Ruptured Cerebral Aneurysm Patients Treated by Clipping or Coiling: Comparison of Long-term Neuropsychological and Personality Outcomes

Abstract

Background and Purpose: A prospective study was conducted to compare the neuropsychological outcome of surgical versus endovascular treatment in patients with cerebral aneurysms.

Methods: From April 2001 to 2005, 211 patients with ruptured cerebral aneurysms were treated at the senior author's institution. Of these 211 patients, 75 that were able and willing to undergo neuropsychological assessment 1 year after treatment of their aneurysm were enrolled in the study. Thirty-five patients were treated surgically and 40 by endovascular therapy. Standardized neuropsychological and personality tests were employed to assess cognitive and personality functions. One neurosurgical team using the same treatment protocols treated all patients.

Results: The two groups of patients did not differ significantly with respect to age, gender, concurrent diseases, Hunt and Hess grade, Fisher grade, frequency of complications, vasospasms and hydrocephalus development. No differences in performance on neuropsychological and cognitive tests (AVLT, TMT and WAIS-III) and personality variables and mood scales (TCI, BDI and SMS) were found one year postoperatively. If a full IQ as defined by WAIS-III and 1SD below the mean is considered as the main measure of cognitive deficits, 5.4% of the sample suffered from cognitive deficits. There were no differences between clipped and coiled patients (t=0.03; p=0.97).

Conclusions: The differences in the neuropsychological assessment of patients treated by either coiling or clipping were small and non-significant. Given the small number of patients in the study, however, we suggest the need for further research with a larger sample size and the use of a randomized design before drawing any firm conclusions.

Zusammenfassung

Ziel: Eine prospektive Studie wurde durchgeführt mit dem Ziel, das neuropsychologische Ergebnis von chirurgischer versus endovaskulärer Behandlung bei Patienten mit zerebralen Aneurysmen zu vergleichen.

Methoden: Von April 2001 bis April 2005 wurden 211 Patienten mit zerebralen Aneurysmen in der Institution des Seniorautors behandelt. Von diesen 211 Patienten waren 75 in der Lage und gewillt eine neuropsychologische Untersuchung 1 Jahr nach der Behandlung mitzumachen und wurden deswegen in die Studie eingeschlossen. 35 Patienten wurden chirurgisch behandelt und 40 endovaskulär. Standardisierte neuropsychologische und Persönlichkeitstests wurden angewendet um kognitive und Persönlichkeitsfunktionen zu untersuchen. Alle Patienten wurden von dem gleichen neurochirurgischen Team, das dieselben Behandlungsprotokolle verwendete, behandelt.

Ergebnisse: Die beiden Gruppen unterschieden sich nicht signifikant in Alter, Geschlecht, Begleiterkrankungen, Hunt & Hess Grad, Fisher Grad, Häufigkeit von Komplikationen, Vasospasmus und Hydrozephalusentwicklung. Ein Jahr postoperativ wurden keine Unterschiede bei der Ableistung von neuropsychologischen und kognitiven Tests (AVLT, TMT, WAIS-III) und Persönlichkeitsvariablen und Stimmungsskalen (TCI, BDI und SMS) gefunden. Falls der IQ von WAIS-III und ISD unterhalb des Mittelwertes als das Hauptmaß eines kognitiven Defizits betrachtet wird, würden 5,4% des Untersuchungsguts an einem kognitiven Defizit leiden. Es fanden sich keine Unterschiede zwischen geclippten und gecoilten Patienten (t=0,03; p=0,97).

Schlussfolgerungen: Die Unterschiede in der neuropsychologischen Untersuchung bei Patienten, die entweder mit Coiling oder Clippung behandelt wurden, sind klein und nicht signifikant. Da die Anzahl der Patienten in der Studie gering war, schlagen wir vor, weitere Untersuchungen mit einer größeren Patientenanzahl und dem Gebrauch eines randomisierten Studiendesigns durchzuführen, bevor endgültige Schlussfolgerungen gezogen werden können.

Key words

aneurysm - clipping - coiling - neuropsychology - subarachnoid hemorrhage - cognitive outcome

Schlüsselwörter

Aneurysma - Clippung - Coiling - Neuropsychologie - Subarachnoidalblutung - kognitives Ergebnis

