27.

Westendorff C, Kaminsky J, Ernemann U, Reinert

S, Hoffmann J: Image-guided sphenoid wing meningi-
oma resection and simultaneous computer-assisted
cranio-orbital reconstruction: technical case re-
port. Neurosurgery 60(2 Suppl 1):ONSE173-
ONSE174, 2007.
28. Wester K: Cranioplasty with an autoclaved bone
ap, with special reference to tumour inltration
of the ap. Acta Neurochir (Wien) 131:223-225,
1994.
Conict of interest statement: The authors declare that the
article content was composed in the absence of any
commercial or nancial relationships that could be
construed as a potential conict of interest.
Received 30 November 2010; accepted 27 May 2011
Citation: World Neurosurg. (2013) 79, 1:124-130.
DOI: 10.1016/j.wneu.2011.05.057
Journal homepage: www.WORLDNEUROSURGERY.org
Available online: www.sciencedirect.com
1878-8750/$ - see front matter 2013 Elsevier Inc.
All rights reserved.
Cognitive, Physical, and Psychological Status After Intracranial Aneurysm Rupture: A
Cross-Sectional Study of a Stockholm Case Series 1996 to 1999
Ann-Christin von Vogelsang
1,2
, Mikael Svensson
3,4
, Yvonne Wengstrm
1
, Christina Forsberg
1
INTRODUCTION
Health problems after aneurysmal subarach-
noid hemorrhage (SAH) are common. Up to
32% of patients have been reported to be af-
fected by anxiety 2 to 4 years after the rupture
(29). Symptoms of depression have been re-
portedinupto36%of patients 1 to6years after
rupture (3). In a meta-analysis, Nieuwkamp et
al. (20) have shownthat onaverage 19%of sur-
vivors of aneurysmal SAH become so disabled
that they become dependent onothers for their
daily life, but, incontrast, Carter et al. (3) found
that only 3%of patients were dependent 1 to 6
years after SAH. Sleep-wake disorders (SWD)
are common after stroke, in the forms of in-
creasedsleepneeds, insomnia, orexcessiveday-
time sleepiness. SWDs have previously beenre-
ported in34%of cases 1 year after SAH(25). In
comparisonwithnormativevalues, andincase-
control studies, patientswithSAHscoresigni-
cantly lower on cognition tests (8, 18). It has
beenreportedthatmajorityofpatientswithSAH
areimpairedinsomeaspectsofcognitivecapac-
ity (12).
The severity of the bleeding has a major im-
pact on outcome after intracranial aneurysm
rupture(2). However, other factors haveimpact
on outcome, including the following: ruptured
aneurysms in the posterior circulation of the
brainare associated witha greater risk of death
beforehospitaladmission(10),worseneurolog-
ical grade at admission (24), and unfavorable
outcome3monthsafterSAH(15). Olderagehas
been found to be a prognostic factor for unfa-
vorable neurological outcome both at 3
months after SAH (21) and 12 months after
OBJECTIVE: We sought to (1) describe psychological, physical, and cognitive
functions in patients 10 years after intracranial aneurysm rupture and (2) identify any
differences in outcome variables between age groups, gender or aneurysm locations.
METHODS: A consecutive sample of patients (n 217) treated for intracranial
aneurysm rupture at a neurosurgical clinic in Stockholm, Sweden, were
followed-up in a cross-sectional design 10.1 years after the onset with ques-
tionnaires and telephone interviews. The outcome measures were psychological
functions in terms of symptoms of anxiety or depression and physical and
cognitive functions.
RESULTS: Compared with the reference groups, the aneurysm patients scored
greater levels of anxiety and depression than normal values. Patients with aneurysm
rupture in the posterior circulation scored signicantly more problems with anxiety
and depression. Only 2.8% of the patients scored for severe physical disability. On a
group level, cognition was lower than normal population levels; 21.7% of respon-
dents scored below the cut-off value, indicating cognitive impairments.
CONCLUSIONS: Ten years after aneurysm rupture the majority of patients seem
to be well-functioning physically, whereas the psychological and cognitive functions
are affected. A screening of the mental health of these patients in connection to
radiological follow-up might be helpful to identify which patients need further
referral to psychiatric treatment for anxiety and depression disorders.
