Ethical Issues in Vascular Neurology

2018 ◽  
Vol 38 (05) ◽  
pp. 515-521 ◽  
Author(s):  
Natalie Wheeler ◽  
Sadhana Murali ◽  
Justin Sattin
Keyword(s):  
Ischemic Stroke ◽  
Cerebrovascular Disease ◽  
Ethical Issues ◽  
Ethical Aspects ◽  
Early Complications ◽  
Stroke Treatment ◽  
Ethical Concerns ◽  
Acute Stroke Treatment ◽  
Capacity For Consent

AbstractThere are ethical aspects to each of the three phases of cerebrovascular disease: hyperacute management, acute prognostication and management of early complications, and long-term recovery and reintegration with the community. This article addresses ethical concerns pertinent to each phase. First, we discuss ethical issues regarding consent for thrombolysis and endovascular treatment for acute ischemic stroke, including a review of considerations regarding the provision of acute stroke treatment advice over the telephone. Next, we discuss capacity for consent and prognostication after ischemic stroke and intracranial hemorrhage, with a focus on the problems of the self-fulfilling prophecy. Finally, we discuss residual disability and patients' return to driving. Consideration of these ethical dimensions of cerebrovascular disease will assist neurologists in caring for patients and families suffering from this complex condition.

scholarly journals Mesenchymal Stem Cell Derived Extracellular Vesicles for Repairing the Neurovascular Unit after Ischemic Stroke

Cells ◽  
2021 ◽  
Vol 10 (4) ◽  
pp. 767
Author(s):  
Courtney Davis ◽  
Sean I. Savitz ◽  
Nikunj Satani
Keyword(s):  
Ischemic Stroke ◽  
Extracellular Vesicles ◽  
Neurovascular Unit ◽  
Culture Conditions ◽  
Therapeutic Effects ◽  
Stroke Treatment ◽  
Inflammatory Molecules ◽  
The Brain

Ischemic stroke is a debilitating disease and one of the leading causes of long-term disability. During the early phase after ischemic stroke, the blood-brain barrier (BBB) exhibits increased permeability and disruption, leading to an influx of immune cells and inflammatory molecules that exacerbate the damage to the brain tissue. Mesenchymal stem cells have been investigated as a promising therapy to improve the recovery after ischemic stroke. The therapeutic effects imparted by MSCs are mostly paracrine. Recently, the role of extracellular vesicles released by these MSCs have been studied as possible carriers of information to the brain. This review focuses on the potential of MSC derived EVs to repair the components of the neurovascular unit (NVU) controlling the BBB, in order to promote overall recovery from stroke. Here, we review the techniques for increasing the effectiveness of MSC-based therapeutics, such as improved homing capabilities, bioengineering protein expression, modified culture conditions, and customizing the contents of EVs. Combining multiple techniques targeting NVU repair may provide the basis for improved future stroke treatment paradigms.

scholarly journals Impacts of treatments on recurrence and 28-year survival of ischemic stroke patients

2021 ◽  
Vol 11 (1) ◽  
Author(s):  
Ting-Ann Wang ◽  
Tzy-Haw Wu ◽  
Shin-Liang Pan ◽  
Hsiu-Hsi Chen ◽  
Sherry Yueh-Hsia Chiu
Keyword(s):  
Ischemic Stroke ◽  
Cerebrovascular Disease ◽  
Cox Regression ◽  
Controlled Trial ◽  
Stroke Recurrence ◽  
Long Term Effects ◽  
Stroke Patients ◽  
Double Blind ◽  
Term Survival

AbstractAspirin and nicametate are well-established therapies for preventing recurrence and mortality from stroke in patients diagnosed as ischemic stroke. However, their respective effects on the recurrence, making allowance for the duration of recurrence and death without the occurrence of recurrence, and long-term survival have not been well elucidated. We aimed to evaluate long-term effect of two kinds of treatment on cerebrovascular death among ischemic stroke patients with or without the recurrence of stroke. Data used in this study were derived from the cohort based on a multicenter randomized double-blind controlled trial during 1992 to 1995 with the enrollment of a total of 466 patients with first-time non-cardioembolic ischemic stroke who were randomly allocated to receive aspirin (n = 222) or nicametate (n = 244). The trial cohort was followed up over time to ascertain the date of recurrence within trial period and death until Sep of 2019. The time-dependent Cox regression model was used to estimate the long-term effects of two treatments on death from cerebrovascular disease with and without recurrence. A total of 49 patients experienced stroke recurrence and 89 cerebrovascular deaths was confirmed. Patients treated with nicametate were more likely, but non statistically significantly, to have recurrence (aHR: 1.73, 95% CI 0.96–3.13) as compared with those treated by aspirin. Nicametate reduced the risk of cerebrovascular death about 37% (aHR: 0.63, 95% CI 0.41–0.97) compared with aspirin. The aspirin group had a lower recurrence rate than the nicametate group even with recurrence after 1–2 years of follow-up of first stroke but the latter had significantly reduced death from cerebrovascular disease for nicametate group, which requires more research to verify.

