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Shlobin NA, Regenhardt RW, Young MJ. Ethical Considerations in Endovascular Thrombectomy for Stroke. World Neurosurg 2024; 185:126-134. [PMID: 38364896 DOI: 10.1016/j.wneu.2024.02.047] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/19/2024] [Revised: 02/07/2024] [Accepted: 02/08/2024] [Indexed: 02/18/2024]
Abstract
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.
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Affiliation(s)
- Nathan A Shlobin
- Department of Neurological Surgery, Northwestern University Feinberg School of Medicine, Chicago, Illinois, USA.
| | - Robert W Regenhardt
- Departments of Neurosurgery and Neurology, Neuroendovascular Service, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Michael J Young
- Department of Neurology, Center for Neurotechnology and Neurorecovery, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, USA
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Fargen KM, Kittel C, Curry BP, Hile CW, Wolfe SQ, Brown P, Mokin M, Rai AT, Chen M, Starke RM, Albuquerque FC, Ansari SA, Kan P, Spiotta AM, Dabus G, Leslie-Mazwi TM, Hirsch JA. Mechanical thrombectomy decision making and prognostication: Stroke treatment Assessments prior to Thrombectomy In Neurointervention (SATIN) study. J Neurointerv Surg 2023; 15:e381-e387. [PMID: 36609542 DOI: 10.1136/jnis-2022-019741] [Citation(s) in RCA: 10] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/15/2022] [Accepted: 12/28/2022] [Indexed: 01/09/2023]
Abstract
BACKGROUND Mechanical thrombectomy (MT) is the standard-of-care treatment for stroke patients with emergent large vessel occlusions. Despite this, little is known about physician decision making regarding MT and prognostic accuracy. METHODS A prospective multicenter cohort study of patients undergoing MT was performed at 11 comprehensive stroke centers. The attending neurointerventionalist completed a preprocedure survey prior to arterial access and identified key decision factors and the most likely radiographic and clinical outcome at 90 days. Post hoc review was subsequently performed to document hospital course and outcome. RESULTS 299 patients were enrolled. Good clinical outcome (modified Rankin Scale (mRS) score of 0-2) was obtained in 38% of patients. The most frequently identified factors influencing the decision to proceed with thrombectomy were site of occlusion (81%), National Institutes of Health Stroke Scale score (74%), and perfusion imaging mismatch (43%). Premorbid mRS score determination in the hyperacute setting accurately matched retrospectively collected data from the hospital admission in only 140 patients (46.8%). Physicians correctly predicted the patient's 90 day mRS tertile (0-2, 3-4, or 5-6) and final modified Thrombolysis in Ischemic Cerebral Infarction score preprocedure in only 44.2% and 44.3% of patients, respectively. Clinicians tended to overestimate the influence of occlusion site and perfusion imaging on outcomes, while underestimating the importance of pre-morbid mRS. CONCLUSIONS This is the first prospective study to evaluate neurointerventionalists' ability to accurately predict clinical outcome after MT. Overall, neurointerventionalists performed poorly in prognosticating patient 90 day outcomes, raising ethical questions regarding whether MT should be withheld in patients with emergent large vessel occlusions thought to have a poor prognosis.
