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Background:
Nearly two third of all patients with good outcome after aneurysmal subarachnoid haemorrhage (aSAH) suffer from neuropsychological deficits (NPD). Even five years after discharge, neuropsychological impairments can persist with a heavy influence on the patient’s ability to lead an independent life. One of the factors feared most after successful early aneurysm occlusion is delayed cerebral ischemia (DCI) with a prevalence of 30% and peak incidence on days 4 to 10 post haemorrhage. Focal neurological deficits (aphasia, hemiparesis) or a decrease in consciousness without other explanation can be attributable to neurological deterioration caused by DCI. DCI is one of the main factors influencing outcome after SAH. It was our aim to test the hypothesis that cerebral vasospasm (CVS) / DCI and neuropsychological deficits after hospital discharge are associated.

Methods:
Files of patients treated for aSAH between 01-2009 and 08-2012 at the neurovascular centres (KSSG or KSA) were reviewed and relevant data concerning the clinical course (e.g. CVS, DCI) were extracted. Clinical deterioration attributable to DCI was defined as occurrence of focal neurological impairment, or a decrease of at least 2 points on the Glasgow Coma Scale after ruling out of other causes (hydrocephalus, electrolyte disturbance, epilepsy, infection) (Vergouwen et al., STROKE 2010). CVS was defined as mean blood flow velocity (Vmean) > 140 cm/sec or increase in Vmean > 50cm/sec/24h or as a Lindegaard-Index > 3 in transcranial Doppler sonography or diagnosis was confirmed in a CT- or conventional angiography. Only those patients with thorough neuropsychological assessment by R.W. (KSA patients) or the discharging rehabilitation centre (KSSG patients) were selected for analysis. The neuropsychological outcome was assessed after a mean of 70.4 ± 67.3 days after aneurysm occlusion and graded as regular, minimum, moderate or severe by an experienced neuropsychologist. Furthermore, the affected neuropsychological domains were recorded in each patient (alertness, executive function, memory, visuoconstruction, language/calculation, behaviour).

Results:
- A total of 92 patients (35 male and 57 female) with a mean age of 51.4 ± 11.6 years were analyzed
- All patients were treated; 58 aneurysms were clipped and 36 were coiled (2 patients received both clipping and coiling)
- 39/92 patients (42.4%) suffered from CVS and 28/92 (30.4%) experienced DCI
- Of the 39 patients with CVS, 29 (74.4%) had moderate to severe NPD, while this was the case in 26/53 patients without CVS (49.0%; p=0.012 (Chi2))
- Of the 28 patients with DCI, 24 (85.7%) had moderate to severe NPD while this was observed in 33/64 patients (51.6%) without DCI (p=0.001 (Chi2))
- The likelihood for a patient with Fisher grade 3 or 4 to develop NPD is 98.5%

Conclusion:
- While there is a 74 and 85% likelihood of patients with CVS and DCI to have a moderate to severe NPD, it is difficult to predict cognitive outcome in patients without CVS and DCI.
- Roughly half of patients without CVS and DCI will still develop NPD, possibly related to further potential factors such as hydrocephalus.
- Fisher grade 3 and 4 SAH was predictive for both CVS/DCI and moderate/severe NPD
- As most patients with DCI show evidence of cognitive impairment, we propose reconsidering the notion of DIND or term a novel entity – delayed neuropsychological deficit (DINPD).

Conflict of interest / funding:
The authors declare no conflicts of interest. There was no funding received for this study.