Outcomes of surgery for unruptured aneurysm & subarachnoid hemorrhage
Research type
Research Study
Full title
Motor & cognitive outcomes of surgical treatment for unruptured aneurysm and subarachnoid hemorrhage
IRAS ID
145257
Contact name
Mark Mon-Williams
Contact email
Sponsor organisation
Leeds Teaching Hospitals NHS Trust
Research summary
Aneurysmal Subarachnoid Hemorrhage (aSAH) can cause a number of cognitive and motor difficulties, which in turn may significantly impact a patient’s quality of life (e.g. Al-Khindi, Macdonald, & Schweizer, 2012). Intracranial Aneurysm Treatment (IAT) options including coiling and clipping are available, but to date there is little high quality empirical research examining the effects of aSAH on fine motor and cognitive outcomes. This is also the case in patients who have been diagnosed with an Unruptured Aneurysm (UA) but in the absence of a hemorrhage (i.e. a problem typically identified on a scan without previous history of stroke), and subsequently undergo IAT as a preventative (non-emergency) measure.
In cases of aSAH, anecdotal reports (from patients and clinical leads) indicate that despite patients scoring well on clinical outcome measures post-operatively (which would suggest a full recovery), many patients encounter memory problems, do not return to work, and experience significant fear and anxiety as a consequence of their experience (e.g. fear of a future stroke). To date, there is also very little research surrounding the potential for IAT to yield post-operative deficits in elective ‘asymptomatic’ patients. Given the crude quality of the standardized clinical measures currently used to determine readiness of discharge and screen for deficits after IAT, it is vital to develop more robust and highly sensitive measures of post-operative neuropsychological and motor outcomes. This will allow us to (i) measure movement and cognition in patient groups with UA and aSAH; (ii) explore differences in outcomes between treatment methods (i.e. coiling vs. clipping); (iii) identify neural underpinnings of post-operative deficits by comparing neuropsychological data with structural brain changes assessed with scans obtained as a standard process during admission and follow up; (iv) design effective screening methods to support post-operative care, and inform the design of appropriate rehabilitation programmes, in the future.
In sum, our research team proposes a longitudinal study whereby a sensitive Kinematic Assessment Tool (KAT) will be used as an objective measure of cognitive and motor domains in UA and aSAH patients that undergo IAT. The KAT is a series of touch-screen computerized tasks that have already been evidenced as providing objective measures of cognitive and motoric performance in adults and children. We will recruit a sample of patients who are matched for surgical procedure (including elective UA coiling and clipping cases, and acute aSAH coiling and clipping patients), but are otherwise fit and healthy. These patients will be tested post-operatively prior to their discharge from the ward (i.e. between 1-30 days, but will depend on the condition and IAT method) and then again at 6 weeks, 6 months and 24 months post-IAT. Our protocol will gain a more detailed understanding of patients’ post-operative abilities above and beyond what can be measured with standardized clinical tests (a selection of which will also be included at all four testing sessions). We will distinguish between the effects of surgery and the effects of the neurological condition by comparing patients who have the same IAT procedure (i.e. coil or clip) but for a different condition (i.e. UA compared to aSAH). We will explore relative outcomes of the two IAT methods by comparing patients with the same condition (i.e. UA or aSAH) but who had a different type of IAT (i.e. coil compared to clip). To explore neurological underpinnings of deficits encountered after treatment for UA or aSAH, we compare kinematic data and standard neuropsychological test scores with structural brain changes assessed with scans (i.e. MR/CT/Catheter angiogram), which are obtained as a standard process during admission and follow-up. This will allow us to make some initial predictions about the underlying neurological causes of the clinical and psychological changes seen in this patient group. All data gathered by our selection performance measures in the patient groups will also be compared with a set of age-matched controls (i.e. no UA or aSAH), recruited as part of our future studies.
Given the paucity of research surrounding the patients’ own perspective of post-operative recovery from UA and aSAH, an optional qualitative interview (i.e. focus group) will be included, where patients will be invited to discuss from their own personal experience, any symptoms, fears and/or concerns that they encountered as a consequence of their treatment. Including this qualitative element within our project will ensure that subtle outcomes are not missed, and inform our approach to examining the motor and cognitive outcomes of UA and aSAH in any future work.
