which potentially influence these shifts. METHOD: In 61 patients the displacement of 2-3 cortical landmarks on the cerebral surface was dynamically quantified during surgery, i.e. during dissection of the tumour at the estimated half-time of surgery, and at the end of microsurgical removal of the cerebral lesion using the neuronavigation system EasyGuide Neuro. In 14 of these patients the displacement of a subcortical landmark was additionally analysed. Age of the patients, preoperative midline shift, location of the lesion, lesion volume, depth of the lesion below the cortical surface, presence or absence of oedema, and size of the craniotomy were analysed for potential influence on the amount of brain shift. Correlations were analysed for all patients together and for the subgroups of vault meningiomas (n=10), gliomas (n=30), and nonglial intra-axial lesions (n=21). FINDINGS: The mean displacement of the cortical landmarks ranged between 0.8 and 14.3 mm (mean: 6.1 mm, standard deviation: 3.4 mm) during surgery (10-210 minutes [mean: 50.7 minutes, standard deviation: 34.5 minutes] after dura opening) and between 2.4 and 15.2 mm (mean: 6.6 mm, standard deviation: 3.2 mm) at the end of microsurgical removal of the tumourous cerebral lesions (20-375 minutes [mean: 107.2 minutes, standard deviation: 65.6 minutes] after dura opening). Significant correlations (p<0.01) for the entire patient group were found between brain shift and tumour volume, midline shift, and size of the craniotomy, respectively. For the subgroup of vault meningiomas a significant correlation (p<0.01) between brain shift and patient age was found. For the subgroup of gliomas a significant correlation (p<0.01) between brain shift and tumour volume, midline shift and size of the craniotomy, respectively, was found. For the subgroup of nonglial intra-axial lesions a significant correlation (p<0.01) between brain shift and midline shift and between brain shift and size of the craniotomy was found. The quantity of shared common variance ranged between 10-50%. Performing a discriminant analysis, lesion volume was the only certain factor influencing brain shift intra-operatively as well as at the end of lesion removal. 58.5% of the extent of brain shift could be correctly classified by the tumour volume as the only discriminating variable during dissection of the tumour and at the end of surgery. Comparing superficial with subcortical brain shift over the same time period, a mean superficial shift of 4.6 mm (1.6-10.8 mm, standard deviation: 2.8 mm) and a mean subcortical shift of 3.5 mm (1.0-7.7 mm, standard deviation: 2.3 mm) was found. A highly significant Spearman correlation (Rho:.97, p<0.001) between superficial and subcortical brain shift emerged. Shifting of superficial landmarks exceeded shifting of subcortical structures in all patients. CONCLUSIONS: The data demonstrate the dynamics of brain shift and the limits of conventional neuronavigation and add additional support for the unavoidable inaccuracy of contemporary neuronavigational systems once the cranium is opened. Brain shift leads to a significant loss of reliability of neuronavigation systems during microsurgical removal of intracranial lesions and there are differences of the course and the amount of brain shift in relation to special subgroups of supratentorial cerebral lesions. However, because of the heterogeneous nature of lesions neurosurgeons have to remove, the modest quantity of shared common variance, and the differences between superficial and subcortical brain shift, it seems unlikely that the amount and course of brain shift become exactly predictable pre-operatively. Only an intra-operative update of image data should have the capacity to overcome this fundamental problem of modern neuronavigation.

Prognostic factors for patients with microsurgically resected brain metastases.