Key words
Activities of daily living
Anxiety
Cognition
Depression
Intracranial aneurysm
Long-term survivors
Subarachnoid hemorrhage
Abbreviations and Acronyms
ACoA: Anterior communicating artery
BI: Barthel Index
HADS: Hospital Anxiety and Depression Scale
IQR: Interquartile range
MCA: Middle cerebral artery
SAH: Subarachnoid hemorrhage
STAI: State Trait Anxiety Inventory
SWD: Sleep-wake disorders
TICS: Telephone interview for cognitive status
From the
1
Department of Neurobiology, Care
Sciences and Society, Karolinska Institutet,
Stockholm;
2
Red Cross University College, Stockholm;
3
Department of Clinical Neuroscience, Karolinska Institutet,
Stockholm; and
4
Department of Neurosurgery, Karolinska
University Hospital, Stockholm, Sweden
To whom correspondence should be addressed:
Ann-Christin von Vogelsang, M.S.N.
[E-mail: ann-christin.von-vogelsang@ki.se]
Citation: World Neurosurg. (2013) 79, 1:130-135.
http://dx.doi.org/10.1016/j.wneu.2012.03.032
Journal homepage: www.WORLDNEUROSURGERY.org
Available online: www.sciencedirect.com
1878-8750/$ - see front matter 2013 Elsevier Inc.
All rights reserved.
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the rupture (19). Poor neurological outcome
at hospital discharge has been found to be
more unfavorable in men (9).
It has been proposed that the location of
the aneurysm may inuence cognitive out-
come, although with inconsistent results.
Hutter et al. (13) found that patients with
ruptured left-sided middle cerebral artery
(MCA) aneurysms had signicantly more
problems in cognition compared with
those patients with right-sided ones. How-
ever, Haug et al. (7) found somewhat-better
cognitive performance for MCA aneurysms
compared with anterior communicating ar-
tery (ACoA) aneurysms, explained by that a
SAH from an ACoA aneurysm rupture
causes damage to the frontal lobes.
Many of the functional problems re-
ported by patients with SAHseemto be on-
going several years after the rupture, but
long-term studies on perceived health for
these patients are scarce. Therefore, the pri-
mary objectives of our study were to (1) de-
scribe physical, psychological, and cogni-
tive functions 10 years after intracranial
aneurysm rupture and (2) to identify any
differences in outcome variables between
age-groups, gender, or aneurysmlocations.
METHODS
A cross-sectional survey design was used,
and the study and was approved by the re-
gional boardfor ethics of researchinvolving
humans. Through clinic patient registers
we retrospectively identied all consecutive
patients diagnosed with acute intracranial
aneurysm rupture who were admitted to a
neurosurgical clinic in Stockholm between
January 1, 1996, and December 31, 1999.
Since1990, theclinichasusedaclinical path-
wayprotocol forrupturedaneurysms, including
early referral, earliest-possible aneurysm oblit-
eration, and aggressive antivasospasm treat-
ment (23). Thetypical radiological follow-upaf-
ter hospital discharge is largely the same
regardless if the patient has been treated with
opensurgeryorendovascularly. Theonlyexcep-
tion is that a conventional x-ray is performed 3
months after the onset for endovascularly
treatedpatients. Thereafter, all aneurysmal SAH
patientsarefollowedwithangiograms(conven-
tional, computedtomography, or magneticres-
onance)at1,3,5,10,and20yearsaftertheonset.
To be eligible to participate in the study, pa-
tients had to be Swedishcitizens (for the ability
to follow-upandassess patient records) andbe
able to communicate in Swedish. Patients with
poor healthconditionsprecludingparticipation
were excluded. Some of the excluded patients
were identied frommedical records, and oth-
ers were identied when conducting the re-
minder calls.
The patient cohort was followed up during
2007 to 2008. Self-reported postal question-
naires with information and informed consent
were sent tothe patients homes approximately
10yearsafter theintracranial aneurysmrupture.
When the questionnaires and signed consents
were returned, a short telephone interviewwas
conducted, including cognitive testing, and
questions concerning physical functioning and
tocollect any missingdata.
