Functional Capacity Scale as a new tool for early functional assessment in patients after surgical treatment of intracranial aneurysms: A prospective study involving 128 patients

Background

Researchers use many different methods in their studies. The results of different studies should be comparable with data in the literature. Comprehensive assessment of a patient with a nervous system disorder should include 3 basic consequences of the disease: damage, disability and impairment. In cerebral diseases and cerebrovascular defects (stroke, hemorrhage, aneurysm) there are 3 areas that should be assessed: clinical condition (damage of the nervous system), functional capacity, and quality of life.

Significant neurological deficit (including functional deficit) may be caused by subarachnoid hemorrhage (SAH), often resulting from ruptured intracranial aneurysms [1–4].

Intracranial aneurysms are the most common vascular anomaly [5,6]. In most cases any rupture results in a subarachnoid hemorrhage, which very often leads to death. The available sources state that the death rate of patients after a subarachnoid hemorrhage is 15% to 45%, 25% of these deaths occur within the first 24 hours [3,6]. The necessity of quick surgical removal of ruptured intracranial aneurysms seems to be unquestionable. Postponing surgical treatment carries the risk of rebleed, vasospasm and post-hemorrhage hydrocephalus, which in effect aggravates the results of the surgical treatment [2,3]. Despite the advancements in the treatment of subarachnoid hemorrhage, many patients who survived the treatment experience debilitating cognitive, emotional and behavioral symptoms [7,8].

The multicenter randomized study of the International Subarachnoid Aneurysm Trial (ISAT) sets new standards for intracranial aneurysms treatment, indicating the advantage of endovascular coiling over surgical clipping, and presents the long-term results of clinical assessment concerning complications and death [9].

Other authors have presented prospective comparisons of outcomes of early surgical and endovascular treatments for aneurysms in the aspect of clinical and neuropsychological assessment within 3 to 12 months after the procedure [10].

Results of studies on clinical assessment of intracranial aneurysms and subarachnoid hemorrhage (intracranial malformation) are well documented in the specialist literature worldwide, especially long-term outcomes 3, 6, and 12 months after the procedure [8,11,12]. On the other hand, little is known about functional capacity assessment in the early period after the procedure, which is crucial from the nursing standpoint.

Results of functional capacity assessment in patients after surgical treatment of intracranial aneurysm are presented with various functional assessment scales.

The Glasgow Outcome Scale (GOS) [10,13], Extended Glasgow Outcome Scale (GOSE) [14,15], Barthel Index (BI) [10,16], Karnofsky Performance Scale (KPS) [17], Rankin Scale (RS) [18], Functional Status Examination (FSE) [14], Short Form-36 (SF-36) [19] and Sickness Impact Profile (SIP) [20] are the most common scales used for functional assessment of patients with SAH caused by ruptured aneurysm. The variety of the scales makes it impossible to compare the results of studies. Apart from the most popular ones (BI and GOS), other scales are used more or less frequently by the researchers.

This study is based on the authors’ personal experience of using the new Functional Capacity Scale (FCS) in the early period after surgical treatment of intracranial aneurysm.

The aim of the study was to verify the usefulness of the new tool (FCS) for early functional assessment of patients after treatment of intracranial aneurysm.

The study covered the following issues:

Material and Methods

MATERIAL:

The research was conducted in the Neurosurgical Department and Clinic, Collegium Medicum (CM) in Bydgoszcz, Nicolaus Copernicus University (NCU) in Torun, Poland. The research included 128 patients: 43 males and 85 females (Table 1). In the presented material, the 24.2% level of morbidity was mainly the result of early post-surgical complications such as recurrent intracranial hemorrhage and, more importantly, premature cerebral vasospasm. The final assessment covered 97 patients.

The inclusion criteria were: (1) patients with a diagnosed vascular anomaly (intracranial aneurysm) on the basis of angiography; (2) patients having undergone surgical removal of aneurysm through clipping and then wrapping; (3) patients after surgical treatment of an intracranial aneurysm; and (4) patients who remained conscious on admittance (possibility of maintaining coherent verbal contact). The exclusion criteria were: (1) patients with several vascular anomalies (multiple aneurysms, angiomas) diagnosed by angiography; (2) patients having undergone more than 1 surgical intervention of clipping and wrapping; (3) patients having undergone embolization; (4) patients treated conservatively, not surgically; and (5) patients not able to remain conscious on arrival (lack of coherent verbal contact).

Methods

ETHICAL CONSIDERATIONS:

To conduct the research, the consent of the Bioethics Commission of Nicolaus Copernicus University in Torun, Collegium Medicum in Bydgoszcz, was obtained. On arrival, each patient accepted for the research gave written consent to the procedure.