BACKGROUND: With the advent of new therapies for metastatic carcinoma to the brain, patterns of intracranial disease and factors influencing survival become important considerations when examining treatment options. This study was conducted at a single institution to determine prognostic factors for tumor response and patient survival after microsurgical resection of brain metastases. PATIENTS AND METHODS: 187 consecutive patients who underwent microsurgical resection of brain metastases between July 1989 and September 1996 were retrospectively reviewed and statistically analyzed. The primary cancers included lung cancer (85), gastrointestinal cancer (20), renal cell cancer (19), breast cancer (17), malignant melanoma (8) and 38 cases of various other carcinomas or of unknown primary site. 111 patients received whole-brain radiation therapy (WBRT) with a mean dose of 32 Gy after tumor resection. The influence of number, size, and localization of brain metastases as well as histology of the primary tumor, preoperative performance status, presence of extracranial systemic disease, time course and adjuvant radiation therapy were statistically evaluated (uni- and multivariate) as prognostic factors for survival. RESULTS: Early postoperative Karnofsky score was improved in 59%, unchanged in 32% and worse in 9% of patients. Median survival time (MST) was 9.8 months (range 1 day-5.3 years). The most important parameter showing a significant influence on survival time was the histology of the primary tumor, with prediction of a bad outcome especially for patients with metastases from renal-cell cancer and malignant melanomas. Patients with breast cancer showed longer survival than patients with other primary cancers. Furthermore, survival varied significantly depending on location of brain metastases, performance status at time of craniotomy and duration of symptoms. None of the other studied variables gained prognostic significance. CONCLUSION: Microsurgical resection of one or more brain metastases followed by WBRT still is a useful and efficient treatment in a carefully selected patient group to prolong median survival and improve or stabilize the performance status. Among the factors determining the survival times in this patient group, histology of the primary tumor is most important, together with preoperative Karnofsky score, location of metastasis and preoperative duration of symptoms.

[The significance of health related quality of life for the evaluation of interventional measures in patients with COPD]. / Die Bedeutung der gesundheitsbezogenen Lebensqualität für die Bewertung interventioneller Massnahmen bei Patienten mit COPD.

Health related quality of life (HRQOL) is an important criterion for the evaluation of rehabilitation measures in patients with chronic obstructive pulmonary disease (COPD). The present paper reviews the current literature about the effects of pulmonary rehabilitation on the HRQOL of patients with COPD. The aim is to summarize critically methods, results and unanswered issues of the present research on the effects of pulmonary rehabilitation on HRQOL. The rehabilitation of patients suffering of COPD is mainly based on six types of interventions: 1. long-term oxygen therapy (LTO), 2. pharmacological management, 3. surgical therapy (bilateral reduction of lung volume), 4. physical therapy, 5. nutritional therapy (special diets), and 6. psycho-social interventions (e.g. psychotherapy, training and education). Thirty-one studies could be included in which HRQOL served as an outcome criterion for the rehabilitation of COPD patients. In 14 (45%) studies exclusively a disease-specific measure for the assessment of HRQOL was employed, while in 12 (39%) studies a generic instrument was applied. In the remaining five (16%) studies two ore more measures were used, whereas four of them combined a generic and a disease-specific method. The St. Georges Respiratory Questionnaire (SGRQ) und the Chronic Respiratory Disease Questionnaire (CRDQ) belonged to the group of the specific instruments, while among the generic measures the Sickness Impact Profile (SIP), the Nottingham Health Profile (NHP), the SF-36 and the Quality of Well-Being Scale (QWB) were most frequently used in COPD patients. The surgical bilateral reduction of lung volume, pharmacological therapy, upper extremities muscle training and psychological measures as single interventions proved to have persistent positive effects on the HRQOL. Several rehabilitation programs, composed of a wide variety of different interventions were effective in terms of HRQOL. On the other hand, at follow-up, the short-term positive effects had decreased in two of the three studies, where the rehabilitation took place exclusively in an inpatient setting. However, in three of four programs implemented in an outpatient setting, a persistent positive effect on HRQOL could be demonstrated. In conclusion from the as of yet available findings, we suggest for future studies to use only such measures of HRQOL which have been tested psychometrically in patients with COPD and to combine disease-specific and generic measures. In order to achieve lasting positive effects of rehabilitation on HRQOL, outpatient settings or ambulatory refreshment sessions following rehabilitation on an inpatient basis should be preferred.

Health-related quality of life after aneurysmal subarachnoid hemorrhage: impacts of bleeding severity, computerized tomography findings, surgery, vasospasm, and neurological grade.