Demographicdataandclinical variablessuch
asmedical historyanddiagnosticinvestigations
were retrospectively collected from paper and
digitalpatientrecords.Clinicalvariablesfromall
admissions from aneurysm rupture until fol-
low-up were examined when this information
was available in patient records. The diagnosis
and aneurysmsite was based on angiogramor
surgery. The scales used for assessing level of
consciousnessandneurological gradeatadmis-
sion were Glasgow Coma Scale (27) and the
Hunt and Hess classication of SAH (11). For
assessment of neurological outcome, the Glas-
gowOutcome Scale (14) was used, assessed by
clinicians and documented at hospital dis-
charge. Of the medical history outcome param-
etersusedinthisstudy, nodistinctionwasmade
between intradural and extradural aneurysms.
Baseremnantswereregisteredif reportedinpa-
tient record, regardlessof sizeandearliertypeof
treatment.
Psychological functioning was measured in
terms of symptoms of anxiety or depression.
The Hospital Anxiety and Depression Scale
(HADS) wasusedfor detectingstatesof anxiety,
depression, and psychiatric disorder. The
HADS has two subscales; one for anxiety
(HADS-A) and one for depression (HADS-D)
(32). Scoresof 8to10identifymildcases, scores
of11to15identifymoderatecases,andscores16
identify severecases onHADSsubscales (4).
The general, normative population in the
United Kingdom comprises, on the HADS-
A subscale, 20.6% mild, 10.0% moderate,
and 2.6% severe. On the HADS-D scale,
the corresponding proportions are 7.8%,
2.9%, and 0.7% (4). On total HADS, a cut-
off score of 11 has been used to detect psy-
chiatric disorder in a recent study on an an-
eurysmal SAH population (29). The level of
anxiety was measured with State Trait Anx-
iety Inventory (STAI) (26). The STAI state
scores range from 20 to 80; greater scores
indicate greater levels of anxiety.
Physical functioning was assessed using the
Barthel Index (BI) and describes mobility and
activities of daily living. The sum of the scores
rangefrom0to100; agreaterscoreisassociated
with a greater likelihood of being able to live
independently at home (17). Scores lower than
60 indicate severe disability, 61 to 79 moderate
disability, 80 to 99 mild disability, and 100 no
disability (3). SWDs were assessed with three
study-specic questions developed by the au-
thorsconcerningdisruptionof night sleep, day-
time sleepiness, and fatigue. The respondents
rated their actual problems on a four-point
scale: not at all, somewhat, moderately so, and
very muchso.
To evaluate cognitive functions the Tele-
phone Interviewfor Cognitive Status (TICS)
(1) was used. The TICS is a structured 11-
item interview that evaluates orientation,
attention, verbal memory, long-term mem-
ory, motor function, and language. The
maximum score is 41 and cut-off scores
31 are used to detect cognitive impair-
ment. Mean score for an American norm
population is 35.8 (1.75) (1).
Data Analysis
Data were analyzed using SPSS 19.0. When
comparing differences in outcome variables by
age, we divided the respondents into three age
groups: 23 to45 years, 46 to65 years, and65
years. Aneurysm locations were dichotomized
into anterior and posterior circulation of the
brain; aneurysms in the anterior circulation in-
clude all arteries forward of the posterior cere-
bral artery, and posterior circulation comprises
theposteriorcerebralarteryandallarteriesback-
wards. Internal consistency of the outcome
measure scales in this sample was tested with
the Cronbach alpha. Because data on outcome
variables were not normally distributed, non-
parametric tests were used to compare differ-
ences between groups; the Mann-Whitney U
test (anterior/posterior circulationand between
gender) and Kruskal-Wallis test (age groups).
The Spearman rho was used for examining as-
sociationbetweenageandcognitivefunctionon
the TICS. Logistic regression analysis was used
to predict psychiatric disorder with HADS total
as the dependent variable, dichotomizedwitha
cut-off level of 11, and age, gender, and aneu-
rysmlocationasexplanatoryvariables. Thelevel
of signicancewas set at P0.05throughout.
