Health-Related Quality of Life After Spontaneous Subarachnoid Hemorrhage Measured in a Recent Patient Population

Objective

This study sought to determine the impact of spontaneous subarachnoid hemorrhage (SAH) on health-related quality of life (HRQOL).

Methods

Data were taken retrospectively from 601 patients (219 male, 382 female) treated between 1998 and 2008. Questionnaires concerning HRQOL were circulated prospectively, and the responses from 253 patients (81 male, 172 female) were analyzed. The questionnaires comprised the standardized Short-Form 36 (SF-36) and Short-Form 12 (SF-12) Health Surveys, a number of nonstandardized questions, and visual analogue scales. Statistical analysis of the results was exploratory, using unifactorial ANOVA (Scheffe), multivariate analyses of variance.

Results

The HRQOL is reduced considerably by SAH and remains so for a period of 10 years. Physical and emotional domains are primarily affected, but also cognitive functions, including memory and concentration in particular. Similarly, certain roles are affected that prove difficult to rehabilitate after acute care and cause serious debility in the long term. The Hunt and Hess Scale, Glasgow Outcome Scale, and seizures were found to have the greatest impact on HRQOL.

Conclusions

Documentation of HRQOL after 6 to 12 months is useful because patients are often found to have a diminished HRQOL in the absence of a clear physical impairment. Because psychological, emotional, cognitive, and social functioning influence HRQOL in the long term, efforts at rehabilitation should focus in particular on improving such factors. Documentation of HRQOL is a useful, additive tool for consolidating and evaluating the outcome, and a treatment end point after SAH, respectively.

Introduction

Spontaneous aneurysmal subarachnoid hemorrhage (SAH) accounts for 3% to 5% of all cases of cerebral apoplexy (65, 71). Among all forms of cerebral apoplexy, it is responsible for 5% of all deaths and a more than 25% loss of potential years of life in those over age 65 (41).

Many patients suffering SAH are left with a neurological deficit (2, 21, 71, 72). After first admittance, patients are often evaluated using the Glasgow Outcome Scale (GOS) (40). Over the further course, the treatment outcome after SAH is often categorized by clinicians in simple terms such as good, moderate, or poor for the purposes of immediate grading. This classification ensues on the basis of the prevailing functional neurological deficits, however, leaving little room for psychological, cognitive, and social components. Although physically intact, many patients still show neuropsychological and cognitive impairments (34, 35). SAH is a life-threatening disease, and therefore can decisively influence the subsequent health-related quality of life (HRQOL).

Standardized tools are used to measure HRQOL based on subjective perception and assessment by the patient and proxy. This is important because the evaluation of the treatment outcome after SAH made by a clinician can differ significantly from that of the patient and his or her family (12). A patient having suffered SAH cannot always be expected to make a full recovery. A patient with no physical traces of hemorrhage on completion of therapy will without doubt achieve a better grade of outcome than if physically debilitated, e.g., by paresis. Yet how does the reduction in HRQOL from paresis compare with that induced by deficits in attention and concentration? In such a case, grading of the individual patient's disability is useful in the clinical context (68).

HRQOL serves to consolidate and evaluate the outcome. It is helpful in understanding a patient's reactions to the disease and evaluating the efficacy of the therapeutic interventions (18). In the clinical approach to long-term, dynamic diseases, the concept of measuring the quality of life represents an independent medical parameter (19).

Many attempts have been made to identify prognostic values for SAH, e.g., in the form of initial symptoms as defined by the Hunt and Hess Scale (HHS) (31) or by the Scale of the World Federation of Neurosurgical Societies (WFNS) (27, 44) which is based on the Glasgow Coma Score (61), as well as Fisher computed tomography (CT) grading (3, 63), localization of the bleeding, treatment method, or age and gender (43, 50, 51). Such attempts have only partly been successful (8, 34, 59). So far there have only been a few studies that have concentrated on identifying the independent determinants of HRQOL over the course (42, 59). Such data are required to promote the development and efficiency of health programs, therapies, and treatment measures, as well as their transition and rehabilitation efforts.

This study has the following objectives: 1) to obtain a detailed account (physical, psychological, cognitive) of the patient's HRQOL after spontaneous aneurysmal SAH, and 2) exploratory identification of determinants to explain the often-diminished HRQOL after SAH.