OBJECT: Based on the results of earlier studies it is agreed that the significance of aneurysm location and surgery for neuropsychological impairments after subarachnoid hemorrhage (SAH) is secondary to the effects of the bleeding itself. Therefore, the present study was performed to evaluate whether bleeding, acute clinical course, and surgery have persistent effects on health-related quality of life (QOL) after SAH. METHODS: A series of 116 patients was examined for 4 to 5 years (mean 52.2 months) after aneurysmal SAH by means of a QOL questionnaire. Eighty-six patients (74.1%) had undergone surgery early (< or = 72 hours post-SAH). There were 77 women (66.4%) and 39 men (33.6%) in the study group, and the mean age of the patients was 50.3+/-13.3 years (range 30-69 years). Patients who had undergone surgery for a left-sided middle cerebral artery (MCA) aneurysm complained of significantly more impairments in social contact, communication, and cognition than those treated for a right-sided MCA aneurysm. No other effects of aneurysm location (including the anterior communicating artery) emerged. Multiple aneurysms, intraoperative aneurysm rupture, and partial resection of the gyrus rectus had no adverse effects on later daily life. Only temporary clipping was associated with increased complaints in some QOL areas. Disturbances of the circulation of cerebrospinal fluid and the presence of intraventricular hemorrhage led to more impairments in daily life. Specific effects of the anatomical pattern of the bleeding could be identified, but no adverse effects of vasospasm were found. Multivariate analyses revealed, in particular, that patient age and admission neurological status (Hunt and Hess grade) are substantial predictors of the psychosocial sequelae of SAH. CONCLUSIONS: In contrast to the mild effects of aneurysm surgery, patient's age, initial neurological state on admission, and the bleeding pattern substantially influence late QOL after SAH.

Influence of intraventricular hemorrhage on outcome after rupture of intracranial aneurysm.

This study was performed to analyze the effect of intraventricular hemorrhage (IVH) on 14-day mortality, outcome at 6 months, and the occurrence of chronic hydrocephalus in patients with aneurysmal subarachnoid hemorrhage. Clinical grade of subarachnoid hemorrhage and the distribution of extravasated blood were evaluated in 219 patients with ruptured aneurysms. Computed tomographic scans performed within 72 h of hemorrhage were analyzed to determine the severity of intraventricular and subarachnoid hemorrhage and the volume of intracerebral hematomas. Outcome at 6 months was assessed using the Glasgow Outcome Scale. Intraventricular hemorrhage extension occurred in 109 of the 219 patients studied. Fourteen-day mortality increased from 7.3% in patients without IVH to 14.1% in those with moderate IVH (IVH score 1-6) and to 41.7% in those with more severe IVH (IVH score > 6). The corresponding figures for unfavorable outcome at 6 months are 19.8%, 30.5%, and 66.7%, respectively. According to logistic regression analyses, the severity of IVH was an independent predictor of mortality and functional outcome. The clinical outcome after aneurysm rupture is at least in part determined by the severity of IVH. Knowledge of the effect of IVH may help guide physicians in the care of patients with aneurysmal bleeding.

[Background and first results about methodological characteristics of the Aachen Life Quality Inventory]. / Grundlagen und erste Ergebnisse zur methodischen Eignung des Aachener Lebensqualitätsinventars.

Health-related quality of life has become an important criterion for assessing disease impact and treatment outcome. Therefore, we developed a questionnaire called Aachen Life Quality Inventory (ALQI) for the use in neurosurgical patients with brain damage. The ALQI is derived from the German version of the Sickness Impact Profile (SIP). The 117 items are formulated on a concrete behavioral level covering the following dimensions of health-related quality of life: 1. activation; 2. mobility; 3. house-work; 4. social contact; 5. family relations; 6. ambulation; 7. work; 8. free-time activities; 9. autonomy; 10. communication; 11. cognitive capacity. As in the SIP, a summary score of total impairment (ALQI Total score), a summary score covering the psycho-social dimension (ALQI Psycho-social score) and a summary score covering aspects of physical functioning (ALQI Physical score) can be calculated. The ALQI consists of a self-rating and a parallel proxy-rating version. The ALQI was validated and psychometrically verified using the data of as yet 231 neurosurgical patients with brain damage of mixed etiology (subarachnoid hemorrhage, closed-head injury, benign brain tumors). Internal consistency (Cronbach's Alpha) ranged from.68 to.91 for the subscales, while it was.97 for the whole instrument,.94 for the psycho-social and.93 for the physical score. The internal consistency for the subscales of the proxy-rating version of the ALQI ranged between.77 and.92, while it was.97 for the whole inventory and.94 for the psycho-social and the physical scores, respectively. Examination of construct validity revealed substantial correlations with a wide range of relevant neurological, neurosurgical and neuropsychological parameters. Beyond other findings, substantial associations emerged with several neuropsychological tests (r =.30 to r =.50), the Glasgow Outcome Scale (r =.39; p <.00) and in patients after subarachnoid hemorrhage with the Hunt& Hess grading (r =.28; p <.001). According to these results, the ALQI promises to become a valid and reliable means for assessing quality of life in patients with brain damage. Nevertheless, further analyses using larger patient samples and with particular emphasis on the investigation of the retest-reliability and the prognostic validity are called for in the future.