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RESULTS
During the inclusion period for this study, 468
patients were admitted to the neurosurgical
clinic, of which273 were eligible for this study,
and 217 participated (79.5%). The mean fol-
low-uptime was 10.1 years after rupture (range,
8.8-12.0 years), and participants mean age at
follow-up was 60.7 years (range, 23.6-90.1
years). Figure1 shows a owdiagramof partic-
ipants anddatacollection.
There were no signicant differences be-
tween the results for nonresponders and
patients who refused to participate (n 56)
and those patients included in the study
concerning age, gender, treatment types, or
aneurysm locations. Table 1 presents char-
acteristics of the participants.
Psychological Functioning
Table 2 shows median and interquartile range
(IQR) on STAI and HADS for the total sample
and anterior/posterior circulation, and values
from two Swedish reference populations. The
majorityofrespondents(52.5%,n114)scored
greater than the Swedish population norm
meanvalueof 33.2ontotal STAI. Therewereno
signicant gender differences or differences in
agegroups. Coefcient alphawas0.95for STAI
state.
On the HADS-A subscale, 73 respondents
(33.6%) scored anxiety symptoms; 35 respon-
dents (16.1%) were identied as mild cases
(scored 8-10), 26 (12.0%) were moderate cases
(scored 11-15), and 12 (5.5%) were severe cases
on this subscale. On the HADS-D subscale, 51
respondents (23.5%) scored for depressive
symptoms;34respondents(15.7%)wereidenti-
ed as mild cases, 13 (6.0%) were moderate
cases, and 4 respondents (1.8%) were severe
cases. Respondentsolder than65yearshadsig-
nicantly lower scores on HADS-A compared
withtheagegroupsof23to45yearsand46to65
years (P 0.004). There were no signicant
gender differences in HADS total or subscales
results.
Ninety-one respondents (41.9%) scored
11 on the HADS total scale, indicating psy-
chiatric disorder. Respondents with aneu-
rysm ruptures in the posterior circulation
had signicantly greater levels of anxiety
and more symptoms of depression (Table
2). Respondents with any untreated aneu-
rysmand/or aneurysmal base remnant (n
43) at follow-up did not have signicantly
greater values on STAI, HADS subscales, or
HADS total. The Cronbach alpha for total
HADS was 0.91. For HADS, anxiety and de-
pression subscales coefcients were 0.91
and 0.82, respectively.
The logistic regression analysis showed
that the primary predictor was aneurysmlo-
cation, where aneurysm rupture in the pos-
terior circulation increased the odds ratio
for psychiatric disorder (5.5, 95% con-
dence interval 2-17, P 0.04). The model t
by Nagelkerke R
2
was 9%(
2
14.9, df 4,
P 0.005).
Physical Functioning and SWDs
The respondents values on BI ranged from
20 to 100; 184 respondents (84.8%) rated
the maximum value of 100, 2.8% (n 6)
hadsevere disability, 1.4%(n3) hadmod-
erate disability, and11.1%(n24) hadmild
physical disability. The median values and
IQR were the same for the total sample, for
the anterior and posterior circulation
(median 100, IQR 100-100).
No signicant differences were found be-
tweenthe gender, the age groups, or aneurysm
locations on the BI. The Cronbachs alpha was
0.91 for the BI. The majority of respondents
(59%, n 128) rated having problems with
night sleep to some extent. Slightly more than
70% (n 153) reported sleepiness during the
day and 63.6% (n 138) reported fatigue.
Ninety-three respondents (42.9%) rated
problems in all of these assessed areas.
Forty-one respondents (18.9%) reported
having no problems. Coefcient alpha for
the three SWD questions was 0.79. There
were no signicant differences between
the gender, the age groups, or aneurysm
locations.
Cognitive Functioning
Twohundredsevenrespondentsparticipatedin
the telephone interviewto assess cognitive sta-
tus. Reasons for not performing the TICS were
ve cases of aphasia/dysphasia, three cases of
impaired hearing/deafness, and two respon-
dents refused. The TICSwas not testedwiththe
Cronbachalpha because the rst question(ori-
Enrollment
Analysis
Received posted self-reported questionnaires ~ 10 years
after aneurysm rupture: State Trait Anxiety Inventory,
Hospital Anxiety and Depression Scale, study-specic.