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Affiliation(s)
- Kyle M Fargen
- Neurological Surgery and Radiology, Wake Forest University, Winston-Salem, North Carolina, USA
| | - Carol Kittel
- Division of Public Health Sciences, Wake Forest University, Winston-Salem, North Carolina, USA
| | - Brian P Curry
- Neurological Surgery, Walter Reed Army Medical Center, Bethesda, Maryland, USA
| | - Connor W Hile
- Neurological Surgery and Radiology, Wake Forest University, Winston-Salem, North Carolina, USA
| | - Stacey Q Wolfe
- Neurological Surgery and Radiology, Wake Forest University, Winston-Salem, North Carolina, USA
| | - Patrick Brown
- Neurological Surgery and Radiology, Wake Forest University, Winston-Salem, North Carolina, USA
| | - Maxim Mokin
- Neurosurgery, University of South Florida College of Medicine, Tampa, Florida, USA
| | - Ansaar T Rai
- Interventional Neuroradiology, West Virginia University Rockefeller Neuroscience Institute, Morgantown, West Virginia, USA
| | - Michael Chen
- Neurological Sciences, Rush University Medical Center, Chicago, Illinois, USA
| | - Robert M Starke
- Department of Neurosurgery and Radiology, University of Miami School of Medicine, Miami, Florida, USA
| | - Felipe C Albuquerque
- Department of Neurosurgery, Barrow Neurological Institute, Phoenix, Arizona, USA
| | - Sameer A Ansari
- Radiology, Northwestern University Feinberg School of Medicine, Chicago, Illinois, USA
| | - Peter Kan
- Neurosurgery, The University of Texas Medical Branch at Galveston, Galveston, Texas, USA
| | - Alejandro M Spiotta
- Neurosurgery, Medical University of South Carolina, Charleston, South Carolina, USA
| | - Guilherme Dabus
- Interventional Neuroradiology and Neuroendovascular Surgery, Miami Neuroscience Institute and Miami Cardiac and Vascular Institute-Baptist Hospital, Miami, Florida, USA
| | | | - Joshua A Hirsch
- NeuroEndovascular Program, Massachusetts General Hospital, Boston, Massachusetts, USA
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Levitt MR. Was it worth it? J Neurointerv Surg 2023; 15:731-732. [PMID: 37451828 DOI: 10.1136/jnis-2023-020752] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/26/2023] [Indexed: 07/18/2023]
Affiliation(s)
- Michael R Levitt
- Neurological Surgery, Radiology, Mechanical Engineering, and Stroke & Applied Neuroscience Center, University of Washington, Seattle, Washington, USA
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Bonatti M, Lombardo F, Valletta R, Comai A, Petralia B, Avesani G, Franchini E, Rossi A, De Santis N, Guerriero M, Ferro F. Myosteatosis as an independent predictor of short-term mortality in successfully reperfused acute ischemic stroke. Neuroradiol J 2023; 36:17-22. [PMID: 35506541 PMCID: PMC9893169 DOI: 10.1177/19714009221098370] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/05/2023] Open
Abstract
BACKGROUND AND PURPOSE Poor clinical outcomes are still common in successfully reperfused acute ischemic stroke patients. The aim of our study was to assess the impact of sarcopenia and myosteatosis on neurological outcomes and mortality in successfully reperfused acute ischemic stroke patients. MATERIALS AND METHODS We included in our retrospective observational study 166 consecutive patients who underwent technically successful mechanical thrombectomy for anterior circulation acute ischemic stroke between Jan 2016 and Dec 2019. ASPECTS and collateral score were assessed on pre-operative CT/CTA. Masseter muscles area and attenuation were measured on CTA images. Clinical and radiological variables were tested in multivariate logistic models to predict the probability of death and, among survivors, of incurring poor outcome. RESULTS At admission, mean NIHSS was 19 (SD = 6.5), mean body mass index 25.5 (SD = 4.4) kg/m2, and mean ASPECTS 8.0 (SD = 1.9). Of all, 48.2% patients showed good collaterals, 38.5% intermediate collaterals, and 13.3% poor collaterals. Overall, 90 days mRS was ≤2 in 48.2% of the patients, 3-5 in 30.7%, and 6 in 21.1%. At multivariate logistic regression, age (OR = 1.08, p = 0.036), ASPECTS (OR = 0.59, p = 0.013), and masseter muscles attenuation (OR = 0.93, p = 0.010) were independent predictors of mortality, whereas sex (OR = 7.15, p = 0.043), age (OR = 1.05, p = 0.042), body mass index (OR = 1.35, p = 0.013), NIHSS (OR = 1.12, p = 0.012), and ASPECTS (OR = 0.64, p = 0.024) were independent predictors of poor neurological outcome (mRS 3-5). CONCLUSION Beyond other well-known variables, low masseter attenuation, indicating myosteatosis, represents an independent negative prognostic factor for 90 days mortality in patients successfully reperfused after anterior circulation stroke.
