Behavioral Assessment With the Coma Recovery Scale-Revised Is Safe and Feasible in Critically Ill Patients With Disorders of Consciousness.

OBJECTIVES: Accurate classification of disorders of consciousness (DoC) is key in developing rehabilitation plans after brain injury. The Coma Recovery Scale-Revised (CRS-R) is a sensitive measure of consciousness validated in the rehabilitation phase of care. We tested the feasibility, safety, and impact of CRS-R-guided rehabilitation in the ICU for patients with DoC after acute hemorrhagic stroke. DESIGN: Retrospective cohort study. SETTING: This single-center study was conducted in the neurocritical care unit at the University of Maryland Medical Center. PATIENTS: We analyzed records from consecutive patients with subarachnoid hemorrhage (SAH) or intracerebral hemorrhage (ICH), who underwent serial CRS-R assessments during ICU admission from April 1, 2018, to December 31, 2021, where CRS-R less than 8 is vegetative state/unresponsive wakefulness syndrome (VS/UWS); CRS-R greater than or equal to 8 is a minimally conscious state (MCS). INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: Outcomes included adverse events during CRS-R evaluations and associations between CRS-R and discharge disposition, therapy-based function, and mobility. We examined the utility of CRS-R compared with other therapist clinical assessment tools in predicting discharge disposition. Seventy-six patients (22 SAH, 54 ICH, median age = 59, 50% female) underwent 276 CRS-R sessions without adverse events. Discharge to acute rehabilitation occurred in 4.4% versus 41.9% of patients with a final CRS-R less than 8 and CRS-R greater than or equal to 8, respectively (odds ratio [OR] 13.4; 95% CI, 2.7-66.1; p < 0.001). Patients with MCS on final CRS-R completed more therapy sessions during hospitalization and had improved mobility and functional performance. Compared with other therapy assessment tools, the CRS-R had the best performance in predicting discharge disposition (area under the curve: 0.83; 95% CI, 0.72-0.94; p < 0.0001). CONCLUSIONS: Early neurorehabilitation guided by CRS-R appears to be feasible and safe in the ICU following hemorrhagic stroke complicated by DoC and may enhance access to inpatient rehabilitation, with the potential for lasting benefit on recovery. Further research is needed to assess generalizability and understand the impact on long-term outcomes.

Desfechos clínicos e funcionais de pacientes com hemorragia subaracnóidea aneurismática em UTI / Clinical and functional outcomes of patients with aneurysmatic subarachnoid hemorrhage in the ICU

INTRODUCTION: Rehabilitation has recently been discussed in patients with subarachnoid hemorrhage (SAH) caused by a ruptured aneurysm. OBJECTIVE: To compare clinical and functional outcomes of surviving and non-surviving patients with aneurysmal SAH in a neurosurgical ICU. METHODS: This is a retrospective documentary study. Medical records of patients with SAH admitted to the neurosurgical ICU of a teaching hospital between July 2014 and July 2019 were analyzed. Data were divided according to the outcomes into survivors group (SG) and non-survivors group (NG). RESULTS: 103 patients were analyzed, 72% female, mean age 55 years, 62% had high ICU outcome. The SG had significantly lower age, SAPS III score, Fisher and Hunt-Hess scales and time on mechanical ventilation (MV) than the NG, in addition, they had a Glasgow Coma Scale (GCS), on admission and discharge from the ICU and length of hospital stay, significantly higher (p≤0.05) than NG. The SG showed significantly higher functionality (p≤0.05) than the NG on admission and a significant increase (p≤0.05) in functionality between admission and discharge from the ICU. CONCLUSION: Surviving patients with aneurysmal SAH had lower age, SAPS III score, neurological scales and time on MV, higher GCS scores at ICU admission and discharge, and longer hospital stay than non-survivors. Surviving patients had better functionality than non-survivors on admission, and, evolved with functional improvement from admission to discharge from the ICU.

