Cerebral aneurysms are some of the most common causes of subarachnoid hemorrhage (SAH) [1–2]. Over the past 30 years, the approaches to SAH treatment have changed significantly [3]. Pathophysiological mechanisms of vasospasm and cerebral ischemia after SAH were investigated; understanding of these mechanisms allowed improving the acute period intensive care methods and reducing the incidence of ischemic complications [4–5]. The achievements in the field of cerebral aneurysm surgery, including methods designed specifically for the acute SAH period, the improvement of the methods of endovascular treatment of aneurysms resulted in reduction of the number of repeated SAH occurrences [6]. Advancements in non-invasive diagnostics and the growing availability of magnetic resonance angiography, computed tomography angiography enabled detection of asymptomatic cerebral aneurysms [7]. Assesing the risk of hemorrhage from an aneurysm takes into account the morphological features of the aneurysm (size, shape, location), the only treatment remains surgical intervention [8]. The rate of occurrence of complications related to such surgery ranges from 3 to 29% [9–11]. However, to date the quality of life of patients after aneurysm surgery remains largely unresearched [12], regardless of such aneurysms staying asymptomatic or causing hemorrhage or have a pseudotumor course. It is known that up to 20–30% of patients acquire disabilities after intracranial hemorrhage [13]. The results of medical rehabilitation of SAH patients, as well as those suffering from post-surgery complications (ischemic or hemorrhagic), can be improved through optimization of rehabilitation algorithms by factoring in the principal neurological disorders [14]. Assessment of the quality of life of patients based on the International Classification of Functioning, Disability and Health (ICF) provides a holistic view of various aspects of their health [15]. This study aimed to apply the International Classification of Functioning (ICF) to assess the quality of life of MCA patients after endovascular treatment (late postoperative period); the goal was to discover the rehabilitation algorithms optimization paths.

METHODS

The study included MCA patients (n = 141) who received endovascular treatment at the Polenov Russian Research Institute of Neurosurgery in 2010–2018. Seventeen percent of the participants were male (24/141), 83% — female (117/141); the mean age of the patients was 54.16 ± 11.24 years. The inclusion criteria were: multiple (>2) cerebral aneurysms treated endovascularly; opportunity to register late results. The exclusion criteria were: age below 18 years; concomitant arteriovenous malformations; history of microsurgical treatment of aneurysm. The number of aneurysms detected ranged from 2 to 6: 2 aneurysms in 62.4% of cases (88/141), 3 aneurysms in 26.2% (36/141), 4 — in 7.8% ( 11/141), 5 aneurysms in 2.8% (4/141), 6 — in 0.7% (1/141). All in all, we detected 349 aneurysms in 141 cases. Their size varied: 22.9% (80/349) were miliary (up to 3 mm) aneurysms, the size of 67.9% (237/349) was regular (4–15 mm), 5.2% (18/349) were large (16–25 mm) and 4.0% (14/349) — gigantic (> 25mm). As for the clinical course pre-surgery, 45.4% (64 cases) of patients suffered one or several subarachnoid hemorrhages, 7.1% (10 cases) had a pseudotumor that affected surrounding structures volumetrically, and in 47.5% (67 cases) of patients the condition developed asymptomatically (accidentally detected aneurysms). All patients had 1 to 6 endovascular surgeries (271 surgeries in total): endovascular occlusion of aneurysms with detachable coils — 42.4% (115/271), assisted (stent and balloon) endovascular occlusion of aneurysms with detachable coils — 32.8% (89/271), flow diverter — 24.7% (67/271). Complications after endovascular treatment (vasospasm, ischemic complications, hemorrhagic complications) occurred in 7.1% of cases (10/141), of which persistent neurological deficiency developed in 4.3% (6/141). We assessed the quality of life in the late period, 6 to 24 months post-surgery. For this purpose, we used the International Classification of Functioning, Disability and Health [15], focusing on the domains of body functions, activity and participation (table).
All data were entered into a Microsoft Excel 7.0 spreadsheet. The clinical data obtained in the study were processed with STATISTICA for Windows 10.0 (StatSoft, Tulsa; USA). Mann- Whitney test, median χ² and the ANOVA module were used to compare the quantitative parameters (scores by ICF domains, Rankin scale, Extended Glasgow Outcome Scale, Barthel Index of Activities of Daily Living (by age groups), SAH complications status, surgery-related complications status, pre-surgery disease development groups). Wilcoxon test was applied to evaluate the dynamics of the activity and participation domain indicators before and after surgery. The findings were considered statistically significant at p < 0.05.