Health-related quality of life, psychological adjustment and compliance to treatment in patients on domiciliary liquid oxygen.

The purpose of this study was to investigate the effects of two different aspects of compliance with liquid oxygen (LOX) therapy on quality of life and to explore possible pulmonary and psychosocial concomitants. The study sample consisted of 57 oxygen-dependent patients with chronic obstructive pulmonary disease under LOX therapy. Compliance was defined as continuous oxygen use as prescribed and also as readiness to use LOX outdoors. The study design encompassed three major measuring points, the first of which was an initial assessment, the second 3 months later and the third follow-up after 14 months. Furthermore, during the course of the study, two telephone interviews were conducted. The psychosocial variables studied included quality of life, psychological adjustment and two different aspects of compliance with LOX therapy. Seven (12%) patients used LOX less than prescribed and 13 (23%) refused to use LOX away from home. Those patients who used LOX insufficiently had a significantly lower life-satisfaction than those who were compliant (p = 0.02). The discriminance analysis included several psychosocial variables discriminating between both groups, allowing the correct classification of 85% of the patients who used LOX as prescribed and 83% of the noncompliant patients (p = 0.01). At follow-up, the data of 25 patients were available. Of these, five refused outdoor LOX use. Their quality of life was significantly worse in almost all areas examined as compared to the outdoor LOX-users (p < 0.05, respectively). Compliance is an essential prerequisite for the beneficial effects of liquid oxygen on quality of life. Because psychological factors influence adherence to liquid oxygen therapy, patients should receive individual psychological counselling and training before transfer to liquid oxygen therapy.

Virtual pointer projection of the central sulcus to the outside of the skull using frameless neuronavigation -- accuracy and applications.

BACKGROUND: The purpose of this prospective study was to localize the central sulcus by frameless neuronavigation and to project this anatomical structure to the outside of the skull on the skin. This method was analyzed in respect to its practicability, accuracy, and potential applications. METHOD: In 27 patients investigated (28 unaffected hemispheres), the central sulcus was virtually projected to the outside of the skull using frameless neuronavigation and a virtual pointer elongation of 15 or 20 mm. The following parameters were measured on the scalp: 1. the distance between the bregma and the midline junction of the central sulcus, and 2. the angle between the central sulcus and the midline. These dada were compared with measurements based on the original axial MR images of these patients. Finally, a laboratory phantom study was designed in analogy to a patient's examination for estimation of the overall accuracy of the neuronavigation system in the experimental setup used in this study. FINDINGS: Virtual pointer projection of the central sulcus to the outside of the skull using frameless neuronavigation was found to be easily possible. The distance between the bregma and the midline junction of the central sulcus amounted to a mean of 55 mm on the left and 56 mm on the right. The angle between the central sulcus and the midline reached a mean of 63 degrees on the left and 60 degrees on the right. These data confirmed results of other studies with no frameless neuronavigation devices. The phantom study revealed a mean overall inaccuracy of 0.9 mm at a virtual pointer elongation of 15 mm. At a virtual pointer elongation of 20 mm, the mean overall inaccuracy of our study was 1.1 mm. These results correspond to the inaccuracy of frame based stereotaxy. INTERPRETATION: It is easily possible, valid, and reliable to virtually project the central sulcus to the outside of the skull with an acceptably low inaccuracy using frameless neuronavigation. This is important for research studies that correlate and integrate different functional imaging methods with the aid of frameless neuronavigation.