Returned questionnaires, included (n = 217)
followed by structured short telephone interviews:
Barthel Index (n = 217)
Telephone Interview for Cognitive Status (n = 207)
And collection of missing data
Eligible: n =273
All patients treated for intracranial aneurysm rupture at a
neurosurgical clinic in Stockholm, 19961999.
Assessment of clinical data for eligibility (n = 468)
Excluded:
Dead (n = 166)
Poor health condition (n = 20)
Emigrated (n = 5)
Not able to communicate in Swedish (n = 4)
Refused to participate (n = 23)
Non-responders (n = 33)
Figure 1. Flow diagram of participants and data collection.
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entation to person) had no variance; thus, an
alpha value for total scale could not be calcu-
lated. The values on the TICS scale ranged be-
tween13and40points(median33.0, IQR31.0-
36.0 for total sample), and 45 respondents
(21.7%) scored 30, which indicates impaired
cognitive function. There were no signicant
differences between gender or aneurysm loca-
tions. Respondents with ruptured aneurysmin
the ACoA (n 77) did not differ from other
locations (n130), nor didleft-sidedMCAan-
eurysms (n 25) differ from the right-sided
ones (n28). Respondents older than65years
ofage(n76)hadsignicantlylowerscoreson
TICS compared with the two younger age
groups(n141; P0.001). Older agealsocor-
related negatively with high cognitive function-
ing on TICS (r
s
0.322, P 0.001), indicat-
ing that older age is related to decreased
cognitivefunctioning.
DISCUSSION
Studies addressing patient reported out-
comes on a long-termbasis after intracranial
aneurysm rupture are scarce. To the best of
our knowledge, this is the rst published
Scandinavian study on patient-reported out-
comes, including clipped and endovascularly
treated patients, a decade after the onset with
a large sample of patients (n 217). Two
Dutch long-term studies have addressed pa-
tient reported outcomes; Wermer et al. (30)
assessedpsychosocial consequences inaneu-
rysmal SAH in mean 8.9 years after SAH but
included only patients treated with clipping
and found signicantly more symptoms of
depressionamongSAHpatients comparedto
a reference population. Greebe et al. (6) as-
sessed functional outcome approximately 13
years after aneurysmal SAH (n 46) and
found reduced physical functions that were
attributed to comorbidities and not to aneu-
rysmal SAH.
Ten years after aneurysm rupture, levels
of anxiety and symptoms of depression are
greater than that of general population; in
our study the majority of patients scored
greater than the general population norm
mean value of 33.2 on STAI (5). Compared
withreference populationmedianvalues on
HADS (16), our sample scoredgreater onall
scales, HADS-A, HADS-D, and HADS total.
Furthermore, when compared with the per-
centage of respondents scoring for anxiety
and depressive symptoms on HADS sub-
scales inthe general populationinthe study
by Crawford et al. (4), more moderate and
severe cases were identied on the anxiety
subscale by the present study. On the de-
pression subscale, a greater percentage of
cases (mild, moderate, and severe) were
identied overall in our sample. In our
study, 33.6% of respondents scored above
the cut-off of 8 on HADS-A, and 23.5% on
HADS-D. These percentages are similar to
ndings by Visser-Meily et al. (29), who re-
ported 32% of participants with elevated
scores on HADS-A and 23%on HADS-D36
months after aneurysmal SAH, indicating
that the levels of anxiety and symptoms of
depression may be unchanged during the
years after the onset.
Our results also showed that patients ex-
periencing aneurysm rupture in the poste-
rior circulation of the brain have signi-
cantly more problems with anxiety and
depression. The majority of patients with
aneurysms in the posterior circulation in
our sample were treated endovascularly,
which in the literature is associated with
more frequent radiological follow-ups (31).
