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Functional capacity of patients in the early period after the embolization of cerebrovascular malformations: preliminary findings.

ABSTRACT

Research into outcomes of endovascular intervention for cerebral blood vessel malformations has previously focused on the clinical picture of the disease, death rate, comparison of surgical methods, and the most common postoperative and postbleeding complications. From the nursing standpoint, the crucial elements in assessing postoperative patients are functional outcome defining patients' ability to function in life and recognition of impairments in which patients will be dependent on the nursing staff. The aim of the study was to assess functional capacity of patients before and after the embolization of cerebral blood vessel malformations in the aspect of nursing care. The study included 38 patients after embolization of cerebral blood vessels. The assessment of their condition using the Functional Capacity Scale was performed twice: before and after the surgical procedure. The research shows that on the day of admission to hospital, patients had greatest difficulty performing hygienic activities (p < .0001), satisfying physiological needs (p < .0001), and consuming their meals (p < .004). Headache (p < .002) and poor psychological state (p < .0001) manifesting itself through mild depression constituted other serious problems. After the surgery, vast majority of patients were independent in terms of self-care (p [less than or equal to] .03). Headache occurred in the case of 21% of patients, and psychological state improved in 34% of patients, which shows that there is a major demand for care in this sphere.

Keywords: cerebrovascular malformation, embolization, endovascular intervention, functional capacity, Functional Capacity Scale (FCS)

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Early assessment of final outcomes of endovascular or surgical treatment of patients with intracranial malformations focuses mainly on the clinical manifestation of the disease, mortality rate, comparison of different methods of treatment, and the most frequent postoperative and postbleeding complications. From the nursing standpoint, the crucial element in assessing postoperative patients is their functional capacity defining patients' ability to function in life. Such assessment reveals patients' impairments in which they will be dependent on the nursing staff.

Cerebrovascular malformations include anomalies of both veins and arteries (Greenberg, 2006). The most common malformations of cerebral blood vessels that require embolization include aneurysms, angiomas, carotid-cavernous fistulae, and dura mater fistulae. They have characteristic features that determine the choice of treatment (Altschul, 2011; Brisman, 2011; Oman, 2011; Sen, 2011). The multicenter randomized study of the International Subarachnoid Aneurysm Trial sets new standards for intracranial aneurysm treatment indicating advantage of endovascular coiling over surgical clipping. They present the long-term results of clinical assessment concerning complications, death included (Molyneux et al., 2005).

Other authors present prospective comparison of outcomes of early surgical and endovascular treatments for aneurysms in the aspect of clinical and neuropsychological assessment within 3 and 12 months after the procedure (Kim, Haney, & Van Ginhoven, 2005). Results of studies on clinical assessment of intracranial aneurysms and subarachnoid hemorrhage (intracranial malformation) are well documented in specialist literature worldwide, especially long-term outcomes: 3, 6, and 12 months after the procedure (Al-Khindi, Macdonald, & Schweizer, 2010; Frazer, Ahuja, Watkins, & Cipolotti, 2007; Hackett & Anderson 2000; Koivisto et al., 2000). 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 endovascular procedure or surgical treatment of cerebrovascular malformation are assessed with various functional assessment scales. Glasgow Outcome Scale (GOS; Jennett & Bond 1975; Kim et al., 2005), Extended Glasgow Outcome Scale (Kirkness et al., 2002; Wilson, Pettigrew, & Teasdale, 1998), Barthel Index (Kim et al., 2005; Mahoney & Barthel 1965), Kamofsky Performance Scale (Chiang, Claus, & Awad, 2000; Kamofsky, 1961), Rankin Scale (Greebe et al., 2010; Rankin, 1957), Functional Status Examination (Kirkness et al., 2002), Short Form-36 (Ware & Sherboume, 1992), and Sickness Impact Profile (Bergner, Bobbit, Carter, & Gilson, 1981) are the most common scales used for functional assessment of patients with subarachnoid hemorrhage, aneurysm, or angioma caused by ruptured aneurysm. The variety of the scales makes it impossible to compare the results of the studies. Apart from the most popular ones (Barthel Index and GOS), other scales are used more or less frequently by the researchers.

The literature concerns mainly the assessment of patients in the long-term period after the procedure. Little is known about the abilities of patients in the scope of activities of daily life shortly after the embolization. Accurate functional assessment of the patient in the early period after the procedure (on the day of discharge) significantly influences the longterm outcomes (after 6-12 months). This study is based on the authors' personal experience of using a new Functional Assessment Scale in the early period after endovascular procedures.