Functional outcome after aneurysmal subarachnoid hemorrhage.

The introduction of the operating microscope, the principle of early surgery, specialized intensive care units, the calcium antagonist nimodipine, the sophisticated pre- and postoperative management and an aggressive antiischemic pharmacological management have substantially reduced morbidity and mortality after aneurysmal subarachnoid hemorrhage (SAH). In spite of this progress, many patients after rupture and surgical repair of an intracranial aneurysm exhibit substantial cognitive deficits and emotional problems although their neurological outcome was rated as good according to the Glasgow Outcome Scale (GOS = I). Therefore, a comprehensive neuropsychological examination is called for in order to evaluate the factual functional outcome after SAH. Neither focal brain damage associated with aneurysm location nor surgery but the hemorrhage itself and related events can be regarded as the most important causal factors for the late result after SAH. In contrast to the mild permanent effects of aneurysm surgery, the initial bleeding itself seems to have substantial lasting adverse neurobehavioral effects after. In concordance with other authors our own data stress the strong predictive power of the bleeding pattern such as the presence of intraventricular and/or intracerebral blood on the functional outcome after aneurysmal SAH.

[Functional capacity (dyspnea) and quality of life in patients with chronic obstructive lung disease (COPD): instruments of assessment and methodological aspects]. / Funktionelle Kapazität (Dyspnoe) und Lebensqualität bei Patienten mit chronisch obstruktiven Lungenerkrankungen (COPD): Erhebungsinstrumente und methodische Aspekte.

Functional capacity (dyspnea) and quality of life are important criteria for the assessment of disease impact and treatment outcome in patients with chronic obstructive pulmonary disease (COPD). We will review measures for dyspnea and quality of life with particular emphasis on their methodological properties. Because asthma and COPD exhibit important differences and are therefore not comparable, we discuss only those measures which have been verified methodologically in patients with COPD. A critical review of current measures for dyspnea reveals at best an only fair association between perceived dyspnea and physiological lung function, sharing not more than 30% of common variance. Moreover, the affective state of the patients, their individual adaptation level and further psychological variables serve as mediators between lung function and perceived dyspnea. However, several valid and reliable measures for dyspnea are available for research and clinical practice. While the term "quality of life" is rather broad and unspecified, many researches in the field prefer the more restrictive term "health-related quality of life (HRQOL), that is the quality of life as affected by health status. The concept of HRQOL encompasses the impact of the individual's health on his or her ability to perform activities of daily living such as social role functioning, home management, social and family relationships, self-care, mobility, recreation and hobbies. In the past 15 years there has been an increasing body of literature on the measurement of HRQOL in patients with COPD. Several disease-specific and generic instruments for the use in COPD patients have been published. There is a growing consensus about the methodological criteria a given instrument has to fulfill. These are validity, sensitivity (for change) and reliability. They have to be tested in patients suffering from the illness for which the HRQOL instrument is planned to be applied in clinical studies or routine. The disease-specific instruments are supposed to be more sensitive to small therapeutically induced changes. However, the empirical results in patients with COPD are mixed and do not clearly favour disease-specific instruments. Lung function, dyspnea measures and exercise tolerance as well do not correlate strongly with HRQOL. Most associations cover only between 10% and 16% of shared variance. Exercise tolerance is not well associated with lung function but correlates better with HRQOL. Nowadays we can rely on several measures for dyspnea and HRQOL which have been thoroughly verified methodologically in COPD patients. However, some disease-specific and generic instruments exhibit substantial flaws, so that they need to be revised and it seems better not to use them at present. Many methodological and conceptual questions remain unanswered in the field indicating a strong need for more research.

Cognitive deficits in the acute stage after subarachnoid hemorrhage.

