Recovery to Preinterventional Functioning, Return-to-Work, and Life Satisfaction After Treatment of Unruptured Aneurysms
Background and Purpose—The eventual goal of preventive treatment of unruptured intracranial aneurysms is to increase the number of life years with high life satisfaction. Insight in the time with reduced functioning, working capacity, and life satisfaction after aneurysm treatment is pivotal to balance the pros and cons of preventive aneurysm occlusion.
Methods—We sent a questionnaire on time-to-recovery to preintervention functioning and return-to-work and life satisfaction to patients treated for an unruptured aneurysm between 2000 and 2013. Changes in life satisfaction before treatment, during recovery, and at follow-up were assessed with Wilcoxon signed-rank tests.
Results—The questionnaire was sent to 159 patients of whom 110 (69%) responded. The mean follow-up time after aneurysm treatment was 6 years (SD 4). Fifty-four patients had endovascular and 56 had microsurgical occlusion. Complete recovery to preintervention functioning was reported by 81% (95% confidence interval [CI], 74–88) of patients, with a median time-to-recovery of 3 months (range 0–48). Complete work recovery was reported by 78% (95% CI, 66–87) of patients. The proportion of patients with high life satisfaction reduced from 76% (95% CI, 67–84) before treatment to 52% (95% CI, 43–61) during the period of recovery (P<0.01) and restored largely at long-term follow-up (67% [95% CI, 59–76], P=0.08).
Conclusion—Life satisfaction is significantly reduced during the period of recovery after treatment of unruptured aneurysms. In the long-term, ≈1 out of 5 patients reports incomplete recovery. These treatment effects should be kept in mind when considering preventive aneurysm treatment. Prospective studies are needed to better compare these losses in patients treated for unruptured aneurysms with those who had subarachnoid hemorrhage.
Preventive treatment of unruptured intracranial aneurysms aims to prevent future rupture and thereby the devastating consequences of aneurysmal subarachnoid hemorrhage. The eventual goal is to increase the number of life years with good quality of life or good life satisfaction. If patients choose to undergo preventive occlusion of intracranial aneurysms, they invest a certain period of time with reduced functioning, working capacity, and life satisfaction. Insight in the amount of time with reduced functioning, working capacity, and life satisfaction after preventive aneurysm treatment is pivotal to balance the pros and cons of preventive aneurysm occlusion. We studied these outcomes in a series of consecutive patients who had undergone endovascular or microsurgical treatment in our center.
Approval for this study was obtained from the Institutional Research Ethics Board of the University Medical Center Utrecht, Utrecht, the Netherlands. Patients were selected from our prospectively collected institutional database of consecutive patients with unruptured aneurysms. Inclusion criteria were (1) ≥18 years; (2) no medical history of subarachnoid hemorrhage; and (3) endovascular or microsurgical treatment of one or more unruptured intracranial aneurysms between January 1, 2000, and January 1, 2013. We excluded patients who were living abroad or deceased. All other patients were sent a questionnaire about their functioning, employment status, and life satisfaction by regular mail.
Patient and Aneurysm Characteristics
The following data were retrospectively collected from the electronic patient files by 2 investigators (D. Backes and J.A. Nij Bijvank): age at time of first aneurysm treatment, sex, reason of aneurysm detection, number of treated aneurysms, aneurysm size and location, type of aneurysm treatment, and in-hospital neurological complications.
Reasons for aneurysm detection were classified as incidental, symptomatic (symptoms of mass effect, such as cranial nerve palsy, ischemic event in the same vascular territory as the aneurysm, or epileptic seizure), or familial screening. During the study period, screening for asymptomatic aneurysms was offered to patients with ≥2 first degree relatives with intracranial aneurysms.1,2 Aneurysm size was categorized into 1 to 7 mm, 8 to 14 mm, and >15 mm. Aneurysm treatment was dichotomized into endovascular (coiling, stenting, parent artery occlusion) and microsurgical occlusion. In our center, all patients with a possible indication for aneurysm treatment are discussed within a multidisciplinary consensus meeting with neurologists, neurosurgeons, and interventional neuroradiologists to determine the optimal treatment strategy. If the team decides to an advice for treatment, the choice of treatment depends on many factors, including the age of the patient and the complexity and location of the aneurysm. In-hospital neurological complications were classified as in-hospital death, cerebral infarction, intracranial hemorrhage (intracerebral, subarachnoid, subdural, epidural, or intraventricular hemorrhage), hydrocephalus, and transient neurological deterioration. In-hospital death was defined as death by any cause between aneurysm treatment and discharge from the hospital. The diagnosis of cerebral infarction, intracranial hemorrhage, and hydrocephalus was based on a combination of neurological deterioration with compatible findings on MRI or computed tomography. If a patient had a transient neurological deterioration after aneurysm treatment without compatible findings on MRI or computed tomography and recovered completely during admission, it was defined as transient neurological deterioration (ie, delirium, transient ischemic attack).
