sah outcome and rehabilitation

Outcome and Rehabilitation of Patients Following Aneurysmal SAH

Dhaval Shukla Professor of Neurosurgery

NIMHANS, Bangalore, India

ISNACC 2017, Chandigarh

Shukla DP. Outcome and rehabilitation of patients following aneurysmal subarachnoid haemorrhage. J Neuroanaesthesiol Crit Care [serial online] 2017 [cited 2017 Mar 6];4, Suppl S1:65-75. Available from: http://www.jnaccjournal.org/text.asp?2017/4/4/65/199952

http://www.jnaccjournal.org/text.asp?2017/4/4/65/199952

Introduction• SAH is a lethal disease

Lovelock, et al. Neurology 2010.


Introduction• SAH is still one of the most feared neurologic

disorders• Survivors

• ~ 2/3rd have reduced QOL• ~ 1/3rd are dependent

Jaja, et al. Neurocrit Care. 2014.http://www.stmichaelshospital.com/neuroscience/SAHIT.php


GOS

0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100%

Subarachnoid Hemorrhage International Trialists (SAHIT) repository

~ 14000 patientsOutcome at 3 months

GR MD SD VS D

Determinants of Outcome

• Clinical• Age• Hypertension• WFNS grade

• Imaging• Fisher grade• Size of aneurysm• Location of aneurysm


Jaja, et al. Neurocrit Care 2014.

Spline plot of the relation of age to outcome at different dichotomization split points of the GOS1= Probability of less than good outcome (GOS 1 versus GOS2-5)2=Probability of unfavorable outcome (GOS 1-2 versus GOS 3-5)3= Probability of death/vegetative outcome (GOS1-3 versus GOS4-5)4= Probability of death (GOS1-4 versus GOS5)

AgeISNACC 2017, Chandigarh

Forest plot of the effect of premorbid hypertension across studies

Jaja, et al. JNS. 2015.


1 2 3 4 50

1020304050607080

4 918 26

46

1426

4453

71

R² = 0.934842375366569

R² = 0.991472172351885

WFNS Grade and Outcome

MortalityLinear (Mortality)Unfavorable OutcomeLinear (Unfavorable Outcome)


1 2 3 40

10

20

30

40

5 5

16 131015

3338

R² = 0.646437994722955

R² = 0.93898916967509

Fisher Grade and Outcome

DeathLinear (Death)Unfavorable OutcomeLinear (Unfavorable Outcome)

U-shaped relation of aneurysm size to outcome with change point at 5.5mmJaja, et al. JNS. 2016.

Aneurysm size

Prognostic Score

http://sahitscore.com/


Other Determinants of Outcome

• Case Load

• Availability of Neurointensive Care

• Availability of Endosvascular Therapy


SAH caseload per year and fitted 6-month mortality rate

Lisa McNeill et al. Stroke. 2013.


Diringer, et al. Crit Care Med 2001.


Effect of Neurointensive Care on Outcome

Areas of dysfunction after SAH

• Neurophysical impairment

• Neuropsychological (Cognitive) impairment


Neurophysical impairment

• Neurological deficits are not uncommon

• IHAST study: Postoperative neurological deficits in 42.6% patients• New focal motor deficit – 65%• NIHSS total score change (>4-point) – 60%• GCS score change – 51%


Mahaney, et al. J Neurosurg 2012.

Neuropsychological (Cognitive) impairment

• Cognitive deficit after SAH is well known, but the neuropsychological outcome is underreported.

• Only 6.5% of studies reported the neuropsychological outcome

• Memory• Verbal memory - 14% to 61%

• Executive function• planning, inhibition, strategizing, problem solving, attention, and decision

making are impaired - 3% to 76%.

• Language• Various types 0% to 76%


Al-Khindi, et al. Stroke 2010.

Neuropsychiatric symptoms after SAH

• Depression (45%)• Apathy (42%), • Denial (21%)• Catastrophic reaction (17%)

• Feeling tired (31%)• Impaired sleep (37-45%)• Anxiety (54%)• Ptsd (60%)


Caeiro, et al. Eur J Neurol 2011.

