Journal of Clinical Neuroscience xxx (2014) xxx–xxx
Contents lists available at ScienceDirect
Journal of Clinical Neuroscience journal homepage: www.elsevier.com/locate/jocn
Clinical Study
Neuropsychiatric disturbance after aneurysmal subarachnoid hemorrhage George Kwok Chu Wong a,⇑, Sandy Wai Lam a, Sandra S.M. Chan b, Mary Lai a, Patty P.P. Tse a, Vincent Mok c, Wai Sang Poon a, Adrian Wong d a Division of Neurosurgery, Department of Surgery, 4/F Clinical Science Building, Prince of Wales Hospital, The Chinese University of Hong Kong, 30-32 Ngan Shing Street, Shatin, New Territories, Hong Kong Special Administrative Region b Department of Psychiatry, Prince of Wales Hospital, The Chinese University of Hong Kong, Hong Kong Special Administrative Region c Division of Neurology, Department of Medicine and Therapeutics, Prince of Wales Hospital, The Chinese University of Hong Kong, Hong Kong Special Administrative Region d Department of Psychological Studies, The Hong Kong Institute of Education, Tai Po, New Territories, Hong Kong Special Administrative Region
a r t i c l e
i n f o
Article history: Received 15 October 2013 Accepted 23 February 2014 Available online xxxx Keywords: Cerebral aneurysm Neuropsychiatric disturbance Stroke Subarachnoid hemorrhage
a b s t r a c t Although aneurysmal subarachnoid hemorrhage (aSAH) accounts for only 3–5% of all strokes, a high degree of morbidity has been reported in this relatively young subset of patients. Neuropsychiatric disturbance has often been neglected in these reports. We aimed to investigate the pattern and pathological factors of chronic neuropsychiatric disturbance in aSAH patients. This cross-sectional observational four-center study was carried out in Hong Kong. Neuropsychiatric outcome (Neuropsychiatric Inventory Chinese Version [CNPI]) assessments were conducted cross-sectionally 1–4 years after ictus. Pathological factors considered were early brain injury as assessed by admission World Federation of Neurosurgical Societies grade, aneurysm treatment (clipping versus coiling), delayed cerebral infarction, and chronic hydrocephalus. One hundred and three aSAH patients’ spouses or caregivers completed the CNPI. Forty-two (41%) patients were reported to have one or more domain(s) of neuropsychiatric disturbance. Common neuropsychiatric disturbance domains included agitation/aggression, depression, apathy/indifference, irritability/lability, and appetite/eating disturbance. Chronic neuropsychiatric disturbance was associated with presence of chronic hydrocephalus. A subscore consisting of the five commonly affected domains seems to be a suitable tool for aSAH patients and should be further validated and replicated in future studies. Ó 2014 Elsevier Ltd. All rights reserved.
1. Introduction Although aneurysmal subarachnoid hemorrhage (aSAH) accounts for only 3–5% of all strokes, a high degree of morbidity has been reported in these relatively young patients [1–5]. Neuropsychiatric disturbance has often been neglected in these reports. Depression, fatigue, and post-traumatic stress disorder are important factors affecting vocational and social functioning of rehabilitated patients after aSAH. Reported frequencies of chronic fatigue after aSAH range from 31% to 90%, and were recently recognized to be associated with sleep disturbance, anxiety, depression, and cognitive and physical impairment [6,7]. Up to 34% of aSAH patients develop post-traumatic stress disorder due to a persistent and disproportionate fear of aSAH recurrence [8]. Moderate and severe depression has been found in 20% of survivors after aSAH and may require medications and/or psychological treatment [9,10]. ⇑ Corresponding author. Tel.: +852 2632 2624; fax: +852 2637 7974. E-mail address: [email protected] (G.K.C. Wong).