INTRODUÇÃO: Recentemente tem sido discutido quanto à reabilitação em pacientes com hemorragia subaracnóidea (HSA) causada pelo rompimento de um aneurisma. OBJETIVO: Comparar desfechos clínicos e funcionais de pacientes com HSA aneurismática, sobreviventes e não sobreviventes em uma UTI neurocirúrgica. MÉTODOS: Trata-se de um estudo documental retrospectivo. Foram analisados prontuários de pacientes com HSA internados na UTI neurocirúrgica de um hospital escola, entre julho de 2014 e julho de 2019. Os dados foram divididos de acordo com os desfechos em grupo sobreviventes (GS) e grupo não sobreviventes (GN). RESULTADOS: Foram analisados 103 pacientes, 72% do sexo feminino, idade média de 55 anos, 62% apresentaram alta da UTI como desfecho. O GS apresentou idade, escore SAPS III, escalas de Fisher e Hunt-Hess e tempo de ventilação mecânica (VM) significativamente menores (p≤0,05) que o GN, além disso, apresentaram escala de coma de Glasgow (ECG), na admissão e na alta da UTI e tempo de internação hospitalar, significativamente maiores (p≤0,05) que o GN. O GS apresentou funcionalidade significativamente maior (p≤0,05) que o GN na admissão e incremento significativo (p≤0,05) da funcionalidade entre a admissão e alta da UTI. CONCLUSÃO: Pacientes com HSA aneurismática sobreviventes apresentaram menores idades, escore SAPS III, escalas neurológicas e tempo de VM, maiores escores de ECG, na admissão e na alta da UTI e maior tempo de internação hospitalar que os não sobreviventes. Os pacientes sobreviventes apresentaram melhor funcionalidade que os não sobreviventes na admissão, e, evoluíram com melhora funcional da admissão até a alta da UTI.

Impact of blood pressure on the outcomes of inpatients with Subarachnoid hemorrhage: A retrospective cross-sectional study.

ABSTRACT: It is unclear whether antihypertensive treatment should be indicated after subarachnoid hemorrhage (SAH). Hence, we investigated the impact of blood pressure on inpatient outcomes after SAH rehabilitation.This retrospective cross-sectional study analyzed data of SAH inpatients, as obtained from the Japan Association of Rehabilitation Database for inpatients undergoing SAH rehabilitation. Inpatients admitted to a conventional ward with a diagnosis of cerebrovascular disease were voluntarily registered in this database between January 2006 and December 2013 from hospitals in Japan. Patients were categorized into hypertensive and non-hypertensive populations and assessed using the Barthel Index (BI) and the total BI score at hospital discharge. We compared the independent population (patients with the highest score for each activity) with its non-independent counterpart. Data on the patients' age, BI score on admission, total BI score, BI score increase, daily BI score increase, hospitalization duration, BI activities, patients' sex, and Brunnstrom recovery stage were compared.Eighty-eight patients with SAH were analyzed; 43 were hypertensive and 45 non-hypertensive. Hypertension was associated with increased non-independence levels (hypertensive versus non-hypertensive patients, transfers [bed to chair and back]: 15 versus 24, P = .03, odds ratio (OR) = 2.532 (95% confidence interval [CI], 1.065-6.024); toilet use: 15 versus 24, P = .03, OR = 2.532 (95% CI, 1.065-6.024); bathing: 23 versus 34, P = .0061, OR = 3.623 (95% CI, 1.414-9.259); stair climbing: 22 versus 31, P = .03, OR = 2.703 (95% CI, 1.114-6.579); and bladder control: 14 versus 24, P = .02, OR = 2.801 (95% CI, 1.170-6.711)). The total BI score of the hypertensive inpatients at discharge was lower than that of their non-hypertensive counterparts (0-75 versus 80-100, 30 versus 19, P = .03). Moreover, the BI score increase per day was significantly lower in the hypertensive group than in the non-hypertensive group (.67 versus 1.8, P = .02). The hypertensive group also had a significantly longer duration of hospitalization than the hypertensive group (52 versus 30 days, P = .02).Hypertension was associated with longer hospitalization and poorer outcomes post-discharge, suggesting the importance of strict blood pressure control in patients who have experienced SAH.

Return to Driving Is a Better Predictor of Patient Outcome Than Return to Work After Aneurysmal Subarachnoid Hemorrhage.

