Brain, Vol. 124, No. 8, 1671-1672,
August 2001
© 2001 Oxford University Press
Book reviews |
NEUROPSYCHOLOGICAL SEQUELAE OF SUBARACHNOID HEMORRHAGE AND ITS TREATMENT.
By B. O. Hitter. 2000. New York: Springer-Verlag. Price $78. Pp. 200. ISBN 3-21183-442-7.
Department of Psychiatry, University of Cambridge, Addenbrooke's Hospital, Cambridge, UK
Interest in the field of neuropsychology of subarachnoid haemorrhage (SAH) has undergone a rapid growth in the last several decades. Reductions in mortality and morbidity in SAH patients due to advances in both surgical and medical management (Ingall et al., 1989
; Le Roux et al., 1995, Sheridan and Pickard, 2000) have led to the increased attention of researchers being devoted to the important areas of psychosocial and cognitive outcome, particularly with respect to the growing numbers of patients who are now making a good neurological recovery.
Measures such as the Glasgow Outcome Score, which assess primarily the neurological status of the patient, do not adequately reflect the functional difficulties patients may face after haemorrhage (Ljunggren et al., 1985; Hutter and Gilsbach, 1993; Ogden et al., 1993). These often include problems with memory and concentration, emotional changes, altered personality, breakdown in interpersonal relationships and inability to return to work (Ljunggren et al., 1985; Saveland et al., 1986; Ogden et al., 1993). Clearly such sequelae are a major burden on patients and their families, often more so than the physical symptoms of the haemorrhage. This book is the first of its kind, to our knowledge, to explore exclusively the subject of the neuropsychological sequelae of SAH and its treatment. It is timely in view of the recent advances in neurosurgical management of SAH that may impact on neuropsychological outcome, and in the important need to bring together the wealth of historical information and recent studies that have been carried out in the field. The book is impressively wide in its scope and addresses most relevant issues of import to this field, covering in addition to a survey of the neuropsychological impairments observed across a majority of studies, the basics of SAH aetiology, diagnosis and management, methodological concerns, issues of functional outcome, quality of life, psychological adjustment and rehabilitation.
The author's central thesis, for which he argues strongly throughout the book, is that neuropsychological deficit in SAH results from the initial bleeding into the subarachnoid space, particularly the frontobasal cisterns, and the subsequent intraventricular and intracerebral spread of blood. This has practical application in the contemporary debate about endovascular coiling versus surgical intervention, in that, according to the author, surgery may have the advantage of clearing any blood and haematoma from the subarachnoid space, thus reducing the risk of neuropsychological impairment. The author rejects the case for any differences in neuropsychological outcome being related to the area of aneurysmal supply.
Although historically patients with aneurysms of the anterior communicating artery (ACoA) have been observed to have a particularly poor neuropsychological outcome, more recent studies have failed to show any significant differences between those with SAH due to rupture at different aneurysm sites in measures of cognitive impairment and functional outcome (Ljunggren et al., 1985; De Santis et al., 1989; Ogden et al., 1993). The author argues that the apparently more severe neuropsychological sequelae reported in some studies of ACoA ruptured patients are a result of the lack of adequate control groups of patients with ruptured aneurysms at other sites being used for comparison, as well as the inclusion of patients with secondary complications in patient series. In older studies prior to the 1970s, observed differences are attributed to the inavailability of the operative microscope and to microsurgical techniques that now help in preserving the perforating arteries of the ACoA during surgery. While the author argues these points with much conviction, the debate between those attributing neuropsychological sequelae of SAH to global, and those attributing them to focal causes, cannot be said to be over. Further discussion and work on developing the theoretical basis for the neuropsychological sequelae of SAH is imperative for both issues of prevention and management. For example, many researchers continue to believe that much of the neuropsychological deficit in ACoA rupture is due to focal ischaemic damage in the territory of the anterior cerebral circulation. In particular, the ACoA supplies areas of orbitofrontal cortex, and damage to this area has been hypothesized to produce changes in personality (Bechara et al., 1994; Damasio, 1994). Recent studies have shown that SAH patients with ACoA aneurysmal rupture demonstrate risk-taking behaviour on tests which model real-life decision-making and correlate with aspects of personality change (Mavaddat et al., 2000). This growing field of `emotional cognition' addresses the role of conscious and non-conscious emotional responses in the decision-making process. It is of especial importance in the study of SAH in view of the possible impact of poor social