Aim

The aim of this study was to assess functional capacity of patients before and after the embolization of cerebral blood vessel malformations in the aspect of nursing care.

Material and Methods

Material

The study included 38 patients hospitalized in the Neurosurgical Department and Clinic, Collegium Medicum in Bydgoszcz, Nicolaus Copernicus University in Torun. Twenty-eight of them were diagnosed with endocranial aneurism (73.7%). The remaining patients were diagnosed with angiomas--angiomas malformation (26.3%). All the patients underwent embolization of cerebral blood vessel malformations. Characteristics of the group are shown in Table 1. Criteria for subject inclusion are as follows:

* patients with a diagnosis of single vascular malformation (aneurysms, arteriovenous malformations) based on full angiography and/or angio-MRI;

* patients after one embolization procedure;

* patients without disturbances of consciousness on admission-clinical assessment using Hunt and Hess Scale, Spetzler-Martin Scale, and Glasgow Coma Scale (logical verbal contact with the patient).

Criteria for subject exclusion are as follows:

* patients with a diagnosis of more than one vascular malformation (plural aneurysms, cavernous angiomas, fistulae) based on full angiography and/or angio-MRI;

* patients after more than one endovascular procedure;

* patients after traditional neurosurgery;

* patients undergoing medical treatment (non surgical treatment);

* patients with disturbances of consciousness on admission (lack of logical verbal contact with the patient).

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

Methods

Direct observation and measurement were used in the study. The first assessment was done before the embolization using Hunt and Hess Scale (Hunt & Hess, 1968), Spetzler-Martin Scale (Spetzler & Martin, 1986), and Glasgow Coma Scale (Teasdale & Jennett, 1974). The functional capacity of the patients was assessed using Functional Capacity Scale (FCS; Slusarz, Beuth, & Kasprzak, 2003, 2006, 2009). The second assessment was done on the day of discharge using FCS and GOS (Jennett & Bond, 1975). Assessments before and after the procedure were done in accordance with the criteria described by the authors of the scales.

Statistical Analysis

The results were calculated using Microsoft Excel software. For statistical analysis, the test for two fractions was used (u) in order to compare the incidence of selected cases in two studied groups. Nonparametric (Wilcoxon pairs test, W) was used to compare the distribution of the two related groups. Statistical hypotheses were verified according to relevance level p < .05.

Results

Ten of 12 determinants of functional capacity in patients after embolization showed statistically significant differences between the periods before and after the procedure (Table 2). On the day of admission, patients had the biggest problem with performing personal hygiene activities (p < .0001), physiological needs (p < .0001), and alimentation (p < .004). They also complained of severe headache (p < .002) and experienced lowered mood (p < .0001). On the day of discharge, most of the patients (80%) were able to take care of themselves in the scope of activities of daily living (ambulation, hygiene activities, physiological needs, alimentation; p < .03). The determinant of the degree of pain (headache) occurred in only 21% of patients. Mood lift was observed in only 34% of patients, which shows that there is a need for care in this area. When we compare the functional capacity assessments of patients before and after the procedure, it is clear that the mean score in the studied group (n = 38) after the procedure (43.63 points) is higher than before the procedure (39.05 points), which indicates improved functional capacity of patients after the procedure. The difference is 4.58 points, and it is statistically significant, W = 4.46, p < .0001 (Table 3).

Discussion

The criterion of functional capacity assessment in patients in the early period after endovascular treatment of cerebrovascular malformations were the determinants of nursing care, which clearly show the care deficit in the particular area (e.g., ambulation, getting dressed, etc). The FCS seems to be a useful tool for such assessment. It enables the medical staff to assess the deficits in the scope of 12 defined determinants characteristic of neurosurgical patients. The research conducted with a view to checking the scale's psychometric reliability and validity showed that the scale is reliable (Cronbach's alpha test internal consistency coefficients ranged between .79 and .96; W-Kendall correlation coefficients for the particular nursing indications reached high score from .79 to 1.000) and accurate when taking into consideration Independence Capacity Score (r = .57, p < .005), with the Functional Index "Repty" (r = .60, p < .003) and with GOS (r = .86, p, < .001). This scale may be easily put into practice (Slusarz et al., 2006, 2009).