OBJECTIVE: Return to work and driving are major rehabilitation goals for patients after an aneurysmal subarachnoid hemorrhage (aSAH). Our goal is to identify factors that may predict return to work or driving after aSAH. METHODS: Medical records of patients with aSAH were retrospectively reviewed from 2010 to 2018. Information on return to work and driving were prospectively collected. Univariate analyses were performed to assess the association between return to work or driving with patient characteristics, social factors, and admission clinical and radiographic severity. Multivariate regression models were used to evaluate return to work and driving and generate predictive models. RESULTS: A total of 193 patients were included, of whom 32% (62/193) resumed work and 57% (110/193) returned to driving. Median follow-up time was 3.4 years (interquartile range, 0.7-7.5 years). Return to work was associated with younger age (odds ratio [OR], 0.89; 95% CI, 0.85-0.94), lower Hunt and Hess grade (OR, 0.34; 95% CI, 0.23-0.54), and lack of seizures (OR, 0.09; 95% CI, 0.02-0.47). Return to driving was associated with younger age (OR, 0.94; 95% CI, 0.91-0.98), lower Hunt and Hess grade (OR, 0.36; 95% CI, 0.23-0.56), married status (OR, 3.4; 95% CI, 1.2-9.4), current or former smoking (OR, 3.9; 95% CI, 1.5-10.1), lack of recreational drug use (OR, 0.08; 95% CI, 0.01-0.77), and lack of seizures (OR, 0.28; 95% CI, 0.08-0.96). Admission risk factors were predictive of return to driving and return to work in the final multivariate models generated (area under the receiver operating characteristic curve 88% vs. 89%, respectively). CONCLUSIONS: Because work may be highly dependent on complex individual and social factors, driving is a simple and more accurate assessment for an individual's status after aSAH.

Long-Term Complications and Influence on Outcome in Patients Surviving Spontaneous Subarachnoid Hemorrhage.

BACKGROUND: While the short-term clinical outcome of patients with subarachnoid hemorrhage (SAH) is well described, there are limited data on long-term complications and their impact on social reintegration. This study aimed to assess the frequency of complications post-SAH and to investigate whether these complications attribute to functional and self-reported outcomes as well as the ability to return to work in these patients. METHODS: This retrospective single-center study included patients with atraumatic SAH over a 5-year period at a tertiary care center. Patients received a clinical follow-up for 12 months. In addition to demographics, imaging data, and parameters of acute treatment, the rate and extent of long-term complications after SAH were recorded. The functional outcome was assessed using the modified Rankin Scale (mRS; favorable outcome defined as mRS = 0-2). Further outcomes comprised self-reported subjective health measured by the EQ-5D and return to work for SAH patients with appropriate age. Multivariable analyses including in-hospital parameters and long-term complications were conducted to identify parameters independently associated with outcomes in SAH survivors. RESULTS: This study cohort consisted of 505 SAH patients of whom 405 survived the follow-up period of 12 months (i.e., mortality rate of 19.8%). Outcome data were available in 359/405 (88.6%) patients surviving SAH. At 12 months, a favorable functional outcome was achieved in 287/359 (79.9%) and 145/251 (57.8%) SAH patients returned to work. The rates of post-acute complications were headache (32.3%), chronic hydrocephalus requiring permanent ventriculoperitoneal shunting (VP shunt 25.4%) and epileptic seizures (9.5%). Despite patient's and clinical characteristics, both presence of epilepsy and need for VP shunt were independently and negatively associated with a favorable functional outcome (epilepsy: adjusted odds ratio [aOR] (95% confidence interval [95% CI]): 0.125 [0.050-0.315]; VP shunt: 0.279 [0.132-0.588]; both p < 0.001) as well as with return to work (aOR [95% CI]: epilepsy 0.195 [0.065-0.584], p = 0.003; VP shunt 0.412 [0.188-0.903], p = 0.027). Multivariable analyses revealed presence of headache, VP shunt, or epilepsy to be significantly related to subjective health impairment (aOR [95% CI]: headache 0.248 [0.143-0.430]; epilepsy 0.223 [0.085-0.585]; VP shunt 0.434 [0.231-0.816]; all p < 0.01). CONCLUSIONS: Long-term complications occur frequently after SAH and are associated with an impairment of functional and social outcomes. Further studies are warranted to investigate if treatment strategies specifically targeting these complications, including preventive aspects, may improve the outcomes after SAH.

Dynamics of outcome after aneurysmal subarachnoid hemorrhage.

