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Thick aSAH, with IVH in both

17% (47)

40% (19/47)

28% (13/47)

lateral ventricles

Abbreviations: aSAH, aneurysmal subarachnoid hemorrhage; IVH, intraventricular hemorrhage; DCI, delayed cerebral ischemia. Source: From Ref. 11.

lateral ventricles

Abbreviations: aSAH, aneurysmal subarachnoid hemorrhage; IVH, intraventricular hemorrhage; DCI, delayed cerebral ischemia. Source: From Ref. 11.

Table 5 World Health Organization Hierarchy of Stroke Outcomes

Level of outcome

Description

Typical scales used in subarachnoid hemorrhage research

Global outcome Death to full recovery

Impairment Loss of normal neurologic function

Disability Loss of independence in basic or instrumental activities of daily living

Handicap Loss of interpersonal, social, or societal role function

Quality of life Multidimensional and often subjective assessment of physical, emotional, social well-being

Modified Rankin Score, Glasgow Outcome Scale

National Institutes of Health Stroke Scale, Telephone Interview of Cognitive Status, Folstein Mini-Mental Status Examination Barthel Index, Lawton Scale

Return to work,a change in marital status8 Sickness Impact Profile, Short Form-36

aHandicap is generally evaluated via questionnaire, rather than a specific scale.

are inadequate for aSAH (18), because they focus primarily on impairment related to focal neurologic deficits, which occur in only 15% of aSAH survivors (19). By contrast, most neurologic impairment after aSAH is related to cognitive dysfunction, which is best detected by detailed neuropsychometric evaluations. For example, the Cooperative Nicardipine Study (20) assessed levels of impairment at 3 months using both the NlHSS and the Mini-Mental State Score (MMS). A ceiling effect developed, with nearly half of patients scoring a perfect 30 on the MMS and over half scoring a perfect 0 on the NIHSS.

Comprehensive neuropsychologic testing (Table 7) can reveal cognitive impairment following aSAH and is invaluable in characterizing the extent of impairment in individual patients. However, several problems are associated with the use of detailed neuropsychometric testing in aSAH clinical trials. First, testing can be long, arduous, and difficult to complete by severely impaired individuals, potentially leading to missing data, which may result in selection bias, as the most severely impaired patients are unable to complete the evaluation. Second, tests used multiple times can yield variable scores that can be difficult to interpret. Ideally, the extent of cognitive impairment in each patient should be expressed as a single score, but no standardized or well-validated method exists for accomplishing this. Third, testing must be performed in person and can therefore increase missing data due to difficulty in ensuring this level of patient follow-up. Finally, and possibly most important of all, test performance is highly influenced by age, race, and educational background (3). An ideal measure of aSAH-induced

Table 6

Measures of Global Outcome

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