The first assessment done on the day of admission showed significant deficit of functional capacity, especially in the area of performing activities related to physiological needs and hygiene, which is connected to bed regime and limitation of physical activity in patients with subarachnoid hemorrhage (Hickey & Buckley, 2003; Pillai, Delaune, Nanda, & Barker, 2008). The patients also needed help with eating. Severe headache was another serious problem for most patients. Intravenous analgesics were used to relieve the pain, which further contributed to the limitation of functional capacity (Gulanick & Myers, 2007; Tucker, Canobbio, Paquette, & Wells, 2000). All patients had lowered mood resulting from suffering pain and anxiety connected to the diagnosis and functioning in the future. Undoubtedly, this condition requires nursing emotional support and understanding of patient's psychological needs. It is important for family members and friends to be actively involved in taking care of the patient (Jarvis & Talbot, 2006; Slusarz, 2008; Slusarz & Szewczyk, 2006; Woodward & Waterhouse, 2009).

The second assessment was done on the day of discharge. Thirty patients (80%) were sent home in good condition, and eight were discharged to stationary care institutions to continue treatment and rehabilitation. In 80% of patients, ambulation was not disturbed. Twenty-one percent complained of a headache. Many patients experienced lowered mood, which shows that there is a need for care in this area.

Reports of other authors studying intracranial malformations and different methods of treatment (surgical, endovascular) are similar to our results. Andrzejewska (2008a, 2008b) and Niskanen et al. (2005) also show similar results concerning independence of patients after treatment of vascular malformations, with relation to nursing care. Koivisto et al. (2000) present data comparing results of surgical and endovascular treatments of intracranial aneurysms in 109 patients 12 months after the procedure. In most cases (80%), the results were very good (5-GOS) and good (4-GOS) regardless of method. The following factors were taken into consideration: Hunt and Hess group, Fisher group before the procedure, and location of the vascular malformation. Uda, Murayama, Gobin, Duckwiler, and Vinuela (2001) examined 39 patients, and the final outcome of treatment was good or very good in 90% of cases. The results of a multicenter study of International Subarachnoid Aneurysm Trial were also good in 70% of cases, regardless of method. However, the results in the modified Rankin Scale 2 and 12 months after the procedure (Brisman, 2011)were slightly better in patients treated with the endovascular method.

Studies conducted in Poland confirm data concerning results of vascular malformation treatments gathered by foreign centers. Results from Uhl, Turski, Kamieniecka, Czepko, and Pietruszko (2004), depending on the method in correlation with the size of aneurysm, were satisfying in 60% (MDS method) and 80% (GDC) cases in 4- and 5-GOS groups. Juszkat et al. (Juszkat, Blok, Kociemba, Smol, & Moskal, 2006; Smol et al., 2007) also present satisfying early outcomes of vascular malformation treatment depending on gender, age, and clinical condition before the procedure. A study conducted by a center in Wroclaw (Guzinski, Hendrich, & Sasiadek, 2008) in a sample of 32 patients with intracranial arteriovenous malformations shows that single or multistage embolization of cerebral arteriovenous malformations should be the first choice method for treatment in most cases. Because of low risk of complications and rapid progress in the technique of endovascular procedures, it seems that the method will soon become the most popular method of treatment of small- and medium-sized malformations, either as a single method or combined with other methods. Other studies focusing on retrospective comparative analysis of 40 microsurgical procedures and endovascular embolization of arteriovenous malformations show 80% of satisfying outcomes (4- and 5-Glasgow Coma Scale groups) on the last day of hospitalization (Guzinski et al., 2010).

Conclusions

Before surgery, patients required considerable care of the nursing team, mainly in the area of performing hygienic activities, satisfying physiological needs, and consuming meals. On discharge, the vast majority of patients (80%) were independent in basic day-to-day activities.

Implications for Neuro Nurses/Implications for Nursing Practice

The authors present results of research on functional capacity of patients in the early period after embolization of cerebrovascular malformations, as assessed using standard clinical scales. Also practical usage of the new measuring scale (FCS) used for functional outcome assessment shortly after the procedure is outlined in the study. There is the need for multicenter research to validate the scale and allow comparison of the results.