In this observational study, we analyzed and described the dynamics of the outcome after aneurysmal subarachnoid hemorrhage (SAH) in a collective of 203 cases. We detected a significant improvement of the mean aggregate modified Rankin Score (mRS) in every time interval from discharge to 6 months and up to 1 year. Every forth to fifth patient with potential of recovery (mRS 1-5) at discharge improved by 1 mRS point in the time interval from 6 month to 1 year (22.6%). Patients with mRS 3 at discharge had a remarkable late recovery rate (73.3%, p = 0.000085). Multivariate analysis revealed age ≤ 65 years (odds ratio 4.93; p = 0.0045) and "World Federation of Neurological Surgeons" (WFNS) grades I and II (odds ratio 4.77; p = 0.0077) as significant predictors of early improvement (discharge to 6 months). Absence of a shunting procedure (odds ratio 8.32; p = 0.0049) was a significant predictor of late improvement (6 months to 1 year), but not age ≤ 65 years (p = 0.54) and WFNS grades I and II (p = 0.92). Thus, late recovery (6 month to 1 year) is significant and independent from age and WFNS grade.

Long-term functional prognosis of patients with aneurysmal subarachnoid hemorrhage treated with rehabilitation combined with hyperbaric oxygen: Case-series study.

The long-term prognosis of patients with aneurysmal subarachnoid hemorrhage (aSAH) has received increasing attention in recent years. Hyperbaric oxygen and rehabilitation are already used in clinical treatment of patients with aSAH, but it is unclear whether it can improve the long-term prognosis of patients postoperation. The purpose of this study was to evaluate the long-term prognosis and prognostic factors associated with combined rehabilitation and hyperbaric oxygen therapy for patients with aSAH.Information were retrospectively collected from patients with aSAH treated from October 2014 to July 2017, including demographics, history of hypertension, Hunt-Hess Grade at the time of onset, location of aneurysm, surgical treatment, status of delayed cerebral ischemia and tracheotomy, level of consciousness impairment (Glasgow Coma scale [GCS], neurologic function damage (National Institutes of Health Stroke Scale [NIHSS]), status of hydrocephalus, time of initial hyperbaric oxygen and rehabilitation therapy, as well as duration and frequency of hyperbaric oxygen therapy, and so on. Long-term functional prognosis was measured by modified Rankin scale (mRS), and mRS ≤3 was defined as good prognosis. Univariate and multivariate logistic regression were used to analyze predictors associated with poor prognosis.A total of 44 patients with aSAH were enrolled, and 25 patients (56.8%) had a good functional prognosis 6 months after disease onset. Univariate analysis showed age (P = .028), hyperbaric oxygen and rehabilitation start time (P = .039), NIHSS (P = .000), hydrocephalus (P = .024), frequency of hyperbaric oxygen therapy (P = .016), GCS ≤8 points (P = .000), and tracheotomy (P = .007) were associated with prognosis. Multivariate logistic regression analysis showed that only a higher NIHSS score was an independent predictor of poor prognosis (odds ratio = 1.59; 95% confidence interval, 1.10-2.30).More than 50% of patients with aSAH can achieve a good functional prognosis after combined rehabilitation and hyperbaric oxygen therapy. The severity of neurological impairment before treatment is closely related to poor prognosis.

Treating Patients with Frontal Neurocognitive Deficits After SAH and Stroke.

Five frontal systems circuits connect with the basal ganglia and other structures to control and regulate thinking and behavior. Subarachnoid hemorrhage and stroke following anterior circulation aneurysms typically disrupt these circuits, sometimes markedly affecting a patient's function. This article reviews the primary pathways and associated brain functions. The principles of cognitively and behaviorally rehabilitating these functions are also discussed by creating external structure and building on what the brain is still capable of doing.

Goal-oriented attentional self-regulation training in individuals with acquired brain injury in a subacute phase: a pilot feasibility study.