OBJECTIVE: In spite of fundamentally improved medical management of subarachnoid hemorrhage (SAH), many patients remain mentally impaired. However, the causes of these disturbances are unclear. The present study was performed to elucidate the significance of the hemorrhage itself and related events in the neuropsychological performance of patients in the acute stage after SAH. METHODS: A series of 51 patients were examined, by means of a battery of cognitive tests, 1 to 13 days (mean, 5.9 d) after SAH. Thirty-three patients had experienced ruptured aneurysms, and 18 had sustained SAH of unknown origin. Furthermore, 25 patients who had undergone surgical treatment (a mean of 5.0 d earlier) of prolapsed lumbar discs served as a control group. RESULTS: The cognitive deficits of the patients after aneurysmal SAH proved to be comparable to those after spontaneous SAH of unknown origin, with the single exception of a significantly worse (P = 0.003) concentration capacity in the surgically treated group. The severity of SAH in computed tomographic scans correlated (up to r = 0.57, P < 0.001) with poor performance on tests of memory, concentration, divided attention, and perseveration. Frontal intracerebral hemorrhage led to significantly more errors in an aphasia screening test (P < 0.001) and a test of perseveration (P < 0.001). If acute hydrocephalus was present, the patients exhibited worse long-term memory (P < 0.001), showed slower reaction times (P = 0.01), and made more errors in the perseveration test (P = 0.004). Patients with intraventricular blood performed at significantly lower levels in the concentration (P = 0.001), divided attention (P = 0.01), long-term memory (P < 0.001), and perseveration (P = 0.003) tests. CONCLUSION: The results emphasize that the severity of SAH (Fisher score) is the most important factor related to cognitive dysfunction, but frontal hematoma, intraventricular hemorrhage, and acute hydrocephalus were also associated with cognitive deficits, compared with patients with SAH without these findings.

Psychologic adjustment in patients after subarachnoid hemorrhage.

A series of 45 patients after subarachnoid hemorrhage (SAH) with no or only marginal neurologic impairment and 36 patients with chronic obstructive pulmonary disease (COPD) were examined with the German Freiburger Personality Inventory-Revised. Both groups showed a comparable frequency of psychologic impairments, except that the patients with COPD had significantly higher scores in the FPI-R bodily complaints and bodily concern subscales (p < 0.05). In the patients after SAH, loss of motivation (42%), abnormal introversion (40%), increased emotional lability (38%), and strain (31%) were found predominantly. The patients after SAH of unknown origin exhibited psychologic disturbances comparable with patients after aneurysmal SAH. A ruptured aneurysm of the anterior communicating artery did not lead to more psychologic disorders than aneurysms at other locations. Right frontal and right parietal infarctions were associated with significantly less emotional sensitivity (p = 0.013) and bodily concern (p < 0.001). The results demonstrate a substantial discrepancy between the prevalence of psychologic maladjustment and the moderate degree of functional impairment in patients after SAH, which remains to be explained by future research.

Cognition and quality of life in patients after transcallosal microsurgery for midline tumors.

OBJECTIVE: The transcallosal route has been propagated as a safe approach to midline tumors. The present study was performed in order to elucidate the neurobehavioral late sequelae in patients after transcallosal microsurgery on near-midline tumors. EXPERIMENTAL DESIGN: The present study was performed retrospectively with a delay between surgery and follow-up examination ranging from 2 to 36 months (mean 10.2 months). SETTING: The study was performed in the Department of Neurosurgery, University Hospital of the University of Technology (RWTH) Aachen, Germany. PATIENTS: A consecutive series of 18 patients treated for an intracranial lesion by transcallosal surgery was included into the study. The patients had to be not younger than 16 and not older than 67 years. The age mean was 38.9 years (range 16 to 65 years). INTERVENTIONS: The surgical approach was performed along the falx cerebi under microneurosurgical conditions with direct use of the microscope after opening the dura. MEASURES: Beyond neurological examinations, the patients were submitted to an extensive neuropsychological testing battery. Furthermore, quality of life was examined by means of a questionnaire. RESULTS: Surgery was performed without persistent new neurological deficits. Cognitive deficits were found in short- and long-term memory, motor fine-coordination, reaction time, divided attention and fronto-cortical capacity. The quality of life was particularly impaired in the area of cognitive capacity in daily life. These findings could be related to the duration of preoperative symptoms and to the tumor location. CONCLUSIONS: The deficits found cannot be explained by surgical damage to the corpus callosum itself. Rather, they seem to correspond to an extra-callosal pathology. Further studies with a prospective evaluation of larger patient samples are called for in the future.