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Affiliation(s)
- Matteo Bonatti
- Department of Radiology, Ospedale Centrale di
Bolzano, Bolzano, Italy
| | - Fabio Lombardo
- Department of Radiology, IRCCS Sacro Cuore-Don
Calabria, Negrar, Italy
| | - Riccardo Valletta
- Department of Radiology, Ospedale Centrale di
Bolzano, Bolzano, Italy
| | - Alessio Comai
- Department of Neuroradiology, Bolzano Central
Hospital, Bolzano, Italy
| | | | - Giacomo Avesani
- UOC Radiologia Diagnostica ed
Interventistica Generale, Dipartimento di Diagnostica per Immagini, Radioterapia
Oncologica ed Ematologia, Fondazione Policlinico Universitario
“A. Gemelli” IRCCS, Rome, Italy
| | - Enrica Franchini
- Department of Neurology, Bolzano Central
Hospital, Bolzano, Italy
| | - Andrea Rossi
- Department of Geriatrics,
Geriatrics, Healthy Aging Center Verona, Azienda Ospedaliera Universitaria
Integrata di Verona, Verona, Italy
| | | | - Massimo Guerriero
- Clinical Research Unit, IRCCS Sacro Cuore-Don
Calabria, Negrar, Italy
| | - Federica Ferro
- Department of Radiology, Ospedale Centrale di
Bolzano, Bolzano, Italy
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Blauenfeldt RA, Damgaard D, Simonsen CZ. Stressed systems: Stroke unit bed occupancy and impact on reperfusion therapy in acute ischemic stroke. Front Neurol 2023; 14:1147564. [PMID: 37064203 PMCID: PMC10100068 DOI: 10.3389/fneur.2023.1147564] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/18/2023] [Accepted: 03/09/2023] [Indexed: 04/18/2023] Open
Abstract
Objectives We observed a decrease in the number of patients who were offered reperfusion therapy. We aimed to investigate if whether hospital system pressure measured as the percentage of stroke bed occupancy influenced decisions on treatment and disposition. Design Data from a regional quality of stroke care database were obtained and linked to the organizational data monitoring of the hourly inpatient stroke bed occupancy rate. Logistic regression was used to analyze the relationship. Results A total of 15,025 admissions were included from 1 January 2019 to 24 August 2022. Of these, 5,659 (38%) had an acute ischemic stroke. The rates of reperfusion therapy treatment were the highest in 2019 (36.2%) and 2020 (34.1%) and declined afterward (30.0% in 2021). In the logistic regression analysis, an occupancy rate of ≥85% in the hour of the first admission was associated with reduced odds of admission at the stroke unit within 3 h from the symptom onset [adjusted odds ratio: 0.80, 95% confidence interval: (0.71-0.90), p < 0.001] and a reduced odds of receiving reperfusion therapy (adjusted odds ratio: 0.83 (0.73-0.95), p = 0.007). Conclusion An increased bed occupancy level in the hour of the first hospital admission for stroke patients was strongly associated with decreased odds of receiving reperfusion therapy.
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Affiliation(s)
- Rolf A. Blauenfeldt
- Department of Neurology, Aarhus University Hospital, Aarhus, Denmark
- Department of Clinical Medicine, Aarhus University, Aarhus, Denmark
- *Correspondence: Rolf A. Blauenfeldt
| | - Dorte Damgaard
- Department of Neurology, Aarhus University Hospital, Aarhus, Denmark
| | - Claus Z. Simonsen
- Department of Neurology, Aarhus University Hospital, Aarhus, Denmark
- Department of Clinical Medicine, Aarhus University, Aarhus, Denmark
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Abstract
ABSTRACT Over the past 30 years, researchers have found that childhood trauma and its subsequent stress have a strong and cumulative effect on health in adulthood. Trauma in childhood often leads to mental health problems, skeletal fractures, and early death from conditions such as heart disease, cancer, lung disease, and liver disease. Compounding the effects of traumatic stress, health care systems often create a population of "never-served" persons who avoid health care settings because they've been subject to judgment and marginalization. Trauma-informed care (TIC) is a skill underutilized by health care providers and organizations, yet nurse ethics and respect for human rights require us to care for all patients equally without judgment, including those living with the stress of complex trauma. The TIC approach respects human rights and supports nursing ethics, promoting a welcoming, inclusive environment in health care systems and patient-provider relationships that eschews implicit and explicit bias toward patients, regardless of presentation or personal circumstances. TIC foundational principles guide the application of the nursing process using patient-centered care to create safety, the first principle in TIC. Here, the authors discuss the application of these core principles in nursing through a deidentified case study.