Questionnaire About Recovery, Return-to-Work, and Life Satisfaction
Questions on return-to-work were adapted from a previous study on quality of life and return-to-work after subarachnoid hemorrhage.3 Patients were asked for the number of months needed to recover completely from their aneurysm treatment, which could optionally be answered with “I am still not completely recovered”. In addition, patients were asked to report their complaints in case of incomplete recovery. Employment status was assessed with questions on the type of job and the number of weekly working hours before and after aneurysm treatment, including any change in job responsibility and the number of months until complete recovery with regard to work after aneurysm treatment.3
Changes in life satisfaction were measured with 3 questions adapted from previous studies, including a validation study that showed good concurrent validity of these questions by strong associations with other life satisfaction questionnaires.4–6 Patients were asked to rate their life satisfaction before aneurysm treatment, during the period of recovery, and at the time of the questionnaire. All 3 questions were scored on a 6-point scale ranging from very unsatisfied (1) to very satisfied (6). In addition, life satisfaction at the time of the questionnaire was measured with the Life Satisfaction questionnaire (LiSat-9), a widely used and validated tool for the evaluation of life satisfaction (Cronbach-α 0.75–0.87).3,4,7–9 The LiSat-9 contains one question about life satisfaction as a whole and 8 questions about domain-specific life satisfaction (self-care ability, leisure time, vocational situation, financial situation, sexual life, partnership relations, family life, and contact with friends) and has to be scored on a 6-point scale ranging from very unsatisfied (1) to very satisfied (6).
Data are presented as mean with standard deviation (SD) or median with range where applicable. In line with previous studies, we used the cutoff point of 5 to dichotomize the life satisfaction scores into unsatisfied (score 1–4; very unsatisfied, unsatisfied, rather unsatisfied, and rather satisfied) and satisfied (score 5–6; satisfied and very satisfied).9 Life satisfaction according to the LiSat-9 questions showed good reliability within our cohort (Cronbach α=0.87). Baseline characteristics, number of months until recovery to preintervention functioning and with regard to work, changes in life satisfaction, and long-term life satisfaction (LiSat-9) were analyzed separately for endovascularly and microsurgically treated patients because of expected differences between the 2 treatment methods. We plotted Kaplan–Meier curves for the time to recovery to preintervention functioning. We calculated risk ratios with corresponding 95% confidence intervals (CI) to evaluate factors associated with incomplete recovery after aneurysm treatment. Changes in quality of life before treatment, during recovery, and at the time of the questionnaire were compared with the Wilcoxon signed-rank test.
During the study period, a total of 177 patients aged ≥18 years were endovascularly or microsurgically treated for a total of 201 unruptured intracranial aneurysms. A questionnaire was sent to 159 patients who were still alive and living in the Netherlands on June 1, 2014. A reminder was sent to patients who did not respond to the first questionnaire after 2 months. Missing values on returned questionnaires were completed by telephone interview. Finally, 110 (69%) patients returned a completed questionnaire. The patient and aneurysm characteristics of study participants and nonparticipants are shown in Table 1. Participants were significantly older than nonparticipants. All other baseline characteristics were comparable between participants and nonparticipants. Of the 110 participants, 54 patients had endovascular treatment and 56 patients had microsurgical clipping. The mean interval between aneurysm treatment and completion of the questionnaire was 6.2 years (SD 3.7). Baseline characteristics are given in Table 2.
Recovery After Treatment
Time to recovery to preinterventional functioning was 1 month (range 0–18) after endovascular and 5 months (range 1–48) after microsurgical treatment, resulting in a median time to recovery to preinterventional functioning of 3 months (range 0–48) for the entire cohort of patients. In the long-term, the proportion of patients reporting complete recovery was 81% (95% CI, 74–88), with 82% (95% CI, 69–91) of patients reporting complete recovery after endovascular treatment and 80% (95% CI, 68–90) of patients after microsurgical occlusion. Kaplan–Meier curves for the time to complete recovery to preinterventional functioning are shown in Figure 1. The most frequently self-reported complaints of patients who were not completely recovered were fatigue (7 patients), memory problems (5 patients), physical complaints (5 patients), and concentration problems (3 patients). Incomplete recovery was associated with in-hospital complications (risk ratios 3.3; 95% CI, 1.6–6.8), aneurysm size >7 mm (risk ratios 3.7; 95% CI, 1.2–11.8), and posterior circulation aneurysm (risk ratios 2.4; 95% CI, 1.1–5.2), but not with female sex, age at aneurysm treatment >55 years, marital status, education level, pretreatment employment status, treatment modality, or treatment of multiple aneurysms (please see Table I in the online-only Data Supplement).