One could then suggest that recurrent fol-
low-ups serve as reminders of the previous
SAH and produce a greater level of anxiety
and depression when compared with
clipped patients, with no need for such a
follow-up. However, the radiological fol-
Table 1. Characteristics of the 217 Participants
Characteristic Number (%)
Age (years) at rupture
Mean (SD) 50.6 (12)
Range 13.079.3
Gender
Men 63 (29.0)
Women 154 (71.0)
Aneurysm locations
Anterior circulation 199 (91.7)
Posterior circulation 18 (8.3)
Glasgow Coma Scale at admission
35 15 (6.9)
612 31 (14.3)
1315 171 (78.8)
Hunt and Hess at admission
IIII 174 (80.2)
IVV 43 (19.8)
Type of aneurysm treatment
Open surgery 181 (83.4)
Endovascular 35 (16.1)
Conservative 1 (0.5)
Glasgow Outcome Scale at discharge
2: Vegetative state 3 (1.4)
3: Severe disability 38 (17.5)
4: Moderate disability 35 (16.1)
5: Good recovery 141 (65.0)
Unsecured aneurysm/base remnant at follow-up
Aneurysm 28 (12.9)
Base remnant 21 (9.1)
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low-up at our clinic is similar between pa-
tients treatedsurgically andendovascularly.
Moreover, we somewhat surprisingly found
no signicant differences in anxiety or de-
pression on STAI, HADS total scale, or sub-
scales for the respondents with additional
untreated aneurysms and/or base rem-
nants, which indicates that this awareness
does not have any signicant impact on
anxiety or depression, despite more fre-
quent radiological follow-ups.
Towgood et al. (28) suggest that patients
who had been living with the knowledge of
an unruptured aneurysm a longer time are
less scared and worried about the aneurysm
than when they rst were informed about
their condition. This nding, that some in-
dividuals can overcome stress and have a
relatively good psychological outcome de-
spite suffering risk experiences, might be
referred to as the concept of resilience. The
key element in this interactive concept is
successful coping; to adapt, habituate, and
cognitively redene the experience (22).
The primary predictor for psychiatric dis-
order in this study was aneurysm location
(posterior circulation), with a 5.5 times
greater risk. However, the aneurysm loca-
tion only explains 9% of the variance. An
extensive logistic regression modeling was
performed, also including Hunt & Hess,
Glasgow Outcome scale, and treatment
type as independent variables, that resulted
in nonsignicant models.
However, the signicantly greater levels
of anxiety and depression among patients
with posterior aneurysms must be inter-
preted with caution because the number of
patients with posterior aneurysms is small.
Further studies are needed to conrmthese
results. To the best of our knowledge, only
one previous study has examined anxiety
and depression symptoms in relation to an-
eurysmsite, but reported no signicant dif-
ferences (30).
The majority of respondents scored the
maximumvalue on BI, indicating they were
managing activities of daily living indepen-
dently, and only 2.8% of respondents
scoredsevere physical disability, whichis in
line with the results of Carter et al. (3). In
our sample, 20 patients were excluded from
follow-upbecause of poor health. However,
patients were excluded for reasons other
than poor recovery fromaneurysmrupture,
such as severe dementia, progressive can-
cer, psychiatric disease, or weakness attrib-
utable to older age.
The cognitive functionfor our study sam-
ple is lower after intracranial aneurysmrup-
ture when compared with published norm
data on healthy controls (m 35.8) (1).
Hillis et al. (8) argues that even when the
group mean performance on neuropsycho-
logical tests is signicantly lower than nor-
mal, only a minority of patients has a clini-
cally signicant cognitive impairment. In
our study 21.7% of respondents scored for
cognitive impairment, which differs largely
to the nding by Hutter and Gilsbach (12),
who reported 54% of respondents scoring
for cognitive impairments. One has to ac-
knowledge that the TICS is not a complete
test battery on cognition; some of the re-
spondents may experience clinically signif-
icant impairments that cannot be assessed
by the TICS.
This study has some limitations that need
to be addressed; clinical data were collected
through digital and paper patient records,
and approximately 10% of paper records
were either incomplete or missing. Some of
the original documents (such as computed
tomography scan and angiogram reports)
were not digitalized and when these docu-
ments were missing, second-hand infor-
mation fromother documents in the digital
records were used, which is a limitation of
the present study. To increase the quality of
data on clinical variables when conducting
long-term studies and for evaluations of
care on these patients, we recommend neu-
rosurgical clinics to prospectively gather
relevant information in separate registers,
not only in patient records.