[Quality of life in patients with chronic obstructive lung diseases: psychometric criteria of the German version of the Sickness Impact Profile and initial results of its application]. / Lebensqualität bein Patienten mit chronisch-obstruktiven Lungenerkrankungen: Psychometrische Gütekriterien der deutschen Version des Sickness Impact Profiles (SIP) und erste Ergebnisse der Anwendung.

BACKGROUND: Quality of life has become an important criterion for assessing disease impact and treatment outcome. The Sickness Impact Profile (SIP) is an internationally widely used generic instrument for the measurement of health related quality of life. Furthermore, it has been frequently employed for research in patients suffering from airway diseases. Therefore, we developed a German version of the SIP and investigated its psychometric properties in patients with chronic obstructive lung disease (COPD). PATIENTS AND METHODS: After translation of the SIP into German, the results of a pilot study suggested several changes. Some items had to be reformulated and the SIP subscales "Emotional and affective behavior", "Alertness" and "Body care and movement" had to be discarded because of insufficient psychometric properties. The reliability, validity and sensitivity of the resulting German SIP version were investigated in a sample of 58 O2-dependent patients with COPD. RESULTS: Internal consistency (Cronbach Alpha) was 0.93 for the entire instrument, while it was 0.85 for the SIP psycho-social scale and 0.89 for the SIP physical scale. The internal consistency ranged from 0.55 to 0.86 for the subscales of the German SIP version. The nutrition subscale was discarded because it showed an insufficient internal consistency (0.40). Indices of respiratory function (FEV1, FVC, Pa, O2, Sa, O2) and severity of dyspnea as assessed by the Baseline Dyspnea Index (BDI) were associated with the total SIP, psycho-social and physical score reaching from r = -0.19 to r = -0.48. Patients who improved after introduction of liquid oxygen therapy (LOX) showed a better total SIP score (p = 0.023) and less impairment in the SIP physical scale (p = 0.009). In order to evaluate the prognostic validity of the German SIP, a discriminance analysis between those patients who were alive 14 months later and those who had died of their illness was performed. A single discriminant function with an Eigenvalue of 0.59 (canonical correlation r = 0.61; CU2 = 21.213; df = 3; p < 0.001) was found. By means of the FVC, the severity of dyspnea (BDI), the SIP total score and the FEV1 85% of the survivors and 91 % of the fatalities could be predicted correctly. CONCLUSIONS: The present results demonstrate sufficient psychometric properties of the German SIP version for the use in patients with COPD and hypoxemia. However, the internal consistencies of the subscales "Work" and "Leisure pastimes and recreation" remain to be improved. Furthermore, the results of factor and cluster analyses suggest some changes in the internal structure of the German SIP.

Early neuropsychological sequelae of aneurysm surgery and subarachnoid haemorrhage.

In order to disclose the immediate cognitive sequelae of early aneurysm surgery and subarachnoid haemorrhage (SAH), a series of 28 patients was examined neuropsychologically one to 13 days (median 5 days) after surgery. Cognitive deficits emerged in short- and long-term memory, language and in different functions of attention. There was no effect of ACoA aneurysm location on neuropsychological test performance. No substantial effect of premature aneurysm rupture or surgical approach could be revealed. Temporary clipping of vessels was associated with significantly worse selective attention and phasic alertness (p < 0.05, respectively). Partial resection of the gyrus rectus led to a worse short-term memory (p = 0.02). In regression analyses, the duration of temporary clipping was associated with worse short-term memory (adjusted r2 = 0.68; p = 0.007) and decreased phasic alertness (adjusted r2 = 0.47; p = 0.035). The clinical state on admission (Hunt and Hess) predicted an impaired phasic alertness (adjusted r2 = 0.43; p = 0.004). It is concluded from the results, that certain procedures and events in aneurysm surgery can have neuropsychological effects. The present study is restricted by the small sample size. Therefore, a prospective study with a larger patient sample is required for further confirmation of the present findings.

Introspective capacities in patients with cognitive deficits after subarachnoid hemorrhage.