STATISTICAL ANALYSES:

Methods of statistical analysis were used (arithmetic average χ̄, and the standard deviation SD) for the presentation of general characteristics of the examined patients and their functional state in FCS, GOS, FIR, BI and RS in consecutive measurements. In order to check if there were statistically significant differences between mean values in compared groups of scales (FCS, GOS, FIR, BI and RS) and H-H scale, the Kruskal-Wallis test was used. Correlation was calculated using Spearman’s rank correlation coefficient (r_s). Statistical hypotheses were verified according to relevance level p<0.05.

Results

On the discharge day, patients classified into the group I FCS (43 people, 44.3%) were dominant (Table 2). This means that this is a self-sufficient population that does not require assistance from nursing personnel (the average number of points in FCS was: 37.0±7.2). Four patients (4.1%) were classified as group IV FCS (fully dependent patients who require intensive care). The other assessment tools show similar classification (Table 2).

The scales for the assessment of the patient’s functional capacity and final assessment of treatment results were verified (Table 3). The highest values of the coefficient were obtained in correlations between FIR and BI (rS=0.97) and between FIR and RS (rS=−0.96) and BI and RS (rS=−0.96). High, statistically significant (p<0.001), values of Spearman’s rank coefficient (rS=0.93), specified for the correlation between FCS and FIR, result from the similarity of structures of these scales. FCS components are similar to FIR components, and both scales classify patients into 4 groups. In the case of the GOS, RS, and BI scales, correlation coefficients are lower, but also statistically significant.

Functional capacity of patients after surgery assessed using FCS, GOS, FIR, BI and RS was dependent on the initial condition measured by the H-H scale. There is a statistically significant difference in the mean number of points received by the patient on the day of discharge on particular functional scales and the patient’s H-H group before the surgery (p<0.001) (Table 4), indicating that better initial condition on H-H scale improves the patient’s functional capacity (and vice versa) on FCS (Figure 1), GOS (Figure 2), FIR (Figure 3), BI (Figure 4) and RS (Figure 5).

Discussion

We performed functional capacity assessment of patients with intracranial aneurysm/SAH in the early post-operative period. The assessment criteria were the markers/components of particular scoring scales (eg, ambulation, alimentation, personal hygiene). Almost 50% of patients assessed at the early stage after surgical treatment of intracranial aneurysm leave the ward as functionally able in the scope of basic daily living activities. Results obtained from 5 different assessment scales confirm this observation.

Deruty et al. [26] present a very good and average result obtained in 85% of the patients, and a poor result obtained in the case of 4% of patients. Saciri and Kos [27] state that on discharge, 72.7% of patients never displayed motoric problems.

Correlations between particular scales prove the usefulness of these assessment scales in patients with SAH and/or intracranial aneurysms. Other authors also confirm the correlation between scales for assessment of functional capacity in patients after SAH, directly after the surgery and at the remote period [10,28]. Kirkness et al. [14] showed correlations between 2 recently improved scales: GOSE (Extended Glasgow Outcome) [15] and FSE (Functional Status Examination) [29] used for final assessment (functional capacity – recovery) of patients after subarachnoid hemorrhage, 3 months after discharge. They suggest that final outcomes measured by GOSE and FSE are closely related and show statistically significant relationship with other clinical scales (eg, GCS, BDI, SF-36 and GOS) [29,30]. Kim et al. [10] compared and looked for correlations between functional scales in a group of 385 patients at between 3 and 12 months after SAH. They analyzed GOS, Barthel, Rankin and SF-36, and also compared NIHSS and MMSE.

Many authors [9,11] who verified quantitative methods used for assessment in patients with SAH/intracranial aneurysm confirm a high correlation between clinical scales (Hunt and Hess Scale – H&H, World Federation of Neurological Surgeons Scale – WFNS, GCS and Fisher Scale – FS) and functional scales in the immediate and long-term period after intracranial aneurysm surgery.

Clinical condition assessed using the H-H scale has an important influence on the final outcomes measured by the functional scales. Most authors confirm worse final outcomes and greater mortality of patients with worse initial condition measured by the H-H scale [31,32]. It is still controversial whether patients classified as H-H groups IV and V should undergo surgery. Many authors suggest that clinical condition of groups IV and V SAH patients can improve after individual treatments Analysis of final outcomes of these patients shows some discrepancies between direct and remote final results, which range from satisfactory to bad. Undoubtedly, it is influenced by many factors [33–35].