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Affiliation(s)
- Elizabeth B Dowdell
- Elizabeth B. Dowdell is a professor and coordinator of undergraduate research at Villanova University, Villanova, PA. Patricia M. Speck is a professor and coordinator of advanced forensic nursing at the University of Alabama at Birmingham School of Nursing. Contact author: Elizabeth B. Dowdell, . This article was inspired in part by a policy dialogue presented at the 2018 American Academy of Nursing Transforming Health, Driving Policy Conference, entitled "Population Trauma: A Systems Approach to Trauma-Informed Care." The authors acknowledge Annie Lewis-O'Connor, PhD, MPH, RN, NP-BC, FAAN for her assistance in providing some of the clinical details in the case study. The authors and planners have disclosed no potential conflicts of interest, financial or otherwise. A podcast with the authors is available at www.ajnonline.com
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Young MJ, Regenhardt RW, Sokol LL, Leslie-Mazwi TM. When Should Neuroendovascular Care for Patients With Acute Stroke Be Palliative? AMA J Ethics 2021; 23:E783-793. [PMID: 34859772 PMCID: PMC8684539 DOI: 10.1001/amajethics.2021.783] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
Noncurative surgeries intended to relieve suffering during serious illness or near end of life have been analyzed across palliative settings. Yet sparse guidance is available to inform clinical management decisions about whether, when, and which interventions should be offered when ischemic stroke and other neurological complications occur in patients whose survival is extended by other novel disease-modifying interventions. This case commentary examines key ethical and clinical considerations in palliative neuroendovascular care of patients with acute stroke.
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Affiliation(s)
- Michael J Young
- Fellow in neurology at Massachusetts General Hospital and Brigham and Women's Hospital in Boston
| | - Robert W Regenhardt
- Neuroendovascular fellow and stroke scientist at Massachusetts General Hospital in Boston
| | - Leonard L Sokol
- Neurology resident physician at Northwestern University in Evanston, Illinois
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Bhat A, Mahajan V, Wolfe N. Implicit bias in stroke care: A recurring old problem in the rising incidence of young stroke. J Clin Neurosci 2021; 85:27-35. [PMID: 33581786 DOI: 10.1016/j.jocn.2020.12.017] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/12/2020] [Revised: 12/02/2020] [Accepted: 12/12/2020] [Indexed: 10/22/2022]
Abstract
Stroke is a leading cause of morbidity and mortality worldwide. Although the majority of strokes affect the elderly, the incidence of stroke in young patients is on the rise. Prompt recognition of stroke symptoms and time critical therapies play a key role in management and prognosis of this condition. This is especially critical in young stroke patients, for whom delays in early recognition and treatment can result in many years of disability with associated social and financial burden. Misdiagnosis and unwarranted variation in treatment of stroke in young patients is problematic. Clinician implicit bias, the unconscious and unintentional process of judgement in healthcare decision-making, is a contributor to the short-falls in outcomes in this population. Interventions in this process have been shown to improve clinical outcomes in young stroke patients and represent an active area of study.
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Affiliation(s)
- Aditya Bhat
- Department of Cardiology, Blacktown Hospital, Sydney, NSW 2148, Australia; School of Public Health and Community Medicine, University of New South Wales, Sydney, NSW 2052, Australia.
| | - Vipul Mahajan
- Department of Cardiology, Blacktown Hospital, Sydney, NSW 2148, Australia
| | - Nigel Wolfe
- Department of Neurology, Blacktown Hospital, Sydney, NSW 2148, Australia
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