Lay Summary of Results:
Results
Standardised clinical outcome measures
Most standard measures did not differ markedly
between sessions. Because of the categorical/ordinal
nature of these scores, the limited change in scores
and the small numbers of participants, it is not useful
to examine these data using grouped statistical methods.
Instead, we examined measures for each individual
and compared individual scores with ceiling performance
on the tests. There was no change in GOS between
sessions, as nine patients received the highest classification
(i.e. ‘Good Recovery’) at Discharge and 6/52. One
patient was scored as having ‘Moderate Disability’
(score¼4) at Discharge and 6/52. The pattern was similar
for SRBI – six patients were ‘functionally independent’
(score¼20) at both sessions, one patient scored 19
at both sessions, and one patient scored 18 at Discharge
and 17 at 6/52. There were also no systematic changes
in the HADs measure. At Discharge, four of eight
patients had ‘borderline abnormal’ or ‘abnormal’
Anxiety scores (scores¼8, 8, 8, 12), and at 6/52, two
scores remained unchanged as ‘borderline abnormal’,
with one patient going from ‘normal’ to ‘abnormal’
(6 to 16) and another from ‘abnormal’ to ‘normal’
(12 to 6). On the Depression scale, two scores were
‘abnormal’ or ‘borderline abnormal’ at Discharge and
at 6/52. Raw data for the SRBI and the HADs subscales
are given in Table 1.
6 Journal of Rehabilitation and Assistive Technologies Engineering
The only standardised measures that showed systematic
changes were the ACE-R and DSST. The ACE-R
scores for six of eight patients improved from
Discharge to 6/52 (mean¼93 increasing to 98) to
scores that are near to maximum. This increase
seemed to be driven mainly by improved Memory
scores on the ACE-R (measuring recall, anterograde
memory and retrograde memory), with an average
increase from 21 to 25 out of 26 for the memory component.
The remaining two individuals who did not
improve on the memory element (scores at
Discharge¼12 and 14; 6/52¼21 and 19, respectively)
also performed poorly (i.e. scores <88, which is the cutoff
with 94% sensitivity and 89% specificity for dementia)
across the whole ACE-R at both testing sessions.
Interestingly, neither of these patients fell below the
MMSE cut-off for cognitive impairment (both patients
scored 27 on the MMSE, which if one point less, would
have indicated cognitive impairment). In fact, there
were no reliable changes in the MMSE sub-test of
the ACE-R across the whole group, with most participants
scoring the same at both sessions. The other
remaining ACE-R sub-tests also failed to display any
impairment (e.g. all except one patient scored 15–16 for
Visuospatial Ability at both sessions). Finally, DSST
scores improved for six of 10 patients, as scores
improved from 45 points at Discharge to 60 points
(out of 93) by 6/52. Scores for the other four individuals
either remained the same at both sessions (i.e. DSST
score¼45 at both sessions for three patients) or
declined between sessions (DSST reduced from 35 to
25 for one patient).
Kinematic motor tests
Analyses of the tracking task showed patients improved
performance accuracy from Discharge to 6/52 (F (1,
9)¼14.20, p<.001, 2 p¼.61; mean RMSE at
Discharge¼17.10 mm; 6/52¼12.27 mm). Accuracy
also increased as dot-tracking speed reduced (i.e.
‘Slow’ tracking; F(2, 18)¼60.23, p<.001, 2p¼.87,
"¼.53). There were no sessionspeed interactions suggesting
performance improved between sessions similarly
for all speeds. A single measure across speeds was
taken to simplify further analysis. This ‘combined’ measure
showed seven out of 10 patients exhibited ‘abnormal’
tracking performance at Discharge (i.e. worse than
mean healthy controls’ performanceþ95% CI;
t(18)¼1.93, p<.05). Furthermore, despite all patients
showing some degree of improvement, two patients still
exhibited ‘abnormal’ tracking at 6/52 (Figure 4).