Limitations to Study

The study shows only the results of early functional capacity, which influence the long-term outcome (e.g., after 3 months, 1 year, or 3 years). Thus, the results are starting point for assessment of long-term functional capacity. The study is also limited by the small sample of analyzed cases, and it is necessary to continue the research to further verify practical use of the assessment tool as well as to draw precise conclusions. Finally, the results of the study cannot be compared with other authors' reports concerning early assessment (performed during hospitalization).

References

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Questions or comments about this article may be directed to Robert Slusarz, PhD MA RN CNS, at zpielnin@cm.umk.pl. He is an adjunct and Head of Neurological and Neurosurgical Nursing Department, Collegium Medicum in Bydgoszcz, Nicolaus Copernicus University, Torun, Poland.

Monika Biercewicz, PhD MA RN CNS, is an assistant at Geriatric Clinic, Collegium Medicum in Bydgoszcz, Nicolaus Copernicus University, Torun, Poland.

Roksana Rybicka, MA, is a senior lecturer at Department of Applied Linguistics, Collegium Medicum in Bydgoszcz, Nicolaus Copemicus University, Torun, Poland.

Wojciech Beuth, PhD, is a professor and Head of the Neurosurgical Department and Clinic, Collegium Medicum in Bydgoszcz, Nicolaus Copernicus University, Torun, Poland.

Maciej Sniegocki, PhD, is a professor and Head of the Neurotraumatology Department, Collegium Medicum in Bydgoszcz, Nicolaus Copernicus University, Torun, Poland.

The authors declare no conflicts of interest.

DOI: 10.1097/JNN.0b013e318266641f
TABLE 1.
Demographic Characteristics (N=38)

Variables                                       n (%)

Sex
  Male                                        14 (36.8)
  Female                                      24 (63.2)
Age (years)
  0-20                                         2 (5.3)
  21-40                                        7 (18.4)
  41-603                                      22 (57.9)
  >60                                          7 (18.4)
Clinical display
  Aneurysm                                    28 (73.7)
  Angiomas malformations                      10 (26.3)
Location of malformations
  Anterior communicating artery                6 (15.8)
  Medial carotid artery                       14 (36.8)
  Internal carotid artery                     10 (26.4)
  Anterior cerebral artery                     4 (10.5)
  Posterior communicating artery               4 (10.5)
Measurement 1 (before the embolization)
 Hunt and Hess Scale/Grade -- group
  0                                           13 (34.2)
  I                                            8 (21.1)
  II                                           7 (18.4)
  III                                         10 (26.3)
  IV                                           0 (0.0)
  V                                            0 (0.0)
Spetzler-Martin Scale/Grade -- group
  I                                            0 (0.0)
  II                                           2 (20.0)
  III                                          4 (40.0)
  IV                                           3 (30.0)
  V                                            1 (10.0)
Glasgow Coma Scale/Score-group (points)
  15-13                                       32 (84.2)
  12-9                                         6 (15.8)
  8-3                                          0 (0.0)
Functional Capacity Scale-group (points)
  I (48-40)                                   21 (55.3)
  II (39-31)                                  10 (26.3)
  III (30-21)                                  4 (10.5)
  IV (20-12)                                   3 (7.9)
Measurement 2 (after the embolization)
 Functional Capacity Scale-group (points)
  I (48-40)                                   30 (79.0)
  II (39-31)                                   4 (10.5)
  III (30-21)                                  3 (7.9)
  IV (20-12)                                   1 (2.6)
Glasgow Outcome Scale/Score -- group
  5                                           28 (73.7)
  4                                            6 (15.8)
  3                                            4 (10.5)
  2                                            0 (0.0)
  1                                            0 (0.0)

TABLE 2. Functional Capacity of Patients Before and After the
Embolization

                        FCS Before the
                        Embolization, n (%)

Care Markers               I          II         III          IV

1. Motor ability        21        1           10          6
                        (55.3)    (2.6)       (26.3) (1)  (15.8)

2. Nutrition            20        11          4           3
                        (52.6)    (28.9) (1)  (10.5)      (7.9)

3. Hygiene              20        2           9           7
                        (52.6)    (5.3)       (23.7) (1)  (18.4)

4. Physiological        16        3           12          7
   needs                (42.1)    (7.9)       (31.6) (1)  (18.4)

5. Measurement of       24        11          0           3
   vital processes      (63.2)    (28.9) (1)  (0.0)       (7.9) (2)
   (GCS)

6. Respiration          35        0           2           1
                        (92.1)    (0.0)       (5.3)       (2.6)

