Sexual Dysfunction Common after Successful treatment of Ruptured Aneurysms: Study

A recent study published in Neurology India suggests that in cases of aneurysmal subarachnoid hemorrhage, sexual dysfunctions are common even after good clinical outcomes.

Sexual well-being is a fundamental requisite of happiness. The symptoms of sexual dysfunctions (SD) may be subtle or overt. The social stigma attached to this problem in conservative societies has kept this issue under the carpet for long times. Nevertheless, sexual dysfunction adversely affects interpersonal relationships and overall quality of life (QOL).

Male sexual arousal is a matter of central physiologic state with a linear sequence model of desire, arousal, orgasm, and resolution. It involves the process of relevant stimuli, general arousal, incentive motivation, and genital response. Literature suggests that patients with good neurologic recoveries after aneurysm clipping have a higher prevalence of sexual dysfunctions as compared to strokes of other etiologies. This disproportionate higher prevalence of sexual dysfunctions after aSAH may be due to the diffuse, global brain damage associated with SAH. Such an extensive injury is more likely to interfere with higher mental functions. It is mediated by dysfunction in bilaterally distributed, large-scale networks such as those underlying memory, executive function, and sexuality. SSASM evaluates both the physiological and subjective components of male sexual function.

A neglected factor is the location of the aneurysm and extent of SAH. Sexual function depends upon a complex network of peripheral and central pathways involving the autonomic and somatic nerves and the integration of numerous spinal and supra-spinal structures in the central nervous system. Hypothalamic and limbic regions play a pivotal role in this basic function. Brain is the master organ in sexual and positron emission tomography recordings during visual sexual stimulation showed activations in the orbitofrontal cortex, claustrum, anterior cingulate cortex, caudate, putamen, and hypothalamus. The anterior, mesial temporal lobe and basal forebrain structures are key regions for human sexual experience. These areas are intimately related to the Acom complex and the blood spillover from ruptured aneurysm in that region is likely to disrupt neurological functions, which include sexual activity as well.

Theoretically, these sexual dysfunctions may be caused by compression of the hypothalamic–pituitary complex by the aneurysm itself, post-hemorrhagic local tissue tamponade, toxic effects of the extravasated blood products, ischemia caused by vasospasm, raised intracranial pressure, hydrocephalus, or injury to delicate perforators of anterior circulation during surgery. This concept holds significant relevance for surgical procedures undertaken for Acom complex. The perforators arising from Acom supply hypothalamus and the hypothalamic-pituitary axis. Acom aneurysms are the most complex aneurysms of the anterior circulation due to flow dynamics and angioarchitecture of the Acom region. Anatomical structures in vicinity to Acom aneurysms are orbito-frontal cortex, claustrum, anterior cingulate cortex, caudate, putamen, and hypothalamus. The location of aneurysms and the perforators probably play a significant role in causing sexual dysfunctions with hypothalamus being final common pathway that controls sexual function. Sexual dysfunctions seem to be due to some neural abnormalities in these areas with Acom aneurysms having relatively more impact on hypothalamus as compared to aneurysms at other sites.

Researchers from PGI Chandigarh attempted to quantify this important parameter with comparative evaluation of anterior circulation aneurysms in different locations. As the sexual activity is related to hypothalamic pituitary axis and Papez circuit, they concentrated on the differential outcomes in different anterior circulation aneurysms only.

The authors prospectively included 40 male patients of ruptured intracranial aneurysms of anterior circulation (age range: 20–60 years; sexually active preoperatively), managed with craniotomy and clipping. They evaluated the sexual outcome in patients with excellent Glasgow outcome score (GOS) five at a minimum one year of follow-up. Patients with GOS-5 status at follow-up were broadly classified into two groups: Anterior communicating artery aneurysm (Acom), and non-Acom) aneurysms. We valued sexual outcome with Subjective Sexual Arousal Scale for Men  (SSASM) at follow-up, and compared in the two groups.

They found that grossly, 65% (26 of 40) patients of ruptured aneurysms scored below 135, suggesting some form of sexual dysfunctions. Statistically significant worse, mean SSASM score (114.520.44) for Acom aneurysm patients as compared to other aneurysms (129.517.90) highlights the increased sensitivity of midline neural structures to toxic blood products and damage.

The authors observed that spontaneous SAH adversely affects the interpersonal relationships and intimate sexual behavior, especially because of the loss of libido. In a patient with good outcome on traditional scales, maintaining the role of a partner and hence a family gradually becomes important. Only a limited number of patients (not more than 20%) are actually able to maintain the same employment and interpersonal relationships despite having a good scoring on the GOS. One of the limitations in these parameters is it takes into account sexual assessment only of the patient, not his partner. Any sexual activity demands a partner and the future assessments should also incorporate the viewpoint of the partner as the patient himself might be biased about his emotions and performance.

In SSASM analysis, mental satisfaction domain was especially low. It highlighted another point that good outcome aSAH patients with chronic complaints (post aSAH syndrome) typically lacked a structural brain damage correlate. Sexual dysfunction could be part of emotional problems, which many good outcome patients struggle with, including depression. 

This study revealed that sexual performance domain, mental satisfaction domain, and sexual assertiveness domain are more commonly and severely affected in patients who underwent surgery for Acom aneurysm as compared to aneurysm located in other regions of anterior circulation. Sexual health, as a significant outcome measure may be better detailed in cases undergoing aneurysm clipping and guarded outcome should become a part of preoperative counseling for aneurysms around Acom complex. Sexual rehabilitation is an important aspect among survivors of aSAH and needs the requisite evaluation of the partner, conclude the authors

Reference:

Tripathi, Manjul; Wankhade, Lomesh; Mohindra, Sandeep; Kumar, Santosh; Chauhan, Rajeev.

Sexual Dysfunction after Clipping of Ruptured Intracranial Aneurysms. Neurology India 72(1):p 110-116, Jan–Feb 2024.

 DOI: 10.4103/neuroindia.NI_1917_20