Depression is often over looked psychiatric sequelae after any brain injury

Frontal lobe syndrome

Functional Outcome after SAH

• Activities of daily living (ADLs) 12%

• Instrumental activities of daily living (IADLs) 93%

• Unemployement 40-80% • return to previous occupation


Outcome assessment tools for SAH

WHO International Classification of Functioning (ICF) domains• Imapairment

• NIHSS

• Activity limitation• Modified Rankin Scale (MRS)• Barthel Index (BI)• Functional Independence Measure (FIM)

• Participation restriction• Glasgow outcome scale extended (GOSE)• Quality of life (QoL)


Sanchez, et al. Neurosurg Focus 2007.

Rehabilitation after SAH

Rehabilitation is the combined and co-ordinated efforts of a physician supervised multi-disciplinary team in helping a diseased person to reach maximum physical, psychological, social, vocational and educational potential, consistent with his or her physiological or anatomical impairment, environmental limitations, desires and life plans.


Early Rehabilitation – Mobilization Old paradigm - rehabilitation is the third phase of medicine

• Decrease in cerebral perfusion and leading to increase in DCI

• Fear of re-bleeding from another unsecured aneurysm

• Mobilization can negatively affect the development and course of cerebral vasospasm

New paradigm - rehabilitation should be initiated as early as possible• As soon as medically and

neurologically advisable, the patient should be mobilised out of bed and encouraged to ambulate if feasible with help of a physiotherapist

• Each step of mobilization during first 4 days after surgery reduces the risk of severe vasospasm


Olkowski, et al. Phys Ther 2013. Karic, et al. J Rehabil Med 2016.

Inpatient Rehabilitation

Assessment [PULSES]• Physical condition• Upper extremities• Lower extremities• Sensory components related to speech, vision, and hearing system• Sphincter function• Sensorium (mental and emotional status)Any who has persistent and stable neurological deficit, and has impairment in

at least two key domains should be transferred to in patient neurorehabilitation facility


Le Roux, et al. Management of Cerebral Aneurysms 2004.

General Principles Rehabilitation


http://www.ntsi.co.in/Version.pdf

Integrated Neurorehabilitation Team • Rehabilitation Physician (Physiatrist).• Neuropsychologist.• Speech & language pathologist.• Physical therapist.• Occupational therapist.• Rehabilitation nurse.• Orthotist.• Social worker.• Access to other medical specialties as best available in the setting.


General Principles Rehabilitation

• Evaluation using FIM• Patient, family and caregiver education is provided • Meaningful, engaging, progressively adapted, task specific and goal-oriented

training to enhance sensory motor function• Training designed to simulate partial or whole skills required in ADL• Spasticity and contractures prevention and joint protection • Minimum 3 hours of daily rehabilitation therapies• The need for special equipment (e.g., wheelchairs, safety devices) should be

evaluated on an individual basis• Assessment should be done weekly


Principles of CRT

• Comprehensive neuropsychological assessment

• Hierarchy of CRT should address attention followed by memory then executive functions.

• A mix of restoration and compensation approaches should be used.• • The therapy should be systematic, structured and repetitive according

to the needs of each particular patient.


Efficacy of rehabilitation for SAH

• SAH patients receiving inpatient rehabilitation make significant functional gains, although the rate of gain is less than for TBI or stroke

• Recovery takes 3 months and continues till 18 months• SAH patients tend to have longer rehabilitation ward stays compared to

stroke or TBI patients • Early mobilization through aggressive rehabilitation programs has been

shown to improve cognitive function as well


Stern, et al. Brain Inj 2006Kara , et al. Turk Neurosurg 2007

Shimamura , et al. World Neurosurg 2014

Conclusion

The outcome after SAH is bad but is improving over years and can be better with neurorehabilitation

Shukla DP. Outcome and rehabilitation of patients following aneurysmal subarachnoid haemorrhage. J Neuroanaesthesiol Crit Care [serial online] 2017 [cited 2017 Mar 6];4, Suppl S1:65-75. Available from: http://www.jnaccjournal.org/text.asp?2017/4/4/65/199952

http://www.jnaccjournal.org/text.asp?2017/4/4/65/199952

sah outcome and rehabilitation

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