Neurological and Psychosocial Outcome After SAH

ABSTRACT & COMMENTARY

Synopsis: Interviewers of survivors of acute SAH identified a general attitude of having recovered well, with only four patients suffering from depression.

Source: Ogden JA, et al. Neurosurgery 1997;41:25-34.

Ogden and colleagues evaluate a long-term follow-up on 123 patients who survived 4-7 years following acute subarachnoid hemorrhage (SAH). Although admission level indices had an average Glasgow Coma Scale of 13.2, admission aneurysm status was graded as 56% Grade 1 or 2, 9% Grade 3, and 31% Grade 4. The sample was drawn from an initial 291 patients, of whom 28 died. From the total of 263 surviving patients, 249 were initially enrolled for outcome studies. Only 136 could be found, however, and, of this group, 123 participated in the present study. The authors provide evidence that the study direct group and those who withdrew were statistically similar in comparison as to acute illness, immediate outcome, and general demographic qualities.

Table

Post SAH Patients Studied 4-7 Years Later

Total patients and characteristics: n = 123; 81 F, 42 M; average age at SAH, 49 ± 14.2 years

Subsequent symptoms

Seizures: 24 total patients, all with aneurysms, 17 after two weeks, five in past five years

Headache: 16% (pre-SAH incidence not given)

Fatigue and/or excess sleepiness: total, 75%; still continuing, 35%; difficult nocturnal sleep, 26%

Memory problems: 41%, mostly mild, seven moderately severe

Personality changes: 48%, mostly irritability, a few severe

Divorced: five, four because of SAH-related incompatibility

Work status: declined in 20%

Neurologic problems: 14% had hemiplegia or weakness, 11% had visual impairment, 8% suffered "significant" language problems

Lifestyle changes: 34%; 16% led a less pressured life, 15% stopped driving, 11% increased exercise, 6% decreased exercise. Smoking moderately decreased, but overall alcohol ingestion modestly increased

Previous reports from other institutions describe patients’ functions one year following immediate "good outcome" after aneurysmal SAH. Recovery of premorbid IQs was the rule, but as many as half of those patients retained limitations in memory, emotional stability, and difficulties with social intercourse. Severe fatigue or daytime drowsiness affected as many as 80%. Headaches were frequent, and only about half returned to an original level of employment. Outcomes were similar whether or not surgical treatment was involved. Against this background of other reports, Ogden et al present the outcome results of a much larger cohort and compare the findings with earlier ones. At three months, a sample of 86 of the current 126 patients had shown a total average outcome level of 1.19 (good [1] or moderately disabled [2]). The 124 studied patients included 81 women and 42 men (mean age, 49); no initial aneurysm, 14%; early admission Glasgow Coma Scale of 13.21 ± 2.14. The table summarizes the findings.

COMMENT BY FRED PLUM, MD

Despite the above tabulation of limitations, interviewers identified a general attitude of having recovered well, with only four patients suffering from depression. This compares to 19% feeling depressed at one year. Also, despite what looks like a high morbidity in the table, potentially incapacitating symptoms other than neurologic disability were practically absent at 4-7 years. Seizure disorders were confined to patients who had aneurysms, and memory loss was somewhat less a problem in patients who had no aneurysm. An interesting point is that none of the 17 patients with subarachnoid hemorrhage in whom no aneurysm was found had an episode of rebleeding. (Dr. Plum is Neurologist-in-Chief, New York Hospital, Cornell Medical Center.)