judgement and disorganized behaviour on the functional outcome and quality of life of SAH patients, and on the burden to their carers. Attention to this aspect of cognition may be increasingly important in the assessment of neuropsychological outcome in relation to neurosurgical advances in the field, e.g. in the question of the timing of surgery or the use of endovascular coiling.Although the developments in this field of `emotional cognition' have not been specifically addressed in the book, the author does pay considerable attention to the increasingly important subject of assessing health-related quality of life and the need for adequate measures of functional outcome in patients who suffer from mainly non-physical disability. Measures that are pertinent to SAH are in short supply. The author advocates the use of his own Aachen Quality of Life Inventory devised for the assessment of health-related quality of life in patients with brain damage. This measure of subjective complaints in daily life has been shown to correlate well with cognitive capacity measured by neuropsychological tests in SAH patients. The importance of psychological factors in the sequelae of brain damage is also highlighted in the book, with the concept of `psychic traumatization' presented as a significant factor in the poor neuropsychological outcome of SAH patients. Findings demonstrating the influence of psychological factors secondary to experiencing a life-threatening episode have particular implications for the need for coping and supportive measures for SAH patients. Studies examining the effects of rehabilitation on neuropsychological outcome are also considered and the potential importance of early rehabilitative measures emphasized. In this context, the question of pharmacological treatment of neuropsychological deficits to date is touched upon and serves as a reminder that this important area of potential therapeutic management has been little developed. This lack of development is particularly surprising in the face of theories implicating cholinergic dysfunction due to basal forebrain damage in the mnenomic sequelae of ACoA (see e.g. Mavadatt et al., 2000, p. 2115). However, the overall message given from the author is that the ultimate goal of rehabilitation should not be the amelioration of isolated functional deficits, but the re-integration of the patient into everyday life.
This book is both an important and timely contribution to the field of the neuropsychology of SAH and, while short, is both thorough and detailed. The author of the book has extensive expertise in working with both SAH patients and neurosurgeons in the field of neuropsychological outcome of SAH, and draws much upon his own work to bring insight into this very complex area. The book is particularly relevant for neurosurgeons and those in neurosurgical training, but can also serve as an important reference for anyone involved in the psychological care and rehabilitation of SAH patients. It heralds a growing and welcome interest in the neuropsychiatry of SAH and its remediation by pharmacological and other means.
References
Bechara A, Damasio A, Damasio H, Anderson S. Insensitivity to future consequences following damage to human prefrontal cortex. Cognition 1994; 50: 7–15.[Web of Science][Medline]
Damasio A. Descartes' error: emotion, reason and the human brain. London: Picador; 1994.
De Santis A, Laiacona M, Barbarotto R, Basso A, Villani R. Neuropsychological outcome of patients operated upon for an intracranial aneurysm; analysis of general prognostic factors and of the effects of the location of the aneurysm. J Neurol Neurosurg Psychiat 1989; 52: 1135–40.
Hutter BO, Gilsbach JM. Which neuropsychological deficits are hidden behind a good outcome (Glasgow = I) after aneurysmal subarachnoid haemorrhage? Neurosurgery 1993; 33: 999–1005.[Web of Science][Medline]
Ingall T, Whisnant J, Wiebers D, O'Fallon W. Has there been a decline in subarachnoid haemorrhage mortality? Stroke 1989; 20: 718–24.
Le Roux P, Elliott J, Downey L, Newell D, Grady M, Mayberg MR, et al. Improved outcome after rupture of anterior circulation aneurysms: a retrospective 10-year review of 224 good-grade patients. J Neurosurg 1995; 83: 394–402.[Web of Science][Medline]
Ljunggren B, Sonesson B, Saveland H, Brandt L. Cognitive impairment and adjustment in patients without neurological deficits after aneurysmal SAH and early operation. J Neurosurg 1985; 62: 673–9.[Web of Science][Medline]
Mavaddat N, Kirkpatrick P, Rogers R, Sahakian B. Deficits in decision-making in patients with aneurysms of the anterior communicating artery. Brain 2000; 123: 2109–17.
Ogden J, Mee E, Henning M. A prospective study of impairment of cognition and memory after subarachnoid haemorrhage. Neurosurgery 1993; 33: 572–87.[Web of Science][Medline]
Saveland H, Sonesson B, Ljunggren B, Brandt L, Uski T, Zygmunt S, Hindfelt B. Outcome evalution following subarachnoid haemorrhage. J Neurosurg 1986; 64: 191–6.[Web of Science][Medline]
Sheridan M and Pickard J. Surgical management of anterior communicating artery aneurysms. In: Kaye AH, Black PM, editors. Operative neurosurgery, Vol. 2. Sidcup: Churchill Livingstone/Harcourt Publishers; 2000. p. 955–66.
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