When Should Neuroendovascular Care for Patients With Acute Stroke Be Palliative?

Outcomes of Mechanical Thrombectomy for Acute Ischemic Stroke in Cancer Patients: A Single-Center Experience and Meta-Analysis

Background and Objectives

The published data about mechanical thrombectomy (MT) in cancer patients is sparse. We present our institutional experience in this clinical scenario, and a meta-analysis.

Methods

The baseline data, procedural data, clinical and radiological outcomes of MT were analyzed and compared among three groups of stroke patients: controls, patients with active malignancy (AM), and patients with history of malignancy (HOM). A meta-analysis of 12 studies was conducted to address the differences between controls and AM patients regarding selected outcomes.

Results

The 3 groups (controls, AM, HOM) showed significant differences regarding previous history of stroke or TIA (7.8% vs 10.5% vs 38.5%, p = 0.006), alcohol consumption (0.9% vs 10.5% vs 0.0%, p = 0.04), thrombophilia (1.7% vs 15.8% vs 7.7%, p = 0.009), deep venous thrombosis (0.4 vs 26.3% vs 7.7%, p = 0.005). The AM group had significantly higher rates of sICH (3.5% [controls] vs 21.1% [AM] vs 0.0% [HOM], p = 0.007), and mortality at 3 months (27.5% [controls] vs 61.5% [AM] vs 40.0% [HOM] vs, p = 0.032). The control and HOM groups had significantly better functional independence at 3 months (52.1% [controls] vs 15.4% [AM] vs 60.0% [HOM], p = 0.032).In the meta-analysis, the AM arm showed significantly higher mortality during hospitalization (n = 6, OR 95% CI = 3.03 [1.62, 5.64]), and at 3 months (n = 10, OR 95% CI = 4.33 [2.80, 6.68]), and significantly lower rates of 3 months functional independence (mRS = 0-2) (n = 10, OR 95% CI = 0.47 [0.32, 0.70]). No significant difference was found in sICH rates (n = 6, pooled OR 95% CI = 2.03 [0.83, 4.95]).

Discussion

Endovascular MT is technically successful and reasonably safe in treating AIS from LVO in active malignancy patients. However, the causes and implications of sICH require further investigation. Despite technical success, these patients experience poor clinical outcomes, and the long-term benefits of MT remain uncertain.

Ethical Considerations in Endovascular Thrombectomy for Stroke

INTRODUCTION

Stroke is a leading cause of morbidity and mortality globally. Endovascular mechanical thrombectomy is considered for patients with large vessel occlusion stroke presenting up to 24 hours from onset and is being increasingly utilized across diverse clinical contexts. Proactive consideration of distinctive ethical dimensions of endovascular thrombectomy (EVT) can enable stroke care teams to deliver goal-concordant care to appropriately selected patients with stroke but have been underexplored.

METHODS

A narrative review with case examples was conducted.

RESULTS

We explain and critically evaluate the application of foundational bioethical principles and narrative ethics to the practice of EVT, highlight key ethical issues that may emerge in neuroendovascular practice and develop an ethical framework to aid in the responsible use of EVT for people with large-vessel occlusive ischemic stroke.

CONCLUSIONS

EVT for stroke introduces important ethical considerations. Salient challenges include decision-making capacity and informed consent, the telos of EVT, uncertainty, access to care, and resource allocation. An ethical framework focusing on combining patient values and preferences with the best available evidence in the context of a multidisciplinary care team is essential to ensure that the benefits of EVT are responsibly achieved and sustained.

Informed consent practices for acute stroke therapy: principles, challenges and emerging opportunities

IMPORTANCE

Informed consent (IC) plays a crucial yet underexplored role in acute stroke treatment, particularly in the context of intravenous thrombolysis (IVT) and endovascular thrombectomy (EVT). This narrative review examines data on current IC practices in acute ischemic stroke management, specifically for patients treated with IVT or EVT, with the aim of identifying areas for improvement and strategies to enhance the IC process.

OBSERVATIONS

IC practices for IVT vary significantly among hospitals and physicians with the frequency of always requiring consent ranging from 21 to 37%. Factors influencing IC for IVT include patient decision-making capacity, standard of care, time sensitive nature of treatments, legal and moral obligations, risk of complications, physician age and speciality, treatment delays, and hospital size. Consent requirements tend to be stricter for patients presenting within the 3-4.5-h window. The content and style of information shared as part of the IC process revealed discrepancies in the disclosure of stroke diagnosis, IVT mechanism, benefits, and risks. Research on IC practices for EVT is scarce, highlighting a concerning gap in the available evidence base.

CONCLUSIONS AND RELEVANCE

This review underscores the significant variability and knowledge gaps in IC for EVT and IVT. Challenges related to decision-making capacity assessment and the absence of standardised guidance substantially contributes to these gaps. Future initiatives should focus on simplifying information delivery to patients, developing formal tools for assessing capacity, standardising ethical frameworks to guide physicians when patients lack capacity and harmonizing IC standards across sites. The ultimate goal is to enhance IC practices and uphold patient autonomy, while ensuring timely treatment initiation.

An Update on Palliative Care in Neurocritical Care: Providing Goal‑Concordant Care in the Face of Prognostic Uncertainty

Purpose of review

We investigate the complexities and interplay between the concepts of prognostic uncertainty and patient preferences as they relate to the delivery of goal-concordant care to patients with severe acute brain injuries (SABI) in the Neurological Intensive Care Unit (Neuro-ICU).

Recent findings

Patients with SABI in the Neuro-ICU have unique palliative care needs due to sudden, often unexpected changes in personhood and quality of life. A substantial amount of uncertainty is inherent and poses a challenge to both the patient's prognosis and treatment preferences. The delivery of goal-concordant care can be difficult to achieve.

Ethical Considerations in Clinical Trials for Disorders of Consciousness

As the clinical trial landscape for patients with disorders of consciousness (DoC) expands, consideration of associated ethical challenges and opportunities is of ever-increasing importance. Responsible conduct of research in the vulnerable population of persons with DoC, including those with coma, vegetative state/unresponsive wakefulness syndrome (VS/UWS), minimally conscious state (MCS), covert cortical processing (CCP), and cognitive motor dissociation (CMD), demands proactive deliberation of unique ethical issues that may arise and the adoption of robust protections to safeguard patients, surrogates, and other key stakeholders. Here we identify and critically evaluate four central categories of ethical considerations in clinical trials involving participants with DoC: (1) autonomy, respect for persons and informed consent of individuals with liminal consciousness; (2) balancing unknown benefits and risks, especially considering the epistemological gap between behavior and consciousness that complicates ordinary ascription of subjective states; (3) disclosure to surrogates and clinical teams of investigational results pertaining to consciousness; and (4) justice considerations, including equitable access to clinical trial enrollment across communities and geographies. We outline guiding principles and research opportunities for clinicians, neuroethicists, and researchers engaged in DoC clinical trials to advance ethical study design and deployment in this complex yet crucial area of investigation.