Examined 58 patients after subarachnoid hemorrhage by means of neuropsychological tests, a self-report questionnaire, proxy ratings, and personality forms. The degree of cognitive impairment showed only a slight association with an impairment self-rating scale (r = .32, p > .01). On the other hand, the proxy impairment ratings correlated well with the degree of cognitive disturbance (r = .68, p < .001). Self-rated impairment correlated substantially with depression (r = .63, p < .001). A 2 x 2 analysis of variance showed a significant two-way interaction (p = .014) between depression and cognitive disturbance explaining the subjective impairment rating. Depressive patients tended to maximize their actual degree of impairment. Patients with right parietal and/or frontal infarcts showed significantly less depression and illness concern than did patients with infarcts at other locations, although both groups had a comparable degree of cognitive and self-rated impairment.

Quality of life and cognitive deficits after subarachnoid haemorrhage.

In a retrospective study of 58 patients after subarachnoid haemorrhage (SAH) with a late result either good (GOS = I) or fair (GOS = II), patients were examined 1-5 years after the acute event for their quality of life including a neuropsychological examination. Cognitive deficits were found in visual short-term memory (46%) and in the three parameters of a reaction-time task ranging from 31 to 65%. Further deficits were found in verbal long-term memory (28%), concentration (5-13%) and language (11%). The quality of life was reduced in the SAH patients according to a self-rating scale in motivation (50%), interests (47%), mental capacity (47%), free-time activities (52%), social relationships (39%), concentration (70%), fine motor co-ordination (25%) and sleep (47%). A further 77% of the patients reported more frequent headaches since their SAH. Depression was found in 30% of the SAH patients. Life-satisfaction was significantly reduced in 37%, whereas 48% of the SAH patients suffered from increased emotional lability and in 41% motivation was significantly reduced. Negative job consequences like loss of job or demotion were reported by 16% of the patients investigated and an additional 15% had been retired.

Is there a difference in cognitive deficits after aneurysmal subarachnoid haemorrhage and subarachnoid haemorrhage of unknown origin?

In a retrospective follow-up study 38 patients with aneurysmal subarachnoid haemorrhage (SAH) and 20 patients without an angiographically proven source of SAH were tested neuropsychologically one to five years after the acute event. All patients were operated on early within 72 hours if an aneurysm was proven angiographically and all were treated with nimodipine. Both patient groups had comparable cognitive deficits in spite of the less severe SAH of non-aneurysmal origin. Only in two cognitive functions the groups differed significantly. The patients after non-aneurysmal SAH had a significantly lower mean in the IQ subtest similarities finding (p < 0.05), while the patients after aneurysmal SAH had a significantly lower mean in a test of visual cognition (p < 0.05). A more detailed analysis with clinically homogeneous subgroups was additionally performed. The results showed in the subgroup with poor clinical grades that patients with aneurysmal SAH were significantly more disturbed in focal cognitive functions like short- and long-term memory and word-finding capacity, while patients with SAH of unknown origin scored significantly worse in a neuropsychological test related to attention, which can be regarded as a more diffuse cognitive function.

Which neuropsychological deficits are hidden behind a good outcome (Glasgow = I) after aneurysmal subarachnoid hemorrhage?

A series of 31 patients with good neurological 6-month outcomes (Glasgow Outcome Scale = I) was examined with a battery of cognitive tests 1 to 5 years after aneurysmal subarachnoid hemorrhage (SAH) and early operation. The results showed a marked disability in 28 to 62% of these patients in the subtests of a complex choice reaction task. Short-term memory was impaired in 53% of the patients neuropsychologically examined, whereas 21% of them had a reduced long-term memory. Concentration was impaired in 7 to 16% of the SAH patients. Also, 10% of the patients rated Glasgow Outcome Scale = I had an indication for an aphasic language disturbance. Multivariate analysis proved significant harmful effects of the severity of the bleeding seen on computed tomographic scan (Fisher scale) on information processing and word-finding capacity. Patients who were older at the time of the SAH were significantly more disturbed in concentration, short-term memory, and information-processing capacity at follow-up. It can be concluded from these results that a good neurological outcome (Glasgow Outcome Scale = I) does not exclude persisting neuropsychological deficits. Therefore, the value of the clinical use of the Glasgow Outcome Scale is limited. As a consequence, a differentiated neuropsychological examination is proposed to evaluate the exact outcome of SAH patients.