Little data exist on the overall pattern and pathological factors associated with chronic neuropsychiatric disturbance after aSAH. The Neuropsychiatric Inventory (NPI) is a commonly employed comprehensive assessment tool for psychopathology in dementia patients. It evaluates 12 neuropsychiatric disturbances common in dementia. The Neuropsychiatric Inventory includes assessments for common neuropsychiatric symptoms encountered in Alzheimer’s disease, including delusion, agitation, anxiety, and personality change, assessments for common neuropsychiatric symptoms encountered in frontotemporal dementia, including apathy, euphoria, irritability, and disinhibition, as well as assessments for common neuropsychiatric symptoms encountered in vascular dementia, including apathy, irritability, and lability [11,12]. Studies in dementia patients have demonstrated good content and concurrent validity, and internal consistency [11,12]. The scoring system is straight-forward. A Chinese Version (CNPI) is also available [13,14]. We therefore aimed to investigate the pattern and prevalence of chronic neuropsychiatric disturbance in aSAH patients. We also aimed to identify if any of four pathophysiological processes
http://dx.doi.org/10.1016/j.jocn.2014.02.018 0967-5868/Ó 2014 Elsevier Ltd. All rights reserved.
Please cite this article in press as: Wong GKC et al. Neuropsychiatric disturbance after aneurysmal subarachnoid hemorrhage. J Clin Neurosci (2014), http://dx.doi.org/10.1016/j.jocn.2014.02.018
2
G.K.C. Wong et al. / Journal of Clinical Neuroscience xxx (2014) xxx–xxx
– early brain injury as assessed by admission World Federation of Neurosurgical Societies (WFNS) grade, aneurysm treatment (clipping versus coiling), delayed cerebral infarction, or chronic hydrocephalus – were significantly associated with chronic neuropsychiatric disturbance. 2. Methods This cross-sectional observational four-center study was carried out in Hong Kong. It was approved by local the Ethics Committees of participating centers. The study conformed to the Declaration of Helsinki, and informed written consent was obtained from patients and/or their next of kin. The inclusion criteria were as follows: (1) spontaneous subarachnoid hemorrhage resulting from an angiographically confirmed intracranial aneurysm; (2) hospital admission within 96 hours of the ictus; (3) aged between 21 and 75 years; (4) Chinese (Cantonese) speaking; and (5) willing and able to provide informed consent (or availability of a person authorized to do so). The exclusion criteria were as follows: (1) previous cerebrovascular or neurological disease other than an unruptured intracranial aneurysm; (2) neurosurgery prior to the ictus; or (3) known psychiatric disorder on treatment. The admission neurological grade was measured by WFNS grade [15]. WFNS grade ranged from fully conscious with no motor or speech deficit (Grade I) to Glasgow Coma Scale 66 (Grade V). Cerebral infarction due to delayed cerebral ischemia was defined as a new cerebral infarction identified on CT scan after exclusion of procedure related infarction [16]. Chronic hydrocephalus was defined as persistent ventricular dilatation requiring internal shunt implantation such as a ventriculo-peritoneal shunt. 3. Assessments Neurological and functional outcome assessments were conducted 1 year after ictus and neuropsychiatric outcome assessments were conducted cross-sectionally 1–4 years after ictus by one of two research assistants (psychology graduates) trained by a post-doctoral research psychologist.
and dependence) after stroke [17]. The mRS score ranges from 0 (no symptoms) to 6 (death).
3.3. Activity of Daily Living: Chinese Lawton Instrumental Activity of Daily Living Scale The Lawton Instrumental Activity of Daily Living (IADL) Scale is an appropriate instrument to assess independent living skills [18,19]. Items that are assessed include ability to use the telephone, go shopping, prepare food, do the housekeeping and do the laundry, as well as the mode of transportation used, responsibility for own medications, and ability to handle finances. The Chinese version had been previously validated and used [19].