The primary aim of this prospective pilot study was to assess feasibility of implementing goal-oriented attentional self-regulation (GOALS) training in Slovenia with patients with multiple cognitive deficits after acquired brain injury in acute phase of recovery. Seven patients with acquired brain injury (i.e. stroke, traumatic brain injury, and subarachnoid hemorrhage) with a mean postinjury time of 4.3 months (SD = 1.25) and mean age of 34.5 years (SD = 18.6) were recruited for the study. The group program consisted of 10 sessions twice a week and included cognitive strategy training, social skills training, and psychoeducation. Structured interviews and neuropsychological tests were used before and after the training to determine the influence of the interventions on daily life tasks and attentional networks performance involving cognitive and behavioral domains. GOALS influenced self-reports of positive effect on the individual goals set by the patients. Training had a positive influence on executive control and memory. The results from the present study suggest that it is feasible to implement GOALS manualized executive function training in Slovenia, with the patients in a somewhat more acute stage than in previous studies, and that GOALS training may be a promising nonpharmacological treatment for cognitive and behavioral difficulties after acquired brain injury. Further research is needed to extend these findings in a larger sample.

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.

Predictors for Functional Outcome in Patients with Aneurysmal Subarachnoid Hemorrhage Who Completed In-Hospital Rehabilitation in a Single Institution.

BACKGROUND: Although many studies evaluated independent prognosis factors of functional outcome in patients with subarachnoid hemorrhage (SAH) at a suitable time point, some patients take a long time to get functional improvement. The purpose of this study is to evaluate predictors for functional outcome in SAH patients who underwent surgical clipping and in-hospital rehabilitation in our single institution using Modified Rankin Scale (MRS) and Barthel Index (BI). METHODS: Two-hundred fifty-one SAH patients were admitted to our hospital from January 2008 to December 2017. Of them, 144 patients who diagnosed aneurysmal SAH, underwent surgical clipping within 72 hours, and completed subsequent in-hospital rehabilitation were included in this study. We explored their clinical variables and evaluated the relationships between those factors and functional outcome using MRS and BI. RESULTS: In multivariate analysis, independent prognostic factors of both MRS and BI were age, World Federation of Neurologic Surgeons grade, and symptomatic vasospasm. CONCLUSIONS: We suggest that age, SAH severity, and symptomatic vasospasm are associated with functional outcome in patients with aneurysmal SAH who completed surgical clipping and in-hospital rehabilitation.

Safety and Feasibility of Early Mobilization in Patients with Subarachnoid Hemorrhage and External Ventricular Drain.

BACKGROUND/OBJECTIVE: In November 2014, our Neurointensive Care Unit began a multi-phased progressive early mobilization initiative for patients with subarachnoid hemorrhage and an external ventricular drain (EVD). Our goal was to transition from a culture of complete bed rest (Phase 0) to a physical and occupational therapy (PT/OT)-guided mobilization protocol (Phase I), and ultimately to a nurse-driven mobilization protocol (Phase II). We hypothesized that nurses could mobilize patients as safely as an exclusively PT/OT-guided approach. METHODS: In Phase I, patients were mobilized only with PT/OT at bedside; no independent time out of bed occurred. In Phase II, nurses independently mobilized patients with EVDs, and patients could remain out of bed for up to 3 h at a time. Physical and occupational therapists continued routine consultation during Phase II. RESULTS: Phase II patients were mobilized more frequently than Phase I patients [7.1 times per ICU stay (± 4.37) versus 3.0 times (± 1.33); p = 0.02], although not earlier [day 4.9 (± 3.46) versus day 6.0 (± 3.16); p = 0.32]. All Phase II patients were discharged to home PT services or acute rehabilitation centers. No patients were discharged to skilled nursing or long-term acute care hospitals, versus 12.5% in Phase I. In a multivariate analysis, odds of discharge to home/rehab were 3.83 for mobilized patients, independent of age and severity of illness. Other quality outcomes (length of stay, ventilator days, tracheostomy placement) between Phase I and Phase II patients were similar. No adverse events were attributable to early mobilization. CONCLUSIONS: Nurse-driven mobilization for patients with EVDs is safe, feasible, and leads to more frequent ambulation compared to a therapy-driven protocol. Nurse-driven mobilization may be associated with improved discharge disposition, although exact causation cannot be determined by these data.

Fatigue After Aneurysmal Subarachnoid Hemorrhage Is Highly Prevalent in the First-Year Postonset and Related to Low Physical Fitness: A Longitudinal Study.