We used a long-term cross-sectional
study design, which has limitations be-
cause the outcome variables could have
been affected by numerous confounding
factors during the 10 years. Swedish norm
data lack some of our outcome measures
(TICS and BI), which imply that the used
norms might not necessarily reect Swed-
ish conditions. Another limitation is that
previous history of depression and anxiety
disorders before aneurysm rupture and the
use of antidepressants duringfollow-upnot
were addressed. A strength of the present
study designis our conducting of telephone
interviews after the return of question-
naires, which enabled the collection of data
Table 2. Psychological Function for Total Sample and by Aneurysms in the Anterior and Posterior Circulation, and Reference
Groups
Instrument
Aneurysm Sample, Median (IQR)
Reference Groups (Central Tendency and Dispersion)
Total Sample,
n 217
Anterior
Circulation,
n 199
Posterior
Circulation,
n 18 P Value
STAI* 34.0 (28.047.0) 34.0 (27.046.0) 46.0 (39.056.5) 0.002 md 32
m (SD) 33.2 (9.6)
Randomized Swedish sample,
n 180, 26-65 years (5)
HADS-A 5.0 (1.09.0) 4.0 (1.08.0) 9.0 (4.812.5) 0.001 md (IQR) 4.0 (2.07.0) Randomized Swedish sample,
n 624, 3059 years (16)
HADS-D 4.0 (1.07.0) 3.0 (1.07.0) 6.5 (2.810.0) 0.036 md (IQR) 3.0 (1.06.0)
HADS total 8.0 (4.015.5) 8.0 (3.015.0) 15.0 (10.821.2) 0.001 md (IQR) 7.0 (4.012.0)
IQR, interquartile range; STAI, State Trait Anxiety Inventory; HADS-A, Hospital Anxiety and Depression Scale-Anxiety; HADS-D, Hospital Anxiety and Depression Scale-Depression; md, median;
m, mean; SD, standard deviation; IQR, interquartile range.
*Greater scores STAI total indicate greater levels of anxiety.
Greater scores on HADS subscales indicate more anxiety or depression.
Greater scores on HADS total scale indicate psychiatric disorder.
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missing from the questionnaires. Another
strength is the homogenous population of
intracranial aneurysm rupture patients that
has been followed, including all available
patients with aneurysm ruptures within a
limited time-span of four years.
CONCLUSION AND CLINICAL
IMPLICATIONS
Ten years after intracranial aneurysm rup-
ture, patients experience greater levels of
anxiety, more symptoms of depression, and
lower cognitive function compared with
reference populations. Patients with rup-
turedaneurysms inthe posterior circulation
of the brainrate signicantly greater anxiety
and symptoms of depression than patients
with aneurysms in the anterior circulation.
A small proportion of patients experience
physical disabilities; however, the majority
of patients manage their activities of daily
living independently.
Physicians and nurses who care for aneu-
rysmal SAHpatients should be aware of the
increased risk of deteriorated mental
health long-term after aneurysm rupture.
A screening for this of patients in connec-
tion to radiological follow-ups might be
helpful to identify vulnerable patients that
may need further referral to psychiatric
treatment for anxiety and depression dis-
orders. Screening could easily be per-
formed with a structured standardized in-
strument such as the HADS.
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Conict of interest statement: This study was supported by
grants from the Center for Health Care Sciences, the Capio
Research foundation, The Red Cross University College in
Stockholm, and the Karolinska Institutet Foundations. The
funding organizations had no role in the design and
conduct of the study; collection, management, and analysis
of the data; or preparation, review, and the decision to
submit the paper for publication.
Received 25 October 2011; accepted 31 March 2012
Citation: World Neurosurg. (2013) 79, 1:130-135.
http://dx.doi.org/10.1016/j.wneu.2012.03.032
Journal homepage: www.WORLDNEUROSURGERY.org
Available online: www.sciencedirect.com
1878-8750/$ - see front matter 2013 Elsevier Inc.
All rights reserved.
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WORLD NEUROSURGERY 79 [1]: 130-135, JANUARY 2013 www.WORLDNEUROSURGERY.org 135
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