4. Statistical analysis Statistical analyses were performed with the Statistical Package for the Social Sciences version 18.0 (SPSS, Chicago, IL, USA). Results are reported as the number (and percentage) of patients or mean ± standard deviation unless otherwise specified. A difference with a p value of
Contents lists available at ScienceDirect
Journal of Clinical Neuroscience journal homepage: www.elsevier.com/locate/jocn
Clinical Study
Neuropsychiatric disturbance after aneurysmal subarachnoid hemorrhage George Kwok Chu Wong a,⇑, Sandy Wai Lam a, Sandra S.M. Chan b, Mary Lai a, Patty P.P. Tse a, Vincent Mok c, Wai Sang Poon a, Adrian Wong d a Division of Neurosurgery, Department of Surgery, 4/F Clinical Science Building, Prince of Wales Hospital, The Chinese University of Hong Kong, 30-32 Ngan Shing Street, Shatin, New Territories, Hong Kong Special Administrative Region b Department of Psychiatry, Prince of Wales Hospital, The Chinese University of Hong Kong, Hong Kong Special Administrative Region c Division of Neurology, Department of Medicine and Therapeutics, Prince of Wales Hospital, The Chinese University of Hong Kong, Hong Kong Special Administrative Region d Department of Psychological Studies, The Hong Kong Institute of Education, Tai Po, New Territories, Hong Kong Special Administrative Region
a r t i c l e
i n f o
Article history: Received 15 October 2013 Accepted 23 February 2014 Available online xxxx Keywords: Cerebral aneurysm Neuropsychiatric disturbance Stroke Subarachnoid hemorrhage
a b s t r a c t Although aneurysmal subarachnoid hemorrhage (aSAH) accounts for only 3–5% of all strokes, a high degree of morbidity has been reported in this relatively young subset of patients. Neuropsychiatric disturbance has often been neglected in these reports. We aimed to investigate the pattern and pathological factors of chronic neuropsychiatric disturbance in aSAH patients. This cross-sectional observational four-center study was carried out in Hong Kong. Neuropsychiatric outcome (Neuropsychiatric Inventory Chinese Version [CNPI]) assessments were conducted cross-sectionally 1–4 years after ictus. Pathological factors considered were early brain injury as assessed by admission World Federation of Neurosurgical Societies grade, aneurysm treatment (clipping versus coiling), delayed cerebral infarction, and chronic hydrocephalus. One hundred and three aSAH patients’ spouses or caregivers completed the CNPI. Forty-two (41%) patients were reported to have one or more domain(s) of neuropsychiatric disturbance. Common neuropsychiatric disturbance domains included agitation/aggression, depression, apathy/indifference, irritability/lability, and appetite/eating disturbance. Chronic neuropsychiatric disturbance was associated with presence of chronic hydrocephalus. A subscore consisting of the five commonly affected domains seems to be a suitable tool for aSAH patients and should be further validated and replicated in future studies. Ó 2014 Elsevier Ltd. All rights reserved.
1. Introduction Although aneurysmal subarachnoid hemorrhage (aSAH) accounts for only 3–5% of all strokes, a high degree of morbidity has been reported in these relatively young patients [1–5]. Neuropsychiatric disturbance has often been neglected in these reports. Depression, fatigue, and post-traumatic stress disorder are important factors affecting vocational and social functioning of rehabilitated patients after aSAH. Reported frequencies of chronic fatigue after aSAH range from 31% to 90%, and were recently recognized to be associated with sleep disturbance, anxiety, depression, and cognitive and physical impairment [6,7]. Up to 34% of aSAH patients develop post-traumatic stress disorder due to a persistent and disproportionate fear of aSAH recurrence [8]. Moderate and severe depression has been found in 20% of survivors after aSAH and may require medications and/or psychological treatment [9,10]. ⇑ Corresponding author. Tel.: +852 2632 2624; fax: +852 2637 7974. E-mail address: [email protected] (G.K.C. Wong).