OBJECTIVE: The aim of the study was to investigate whether low physical fitness and inactive and sedentary lifestyles play a role in the severity of fatigue in patients with aneurysmal subarachnoid hemorrhage (a-SAH). DESIGN: This is a prospective 1-yr follow-up study, including a total of 52 patients with a-SAH. Outcome measures included the Fatigue Severity Scale score, peak oxygen uptake (VO2peak), isokinetic knee muscle strength (peak torque), physical activity (% 24-hr period), and sedentary behavior (% waking hours) and were evaluated at 6 and 12 mos after onset. RESULTS: Fatigue was highly prevalent in the first year and reported by 48% of the patients at 6 mos and by 52% at 12 mos after a-SAH. Fatigue was associated with the knee extension (P < 0.001) and flexion strength (P < 0.001). A nonsignificant trend for a relationship was found between fatigue and the aerobic capacity (P = 0.079). No relationships were found between fatigue and physical activity or sedentary behavior. Fatigue could not be predicted by disease-related characteristics. CONCLUSIONS: Half of the patients were fatigued in the first year after a-SAH. Interventions are necessary to reduce fatigue and should consider exercise training as a potential contributor to a multimodal treatment, preventing debilitating conditions after a-SAH. TO CLAIM CME CREDITS: Complete the self-assessment activity and evaluation online at http://www.physiatry.org/JournalCME CME OBJECTIVES: Upon completion of this article, the reader should be able to: (1) Recognize the association between fatigue and physical fitness in patients after aneurysmal subarachnoid hemorrhage; (2) Determine the severity of fatigue complaints in patient after aneurysmal subarachnoid hemorrhage; and (3) Discuss the role of physical deconditioning in the management of fatigue in patients after aneurysmal subarachnoid hemorrhage. LEVEL: Advanced ACCREDITATION: The Association of Academic Physiatrists is accredited by the Accreditation Council for Continuing Medical Education to provide continuing medical education for physicians.The Association of Academic Physiatrists designates this Journal-based CME activity for a maximum of 1.0 AMA PRA Category 1 Credit(s)™. Physicians should only claim credit commensurate with the extent of their participation in the activity.

Psychosocial Comorbidities Related to Return to Work Rates Following Aneurysmal Subarachnoid Hemorrhage.

Purpose Ability to return to work (RTW) after stroke has been shown to have positive psychosocial benefits on survivors. Although one-fifth of aneurysmal subarachnoid hemorrhage (aSAH) survivors suffer from poor psychosocial outcomes, the relationship between such outcomes and RTW post-stroke is not clear. This project explores the relationship between age, gender, race, marital status, anxiety and depression and RTW 3 and 12 months post-aSAH. Methods Demographic and clinical variables were collected from the electronic medical record at the time of aSAH admission. Anxiety and depression were assessed at 3 and 12 months post-aSAH using the State Trait Anxiety Inventory (STAI) and Beck's Depression Inventory-II (BDI-II) in 121 subjects. RTW for previously employed patients was dichotomized into yes/no at their 3 or 12 month follow-up appointment. Results Older age was significantly associated with failure to RTW at 3 and 12 months post-aSAH (p = 0.003 and 0.011, respectively). Female gender showed a trending but nonsignificant relationship with RTW at 12 months (p = 0.081). High scores of depression, State anxiety, and Trait anxiety all had significant associations with failure to RTW 12 months post-aSAH (0.007 ≤ p ≤ 0.048). At 3 months, there was a significant interaction between older age and high State or Trait anxiety with failure to RTW 12 months post-aSAH (p = 0.025, 0.042 respectively). Conclusions Patients who are older and suffer from poor psychological outcomes are at an increased risk of failing to RTW 1-year post-aSAH. Our interactive results give us information about which patients should be streamlined for therapy to target their psychosocial needs.

Early Progressive Mobilization of Patients with External Ventricular Drains: Safety and Feasibility.