7. Diagnostics          34        0           0           4
                        (89.5)    (0.0)       (0.0)       (10.5) (1)

8. Preparation for      22        13          3           0
   the operation        (57.9)    (34.2) (1)  (7.9) (2)   (0.0)
   and postoperative
   care

9. Dressings,           37        0           0           1
   drainage             (97.4)    (0.0)       (0.0)       (2.6)

10. Degree of pain      17        6           12          3
intensification
                        (44.7)    (15.8)      (31.6) (1)  (7.9)

11. Pharmacotherapy     19        6           1           12
                        (50.0)    (15.8) (1)  (2.6)       (31.6) (2)

12. Mental state        0         30          5           3
    (mood)              (0.0)     (78.9) (1)  (13.2)      (7.9)

                        FCS After the
                        Embolization, n (%)

Care Markers                 I         II     III      IV

1. Motor ability        30           1       0       7
                        (78.9) (2)   (2.6)   (0.0)   (18.4)

2. Nutrition            29           2       3       4
                        (76.3) (2)   (5.3)   (7.9)   (10.5)

3. Hygiene              29           2       0       7
                        (76.3) (2)   (5.3)   (0.0)   (18.4)

4. Physiological        27           6       0       5
   needs                (71.1) (2)   (15.8)  (0.0)   (13.2)

5. Measurement of       36           2       0       0
   vital processes      (94.7) (3)   (5.3)   (0.0)   (0.0)
   (GCS)

6. Respiration          35           0       3       0
                        (92.1)       (0.0)   (7.9)   (0.0)

7. Diagnostics          37           0       1       0
                        (97.4)       (0.0)   (2.6)   (0.0)

8. Preparation for      36           2       0       0
   the operation        (94.7) (3)   (5.3)   (0.0)   (0.0)
   and postoperative
   care

9. Dressings,           36           0       0       2
   drainage             (94.7)       (0.0)   (0.0)   (5.3)

10. Degree of pain      30           3       4       1
intensification
                        (78.9) (2)   (7.9)   (10.5)  (2.6)

11. Pharmacotherapy     34           0       2       2
                        (89.5) (3)   (0.0)   (5.3)   (5.3)

12. Mental state        13           19      4       2
    (mood)              (34.2) (2)   (50.0)  (10.5)  (5.3)

Care Markers                p

1. Motor ability        (1) <.0001
                        (2) <.03

2. Nutrition            (1) <.004
                        (2) .03

3. Hygiene              (1) <.0001
                        (2) .03

4. Physiological        (1) <.0001
   needs                (2) .03

5. Measurement of       (1) <.003
   vital processes      (2) <.02
   (GCS)                (3) .0002

6. Respiration
                        --

7. Diagnostics          (1) .004

8. Preparation for      (1) .0006
   the operation        (2) <.02
   and postoperative    (3) <.0001
   care

9. Dressings,
   drainage             --
                        (1) <.02

10. Degree of pain      (2) <.002
intensification
                        (3) <.002

11. Pharmacotherapy     (1) <.0004
                        (2) <.002
                        (3) <.0001

12. Mental state        (1) .007
    (mood)              (2) <.0001

Note. FCS = Functional Capacity Scale. Superscript numbers
indicate significance levels for the data in the individual rows
of the table.

TABLE 3. Functional Capacity Scale Before and After the Embolization

FCS            FCS Before, n    (FCS After, n (%)

I               21 (55.3)         30 (79.0)
II              10 (26.3)          4 (10.5)
III              4 (10.5)          3 (7.9)
IV               3  (7.9)          1 (2.6)
Average no.
of points
in scale
[+ or -] SD   39.05 [+ or -] 9.76    43.63 [+ or -] 7.63

FCS                  u/p

I                  u = 2.23/p < .03
II                 u = 1.82/p = .07
III                u = 0.40/p = .69
IV                 u = 1.06/p = .29
Average no.
of points
in scale
[+ or -] SD    4.58 [+ or -] 5.70; W = 4.46, p < .0001

Note. FCS = Functional Capacity Scale.
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Author:Slusarz, Robert; Biercewicz, Monika; Rybicka, Roksana; Beuth, Wojciech; Sniegocki, Maciej
Publication:Journal of Neuroscience Nursing
Article Type:Report
Geographic Code:4EXPO
Date:Oct 1, 2012
Words:4455
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