RESULTS

fig. 1 presents the assessment of neurological symptoms and patient complaints in the late postoperative period. fig. 2 presents the assessment of activity and participation domains by the “capacity” and “performance” qualifiers.
The ICF allows a systematic assessment of the state of body functions, with a single impairments severity scale; therefore, we established that the scores registered in the pain (b28010) and memory function (b144) domains were low more often than those describing the status in the voluntary movements coordination (b7602) and muscle power (b7302) domains. In the activity and participation section, the impairments were registered more often in the walking (d450) and housework (d640) domains.
Assessing the impairments detected in the late post-surgery period through the lens of pre-surgery aneurysm development pattern, we established that we found that in patients with ruptured aneurysms, the movement (b 7302, d4602, d640) domains indicators were significantly worse compared to the other types of multiple aneurysms development patterns (p < 0.05). Cranial nerves innervating the eye muscles (III, IV, VI) were significantly more often impaired in the group that had the aneurysms developing pseudotumors, even in the late postoperative period (p < 0.001). In other domains, we registered no significant difference between the MCA development patterns groups (p > 0.05). Assessment of the cephalgic syndrome post-surgery revealed no significant difference in patients with ruptured and unruptured aneurysms. This fact underscores the importance of a detailed study of the cephalgic syndrome structure and its causes.
Comparing the pre-surgery data and those obtained in the late post-surgery period, we discovered that the patients with ruptured MCA enjoyed enjoyed a better quality of life in domains d4602 (Moving around outside the home and other buildings; fig. 3) (p = 0.004) and d640 (Doing housework) (p = 0.03).
The severity of activity impairments (assessed with the Barthel Index of Activities of Daily Living, Rankin Scale, Extended Glasgow Outcome Scale) depended on post-surgery complications (p < 0.05), patient age from 51 to 60 years (p < 0.05), acute SAH period complications (p < 0.001).
The following complications were registered in the late postoperative period: aneurysm rupture — 1.4% (2/141, with focal neurological symptoms), vascular thrombosis — 2.1% (3/141, with focal neurological symptoms in one case). Due to the presence of an unoperated aneurysm that caused intracranial hemorrhage the patients were referred to surgery with subsequent rehabilitation measures.
Thus, using the ICF to score impairments allows qualifying the rehabilitation courses for such patients.

DISCUSSION

The results of our study confirm findings of other researchers [24–26]: a history of subarachnoid hemorrhages in patients with both single and multiple aneurysms negatively affect their functional status. Same as ours, a number of other reports describe the following factors that influence functional outcomes: age of patients at the time of hemorrhage [24], intraparenchymal hemorrhage [24–25], large and gigantic size of the aneurysm [25]. However, unlike other researchers, we did not register as such factors the medial cerebral artery localization of the aneurysm [24, 30] and intraventricular hemorrhage [27].
In the recent years, it became customary to apply the ICF to evaluate the results of treatment and/or rehabilitation in cases with disorders and injuries of the nervous system [28] and other body systems [29]. However, there is an insufficient number of studies addressing application of the ICF in the context of assessment of the results of endovascular treatment of MCA patients. The ICF was used to classify the determinants when summarizing data from various studies investigating QOL deterioration determinants in SAH survivors [30]. It was found that the determinants associated with body structure and  functions (clinical condition at admission, low spirit), activity limitations (physical disability, cognitive status complaints) and personal factors (female sex, advanced age) negatively affect QOL post-SAH. Our study confirms that the QOL of patients with impaired body functions (b7302, b2152) deteriorates.

CONCLUSIONS

In the late postoperative period after endovascular treatment of MCA, a history of SAH and the presence of large aneurysms following the pseudotumor pattern are the factors that negatively affect the QOL of the patients. There is a risk of another SAH linked to the possibility of aneurysm formation de novo and aneurysm recanalization. Thus, further rehabilitation measures should account for neuroimaging data obtained in the late postoperative period. Application of the ICF to assess status of the patient's body functions, activity and participation, allow formulating the goals of rehabilitation, evaluating the results of endovascular treatment and further rehabilitation measures. Using separate scales disallows systematic analysis of the patient's condition. A single description of the severity of impairments is not only convenient in the context of evaluating the results, it also enables research efforts and comparison thereof.