BACKGROUND/OBJECTIVE: Early mobilization of critically ill patients has been shown to improve functional outcomes. Neurosurgery patients with an external ventricular drain (EVD) due to increased intracranial pressure often remain on bed rest while EVD remains in place. The prevalence of mobilizing patients with EVD has not been described, and the literature regarding the safety and feasibility of mobilizing patients with EVDs is limited. The aim of our study was to describe the outcomes and adverse events of the first mobilization attempt in neurosurgery patients with EVD who participated in early functional mobilization with physical therapy or occupational therapy. METHODS: We performed a single-site, retrospective chart review of 153 patients who underwent placement of an EVD. Hemodynamically stable patients deemed appropriate for mobilization by physical or occupational therapy were included. Mobilization and activity details were recorded. RESULTS: The most common principal diagnoses were subarachnoid hemorrhage (61.4%) and intracerebral hemorrhage (17.0%) requiring EVD for symptomatic hydrocephalus. A total of 117 patients were mobilized (76.5%), and the median time to first mobilization after EVD placement in this group of 117 patients was 38 h. Decreased level of consciousness was the most common reason for lack of mobilization. The highest level of mobility on the patient's first attempt was ambulation (43.6%), followed by sitting on the side of the bed (30.8%), transferring to a bedside chair (17.1%), and standing up from the side of the bed (8.5%). No major safety events, such as EVD dislodgment, occurred in any patient. Transient adverse events with mobilization were infrequent at 6.9% and had no permanent neurological sequelae and were mostly headache, nausea, and transient diastolic blood pressure elevation. CONCLUSION: Early progressive mobilization of neurosurgical intensive care unit patients with external ventricular drains appears safe and feasible.

Recovery process of bilaterally injured corticoreticulospinal tracts in a patient with subarachnoid hemorrhage: Case report.

RATIONALE: A few studies using diffusion tensor tractography (DTT) have demonstrated recovery of injured corticoreticulospinal tract (CRT) in patients with intracerebral hemorrhage and infarct. However, no study reported on a patient who showed peri-infarct reorganization of an injured CRT following a middle cerebral artery territory infarct. PATIENT CONCERNS: A 56-year-old right-handed male patient was diagnosed as spontaneous subarachnoid hemorrhage (SAH) and intraventricular hemorrhage (IVH) and underwent clipping for a ruptured anterior communicating artery aneurysm and right frontal extraventricular drainage for IVH at the department of neurosurgery of a university hospital. After onset, he presented with complete weakness of both legs. DIAGNOSES: The patient was diagnosed as spontaneous SAH and IVH. INTERVENTIONS: Clinical assessment and DTT were performed at 1, 3, 6, and 20 months after onset. OUTCOMES: The weakness of both legs showed slow recovery for 10 months until 11 months after onset (medical research council: 6 months; 3/3 and 11 months; 4/4). As a result, he was able to walk independently on an even floor at 6 months and on stairs at 11 months after onset. The discontinued both CRTs on 1-month DTT were restored to the cerebral cortex on 3-month DTT, and then thickened consecutively on 6-month and 20-month DTTs. LESSONS: The recovery process of injured CRTs concurrent with recovery of leg weakness was demonstrated in a patient with SAH using DTT. This study has important implications in terms of regaining gait function by the recovery of bilaterally injured CRTs which was facilitated by the long-term rehabilitation.

The effect of time on cognitive impairments after non-traumatic subarachnoid haemorrhage and after traumatic brain injury.

OBJECTIVES: To compare the effect of time on cognitive impairments after Subarachnoid Haemorrhage and Traumatic Brain Injury and explore associations with baseline variables and global function. METHODS: Patients with a Glasgow Coma Scale score of 3-13, were assessed at 3, 6 and 12 months post injury by use of BNIS for cognitive impairment, RLAS-R to categorise cognitive and behavioural function, Barthel Index to assess performance of daily living, HADS to screen for depression and anxiety, and EuroQoL-5D, LiSat-11 and Glasgow Outcome Scale Extended to assess global function. RESULTS: BNIS T-scores did not differ significantly between groups and the proportion of patients with cognitive impairments was not significantly different at any time point. Cognition improved significantly between all time points in both groups except from 6 to 12 months after TBI. Generalised estimating equation showed non-significant signs of slower recovery of BNIS T-scores over time after SAH. Acute GCS scores were associated with BNIS T-scores after TBI but not after SAH. At 12 months, similar proportions of patients with SAH and TBI had good outcome. CONCLUSIONS: Cognitive improvements after SAH and TBI exhibit similarities and correlate with global function. GCS scores are associated with outcome after TBI but not after SAH.

Early Ambulation in Patients With External Ventricular Drains: Results of a Quality Improvement Project.