A similar pattern was seen in the other motor tests
(Figure 5). The steering task detected impaired accuracy
compared to controls at Discharge (t(18)¼2.02, p<.05)
and accuracy improved from Discharge to 6/52 (F (1,
9)¼9.90, p<.01, 2p¼.52) – all patients improved to
some degree; but three of 10 were still abnormal at 6/52.
Aiming performance was only marginally worse compared
to controls at Discharge (t(18)¼1.58, p¼.074)
but this group performance still improved between
Discharge (mean MT¼1.67 s) and 6/52 (mean
MT¼1.37 s) with shorter duration movements for
seven of 10 patients (t(9)¼2.12, p<.05), though movement
duration was still ‘abnormal’ for two patients at 6/
52. These findings suggest that our KAT motor tests were
Table 1. Individual patient scores on standardised outcome measures and kinematic tests at Discharge (D) and 6/52 weeks postoperation
(6/52).a
SRBI HADS (A) HADS (D) CR Motor ACE-R DSST
P Age Discharge _6/52 Discharge _6/52 Discharge _6/52 Discharge 6/52 Discharge 6/52 Discharge 6/52 Discharge 6/52
#1 52 20 20 6 2 2 2 7 5 1.35 0.16 84 85 51 51
#2 74 20 20 8 8 4 2 4 6 2.49 0.91 #N/A #N/A 27 27
#3 54 20 20 12 6 8 0 7 6 0.87 0.35 92 98 38 48
#4 72 20 20 0 0 0 0 2 6 3.38 0.14 82 82 17 30
#5 68 20 20 8 8 3 1 5 6 1.12 0.59 94 99
95
56 62
#6 31 20 20 3 2 1 1 2 9 0.99 1.34 92 43 75
#7 55 19 19 6 16 5 8 10 13 1 0.38 100 99 64 79
#8 49 18 17 8 7 10 9 10 16 2.32 0:23 89 97 35 25
#9 49 #N/A #N/A #N/A #N/A #N/A #N/A 16 16 0.79 1.12 #N/A #N/A 55 55
#10 24 #N/A #N/A #N/A #N/A #N/A #N/A 16 16 0.75 1.44 93 99 52 65
aThe age of each participant is given, along with the following individual patient scores on (i) SRBI (max¼20); (ii) Anxiety (A) and Depression (D)
subscales of HADs (max¼21 per subscale); (iii) maximum number of items correctly recalled (CR) out of the full 16 movement sequence comprising
the Sequence Learning Task; (iv) a composite measure of motor performance (z-scores) on the motor task battery, including tracking, steering and
aiming tests (i.e. a motor measure); (v) ACE-R (max¼100) and (vi) DSST (max¼93). Impaired performance measures are highlighted in red text. Dark
grey shaded cells highlight patients with impaired CR at 6/52, and light grey shaded cells highlight those with motor difficulties at 6/52. For clarity values
of ACE-R and DSST that are inconsistent with CR and motor impairments have been emboldened and marked with a box.
Raw et al. 7
sufficiently sensitive to detect improvements in performance
between sessions, and identify individuals that had
not yet fully recovered (through comparing performance
with healthy controls).
Sequence Learning Task
Analyses of the maximum number of moves that
patients could recall across the Sequence Learning
Task (i.e. CR) showed that only two patients correctly
recalled all 16 moves in both sessions (i.e. showing no
impairment and thus no room for improvement). Four
patients improved by 2–6 correct responses from
Discharge to 6/52 (some data were not recorded for
two patients at Discharge due to disruptions on the
ward, hence initial performance could not be assessed),
but at 6/52 there were still five patients who could only
recall 5–6 items correctly (out of 16). Two of these
patients also struggled with the ACE-R Memory subtests
(patients 1 and 4 in Table 1), but the other three
scored normally on the ACE-R (i.e. no clear cognitive
impairment identified by the ACE-R).REC name
Yorkshire & The Humber - Leeds West Research Ethics Committee
REC reference
14/YH/0009
Date of REC Opinion
20 Feb 2014
REC opinion
Further Information Favourable Opinion