Of the 68 patients who were employed before aneurysm treatment, 30 patients were treated endovascularly and 38 microsurgically. The proportion of patients reporting complete work recovery was 78% (95% CI, 66–87), with 80% (95% CI, 61–92) after endovascular and 76% (95% CI, 60–89) after microsurgical occlusion (Table 3). In the group of patients with complete work recovery, the median time until return-to-work was 2 months (range 0–12) after endovascular and 3 months (range 1–24) after microsurgical treatment, resulting in a time until return-to-work of 3 months (range 0–24) for the entire group of patients with complete work recovery. In the group with incomplete work recovery, all 7 patients reduced the number of working hours or the level of responsibility. Of the 8 patients not returning to work, 2 patients were unemployed because of aneurysm treatment, one stopped working to care for a family member, one retired directly after treatment, and 4 patients were unemployed because of health problems not related to aneurysm treatment (Table 3).
Overall, the proportion of patients reporting high life satisfaction was 76% (95% CI, 67–84) before treatment, 52% (95% CI, 43–61) during the period of recovery, and 67% (95% CI, 59–76) at the time of filling out the questionnaire (Figure 2). For both endovascularly and microsurgically treated patients, life satisfaction dropped significantly during the period of recovery from aneurysm treatment (Figure 1). At long-term follow-up, a trend toward reduced life satisfaction compared with the time before aneurysm treatment was observed (Figure 1). Table 4 shows the proportion of patients with high life satisfaction on individual LiSat-9 domains at the time of the questionnaire.
This study shows that the duration of reduced functioning and working capacity is ≈1 to 2 months after endovascular and 3 to 5 months after microsurgical preventive treatment of unruptured aneurysms. Life satisfaction is considerably reduced during the period of recovery. In the long term, ≈1 out of 5 patients reports incomplete recovery after aneurysm treatment.
Two previous studies reported on employment status in patients who were treated for unruptured intracranial aneurysms.10,11 In the first study, all patients regained their preoperative employment status within 1 year after treatment.10 However, that study only included 15 patients who were all treated for a middle cerebral artery aneurysm by microsurgical clipping, which limits generalizability.10 The second study reported that only 23 of 63 (37%) included patients were employed after a mean follow-up of 2.5 years after microsurgical or endovascular treatment.11 Unfortunately, no conclusions can be drawn from that study on the possible influence of treatment on employment status because data on pretreatment employment status are lacking.11 Several studies reported on health-related quality of life after treatment of unruptured aneurysms, which is different from life satisfaction.3,12 For microsurgical treatment, other studies found that clipping of unruptured intracranial aneurysms has a negative impact on health-related quality of life in the first 3 months after treatment, which improves markedly but not completely within 1 year after surgery.10,13,14 For endovascular treatment, only one study including 19 patients assessed health-related quality of life after treatment of unruptured aneurysms and found no effect.14 No studies thus far investigated long-term life satisfaction in patients treated for unruptured intracranial aneurysms.
Factors, such as patient’s age, life expectancy, comorbidities, risk factors for aneurysm rupture, and aneurysm characteristics, need to be taken into account when patients with unruptured aneurysms are counselled for treatment.15 Our study has as novel approach that we provide insight in the duration of recovery and return-to-work, and long-term life satisfaction after treatment of unruptured aneurysms. Our results are useful in patient counseling with regard to the pros and cons of preventive aneurysm treatment. Moreover, outpatient rehabilitation should be considered for those patients who do not recover completely.
Our study has some limitations. First, life satisfaction before aneurysm treatment and during the period of recovery and time until return-to-work were evaluated retrospectively. Therefore, life satisfaction measurements may have been subject to response shift, a process in which patients adapt their initial standards, values, and conceptualization of life satisfaction to their changing health status, which may lead to an overestimation of the actual life satisfaction during these periods.16,17 Moreover, during the period patients were treated, neurosurgeons advised not to start working during at least the initial 6 weeks after the treatment, which may have contributed to the difference in time to recovery between microsurgical and endovascular treatment. Second, selection may have occurred because not all patients returned their questionnaire. However, a response rate of 69% is comparable with other studies, and there were no major differences in baseline characteristics between participants and nonparticipants.3,11,18 Third, patients and aneurysms treated by coiling or by surgery were incomparable, making it impossible to compare outcomes between the endovascular and microsurgical treated groups. The strength of our study is the large sample size and the use of a validated questionnaire for evaluation of life satisfaction.
Our data provide a first impression of losses in functioning, working capacity, and life satisfaction after treatment of unruptured aneurysms, which was initially intended to prevent such losses from future aneurysmal rupture. Future prospective studies are needed in patients with treatment of unruptured aneurysms and patients with subarachnoid hemorrhage to better compare these losses. Because the losses seem considerable, there is a need for less invasive treatment strategies to prevent aneurysmal rupture and better risk prediction of which aneurysms have a high risk of rupture because the investments of preventive treatment can then better be directed to those patients who benefit from it.
The online-only Data Supplement is available with this article at http://stroke.ahajournals.org/lookup/suppl/doi:10.1161/STROKEAHA.115.008795/-/DC1.
- Received January 16, 2015.
- Revision received March 20, 2015.
- Accepted March 30, 2015.
- © 2015 American Heart Association, Inc.
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