INTRODUCTION: Prolonged immobility in patients in the intensive care unit (ICU) can lead to muscle wasting and weakness, longer hospital stays, increased number of days in restraints, and hospital-acquired infections. Increasing evidence demonstrates the safety and feasibility of early mobilization in the ICU. However, there is a lack of evidence in the safety and feasibility of mobilizing patients with external ventricular drains (EVDs). The purpose of this study was to determine the safety and feasibility of early mobility in this patient population. METHODS: We conducted a prospective, observational study. All patients in the study were managed with standard protocols and procedures practiced in our ICU including early mobility. Patients with an EVD who received early mobilization were awake and following commands, had a Lindegaard ratio <3.0 or middle cerebral artery (MCA) mean flow velocity <120 cm/s, a Mean Arterial Pressure (MAP) > 80 mm Hg, and an intracranial pressure consistently <20 mm Hg. Data were collected by physical therapists at the time of encounter. RESULTS: Ninety patients with a total of 185 patient encounters were recorded over a 12-month period. The average time between EVD placement and physical therapy (PT) session was 8.3 ± 5.5 days. In 149 (81%) encounters, patients were at least standing or better. Patients were walking with assistance or better in 99 (54%) encounters. There were 4 (2.2%) adverse events recorded during the entire study. CONCLUSION: This observational study suggests that PT is feasible in patients with EVDs and can be safely tolerated. Further research is warranted in a larger patient population conducted prospectively to assess the potential benefit of early mobility in this patient population.

Marriage and Partnership Integrity After Aneurysmal Subarachnoid Hemorrhage: Small Alterations in Neurologic Status Matter Most.

OBJECTIVE: Common sequelae of subarachnoid hemorrhage (SAH) include somatic and/or cognitive impairment. This can cause emotional stress, social tensions, and difficulties in relationships. To test our hypothesis that more severe somatic and cognitive impairments increased the likelihood of disruption of a relationship after SAH, we assessed the integrity of marriage or partnership status in a well-evaluated subset of SAH patients. METHODS: Our sample comprised 50 SAH patients who were discharged to a neurologic, in-house rehabilitation center between 2005 and 2010. Deficits on admission to the rehabilitation center were divided into 18 categories and grouped into minor and major somatic deficits, as well as cognitive deficits. Clinical outcome scores, marital/partnership status, and duration of partnership before ictus were recorded. A follow-up questionnaire after 4.3 (2012) and 8.8 (2017) years was used to assess changes in marital/partnership status. Possible predictor parameters were estimated and included in a stepdown regression analysis. RESULTS: In 2012, after a mean follow-up of 4.3 years, 8 of the 50 SAH patients were divorced or separated, whereas after 8.8 years only 1 additional relationship had ended. In our regression model analysis, a "short duration of relationship" before SAH and the presence of a "few minor somatic deficits" were associated with a higher likelihood of divorce or separation in the near future and remained unchanged at long-term follow-up. CONCLUSION: Contrary to our hypothesis, neither the presence of severe somatic or cognitive deficits nor clinical evaluation scores reliably predicted divorce or separation after SAH.

Injury of the Precommissural Fornix in a Patient with Subarachnoid Hemorrhage: A Case Report.

OBJECTIVES: We investigated injury of the pre- or postcommissural fornix in a patient with subarachnoid hemorrhage (SAH) using diffusion tensor imaging. CASE DESCRIPTION: A 48-year-old male patient was diagnosed as SAH due to rupture of the right middle cerebral artery bifurcation aneurysm. After 9 weeks from onset, he was transferred to the rehabilitation department and he showed memory impairment. The whole fornix was reconstructed using single-tract fornix model based on a fiber assignment by continuous tracking, and separated fornices (pre- and postcommissural fornices) were reconstructed using 2-tract fornix model based on a probabilistic tractography method. The fractional anisotropy (FA), mean diffusivity, and fiber volume were measured in the patient and 6 normal control subjects. The integrities of both reconstructed whole fornices that were reconstructed using probabilistic tractography method were preserved. By contrast, in the results of 2-tract fornix model, the precommissural fornices showed discontinuations in both fornical cruses. In addition, the FA and fiber volume of both precommissural fornices in the patient were decreased by more than 2 standard deviations of those of normal control subjects. CONCLUSIONS: Separate evaluations of the pre- and postcommissural fornices using 2-tract fornix model would be useful for diagnosis in patients with memory impairment following SAH.