Little data exist on the overall pattern and pathological factors associated with chronic neuropsychiatric disturbance after aSAH. The Neuropsychiatric Inventory (NPI) is a commonly employed comprehensive assessment tool for psychopathology in dementia patients. It evaluates 12 neuropsychiatric disturbances common in dementia. The Neuropsychiatric Inventory includes assessments for common neuropsychiatric symptoms encountered in Alzheimer’s disease, including delusion, agitation, anxiety, and personality change, assessments for common neuropsychiatric symptoms encountered in frontotemporal dementia, including apathy, euphoria, irritability, and disinhibition, as well as assessments for common neuropsychiatric symptoms encountered in vascular dementia, including apathy, irritability, and lability [11,12]. Studies in dementia patients have demonstrated good content and concurrent validity, and internal consistency [11,12]. The scoring system is straight-forward. A Chinese Version (CNPI) is also available [13,14]. We therefore aimed to investigate the pattern and prevalence of chronic neuropsychiatric disturbance in aSAH patients. We also aimed to identify if any of four pathophysiological processes
http://dx.doi.org/10.1016/j.jocn.2014.02.018 0967-5868/Ó 2014 Elsevier Ltd. All rights reserved.
Please cite this article in press as: Wong GKC et al. Neuropsychiatric disturbance after aneurysmal subarachnoid hemorrhage. J Clin Neurosci (2014), http://dx.doi.org/10.1016/j.jocn.2014.02.018
2
G.K.C. Wong et al. / Journal of Clinical Neuroscience xxx (2014) xxx–xxx
– early brain injury as assessed by admission World Federation of Neurosurgical Societies (WFNS) grade, aneurysm treatment (clipping versus coiling), delayed cerebral infarction, or chronic hydrocephalus – were significantly associated with chronic neuropsychiatric disturbance. 2. Methods This cross-sectional observational four-center study was carried out in Hong Kong. It was approved by local the Ethics Committees of participating centers. The study conformed to the Declaration of Helsinki, and informed written consent was obtained from patients and/or their next of kin. The inclusion criteria were as follows: (1) spontaneous subarachnoid hemorrhage resulting from an angiographically confirmed intracranial aneurysm; (2) hospital admission within 96 hours of the ictus; (3) aged between 21 and 75 years; (4) Chinese (Cantonese) speaking; and (5) willing and able to provide informed consent (or availability of a person authorized to do so). The exclusion criteria were as follows: (1) previous cerebrovascular or neurological disease other than an unruptured intracranial aneurysm; (2) neurosurgery prior to the ictus; or (3) known psychiatric disorder on treatment. The admission neurological grade was measured by WFNS grade [15]. WFNS grade ranged from fully conscious with no motor or speech deficit (Grade I) to Glasgow Coma Scale 66 (Grade V). Cerebral infarction due to delayed cerebral ischemia was defined as a new cerebral infarction identified on CT scan after exclusion of procedure related infarction [16]. Chronic hydrocephalus was defined as persistent ventricular dilatation requiring internal shunt implantation such as a ventriculo-peritoneal shunt. 3. Assessments Neurological and functional outcome assessments were conducted 1 year after ictus and neuropsychiatric outcome assessments were conducted cross-sectionally 1–4 years after ictus by one of two research assistants (psychology graduates) trained by a post-doctoral research psychologist.
and dependence) after stroke [17]. The mRS score ranges from 0 (no symptoms) to 6 (death).
3.3. Activity of Daily Living: Chinese Lawton Instrumental Activity of Daily Living Scale The Lawton Instrumental Activity of Daily Living (IADL) Scale is an appropriate instrument to assess independent living skills [18,19]. Items that are assessed include ability to use the telephone, go shopping, prepare food, do the housekeeping and do the laundry, as well as the mode of transportation used, responsibility for own medications, and ability to handle finances. The Chinese version had been previously validated and used [19].
4. Statistical analysis Statistical analyses were performed with the Statistical Package for the Social Sciences version 18.0 (SPSS, Chicago, IL, USA). Results are reported as the number (and percentage) of patients or mean ± standard deviation unless otherwise specified. A difference with a p value of