References

• 1 Beck AT, Steer RA, Brown GK. BDI-II. Manual. The Psychological Corporation.  1996; 
• 2 Bellebaum C, Schafers L, Schoch B. et al . Clipping versus coiling: neuropsychological follow up after aneurysmal subarachnoid haemorrhage (SAH).  J Clin Exp Neurospychol. 2004;  26 1081-1092
• 3 Bene V, Mohapl M. Deset let akutn chirurgie mozkovch aneuryzmat.  Ces a Slov Neurol Neurochir. 2002;  65/98 96-100
• 4 Beneš V, Charvát F, Mohapl M. Management lécˇ by mozkových aneuryzmat.  es a Slov Neurol Neurochir. 2002;  65/98 101-108
• 5 Berry E, Jones RAC, West CGH. et al . Outcome of subarachnoid hemorrhage. An analysis of surgical variables, cognitive and emotional sequelae related to SPECT scanning.  Br J Neurosurgery. 1997;  11 378-387
• 6 Brilstra EH, Rinkel GJE, Graf Y van der. et al . Treatment of intracranial aneurysms by embolization with coils: A systematic review.  Stroke. 1999;  30 470-476
• 7 Buchanan KM, Elias LJ, Goplen GB. Differing perspectives on outcome after subarachnoid hemorrhage: the patient, the relative, the neurosurgeon.  Neurosurgery. 2000;  46 831-840
• 8 Chan A, Ho S, Poon WS. Neuropsychological sequelae of patients treated with microsurgical clipping or endovascular embolization for anterior communicating artery aneurysm.  Eur Neurol. 2002;  47 37-44
• 9 Cloninger CR, Svrakic DM, Przybeck TR. A psychobiological model of temperament and character.  Arch Gen Psychiatry. 1993;  50 975-990
• 10 Cloninger CR, Przybeck TR, Svrakic DM. et al . The Temperament and Character Inventory (TCI): a guide to its development and use. Center for Psychobiology of Personality. Washington University, St. Louis, MO 1994
• 11 Fontanela M, Perozzo P, Ursone R. et al . Neuropsychological assessment after microsurgical clipping or endovascular treatment for anterior communicating artery aneurysm.  Acta Neurochir. 2003;  145 867-872
• 12 Hadjivassiliou M, Tooth CL, Romanowski CA. et al . Aneurysmal SAH: Cognitive outcome and structural damage after clipping and coiling.  Neurology. 2001;  56 1672-1677
• 13 Hütter BO, Gilsbach JM, Kreitschmann I. Quality of life and cognitive deficits after subarachnoid haemorrhage.  Br J Neurosurgery. 1995;  9 465-475
• 14 Johnston SC, Dudley RA, Gross DR. et al . Surgical and endovascular treatment of unruptured cerebral aneurysms at university hospitals.  Neurology. 1999;  52 1799-1805
• 15 Kahara VJ, Seppanen SK, Kuurne T. et al . Patient outcome after endovascular treatment of intracranial aneurysms with reference to microsurgical clipping.  Acta Neurol Scand. 1999;  5 284-290
• 16 Koivisto T, Vanninen R, Hurskainen H. et al . Outcomes of early endovascular versus surgical treatment of ruptured cerebral aneurysms. A prospective randomized study.  Stroke. 2000;  31 2369-2377
• 17 Ljunggren B, Sonesson B, Savaland H. et al . Cognitive impairment and adjustment in patients without neurological deficits after aneurysmal SAH and early operation.  J Neurosurg. 1985;  62 673-679
• 18 Lot G, Houdart E, Cophington J. et al . Combined management of intracranial aneurysm by surgical and endovascular treatment. Modalities and results from series of 395 cases.  Acta Neurochir (Wien). 1999;  144 557-562
• 19 MacKenna P, Willison JR, Phil B. et al . Cognitive outcome and quality of life one year after subarachnoid haemorrhage.  Neurosurgery. 1989;  24 361-367
• 20 Molyneux A, Kerr R, Stratton I. et al . International Subarachnoid Aneurysm Trial (ISAT) of neurosurgical clipping versus endovascular coiling in 2143 patients with ruptured intracranial aneurysms: a randomised trial.  Lancet. 2002;  360 1267-1274
• 21 Ogden JA, Mee EW, Henning M. A prospective study of impairment of cognition and memory and recovery after subarachnoid hemorrhage.  Neurosurgery. 1993;  33 572-587
• 22 Powell J, Kitchen N, Heslin J. et al . Psychological outcomes at three and nine months after good neurological recovery from aneurysmal subarachnoid haemorrhage: predictors and prognosis.  J Neurol Neurosurg. 2002;  72 772-781
• 23 Preiss M, Panamá J. Screeningová zkouška organicity.  Čsl. psychologie. 1995;  39 444-448
• 24 Preiss M. Pameˇtový test ucˇení.  , Brno, Psychodiagnostika 1999; 
• 25 Preiss M, Vací K. Beckova sebeposuzovacíškála depresivity (BDI-II).  , Brno, Psychodiagnostika 1999; 
• 26 Preiss M, Klose J, Španiel F. Temperament a charakter podle C. R. Cloningera u psychiatrických pacientu˚ a obecné populace.  Psychiatrie. 2000;  4 251-254
• 27 Preiss M, Klose J. Diagnostika poruch osobnosti pomocí teorie C. R. Cloningera.  Psychiatrie. 2001;  5 226-231
• 28 Richardson JT. Cognitive performance following rupture and repair of intracranial aneurysm.  Acta Neurol Scand. 1991;  83 110-122
• 29 Sonesson B, Ljunggren B, Saveland H. et al . Cognition and adjustment and early operation for ruptured aneurysm.  Neurosurgery. 1987;  21 279-287
• 30 Stenhouse LM, Knight RG, Longmore BE. et al . Long-term cognitive deficits in patients after surgery on aneurysm of the anterior communication artery.  J Neurology Neurosurgery and Psychiatry. 1991;  54 909-914
• 31 International Study of Unruptured Intracranial Aneurysms Investigators . Unruptured intracranial aneurysms' risk of rupture and risks of surgical intervention.  N Engl J Med. 1998;  339 1725-1733
• 32 WAIS-III, WMS-III .Technical Manual. The Psychological Corporation, San Antonio 1997

Correspondence