Commentary: The Broader Context of Long-Term Care Ethics

2016 ◽  
Vol 25 (3) ◽  
pp. 554-556
Author(s):  
Jason Lesandrini ◽  
Carol O’Connell
Keyword(s):  
Care Setting ◽  
Long Term Care ◽  
Ethical Issues ◽  
Term Care ◽  
Ethical Concerns ◽  
Healthcare Settings ◽  
Care Facilities ◽  
Ethics Program ◽  
Made In

Ethical issues in long-term care settings, although having received attention in the literature, have not in our opinion received the appropriate level they require. Thus, we applaud the Cambridge Quarterly for publishing this case. We can attest to the significance of ethical issues arising in long-term care facilities, as Mr. Hope’s case is all too familiar to those practicing in these settings. What is unique about this case is that an actual ethics consult was made in a long-term care setting. We have seen very little in the published literature on the use of ethics structures in long-term care populations. Our experience is that these healthcare settings are ripe for ethical concerns and that providers, patients, families, and staff need/desire ethics resources to actively and preventively address ethical concerns. The popular press has begun to recognize the ethical issues involved in long-term care settings and the need for ethics structures. Recently, in California a nurse refused to initiate CPR for an elderly patient in a senior residence. In that case, the nurse was quoted as saying that the facility had a policy that nurses were not to start CPR for elderly patients.1 Although this case is not exactly the same as that of Mr. Hope, it highlights the need for developing robust ethics program infrastructures in long-term care settings that work toward addressing ethical issues through policy, education, and active consultation.

Abstract P201: Octogenarian and Nonagenarian Outcomes Among Acute Ischemic Stroke Patients

Stroke ◽  
2021 ◽  
Vol 52 (Suppl_1) ◽  
Author(s):  
RAJAN R GADHIA ◽  
Farhaan S Vahidy ◽  
Tariq Nisar ◽  
Destiny Hooper ◽  
David Chiu ◽  
...  
Keyword(s):  
Ischemic Stroke ◽  
Acute Stroke ◽  
Acute Ischemic Stroke ◽  
Combined Treatment ◽  
Stroke Patients ◽  
Stroke Treatment ◽  
Intravenous Tissue Plasminogen Activator ◽  
Significant Difference ◽  
Acute Stroke Treatment ◽  
Iv Tpa

Objective: Most acute stroke treatment trials exclude patients above the age of 80. Given the clear benefit of revascularization with intravenous tissue plasminogen activator (IV tPA) and mechanical thrombectomy (MT), we sought to assess functional outcomes in patients treated above the age of 80. Methods: We conducted a review of all patients admitted to Houston Methodist Hospital between January 2019 and August 2020 with an acute ischemic stroke (AIS) presentation[MOU1] for whom premorbid, discharge, and 90 day modified Rankin Scale scores were available. Patients were categorized by acute stroke treatment (IV tPA, MT, both or none[MOU2] ). mRS values were assessed during admission prior to discharge and at 90 days post stroke event. A delta mRS (Discharge vs. 90-day [MOU3] ) was defined and grouped as no change, improved, or worsened to assess overall functional disability in regards to the index stroke presentation. Results: A total of 865 patients with AIS presentation were included, of whom 651 (75.3%) were <80 years and 214 (24.7%) were > 80 years of age at presentation. A total of 208 patients received IV tPA, 176 underwent revascularization with MT only, 71 had both treatments, and 552 had no acute intervention. In patients >80 yrs who had no acute stroke intervention. mRS improvement was noted in 71.4% compared to 54.1% observed in those patients <80 years. Among patients who received IV tPA, 81.5% of > 80 years improved vs. 61.6% in the younger cohort. A similar trend was noted in the MT and combined treatment groups (76.2% vs. 71.2% and 78.6% vs. 79.3%, respectively). Conclusion: Based on our cohort of acute stroke patients, there was no significant difference in outcomes (as measured by delta mRS) for octogenarians and nonagenarians when compared to younger patients. There was a trend towards improvement in the elderly patients. Chronological age by itself may be an insufficient predictor of functional outcome among stroke patients and age cutoffs for enrollment of patients in acute stroke trials may need additional considerations.

Abstract TP230: Prehospital Timeline of Mobile Stroke Treatment Unit and Traditional Ambulance

Stroke ◽  
2017 ◽  
Vol 48 (suppl_1) ◽  
Author(s):  
Jason Mathew ◽  
Andrew Blake Buletko ◽  
Ather Taqui ◽  
Andrew Reimer ◽  
Stacey Winners ◽  
...  
Keyword(s):  
Ischemic Stroke ◽  
Final Diagnosis ◽  
Stroke Patients ◽  
Treatment Unit ◽  
Hospital System ◽  
Hospital Arrival ◽  
Stroke Treatment ◽  
Early Evaluation ◽  
Acute Stroke Treatment ◽  
The Times

Introduction: Prehospital evaluation and response is vital to effective and early delivery of acute stroke treatment. We aimed to compare the times across various prehospital times among stroke patients arriving by municipal EMS and MSTU. Methods: We performed a retrospective study of 107 patients with a final diagnosis of ischemic stroke within our hospital system from June 2014 to July 2015. We compared on scene arrival, hospital arrival, and time of physician assessment of patients evaluated on MSTU to traditional municipal EMS. Times are reported as medians and groups were compared by Rank-Sum Test. Results: Of 107 patients, 49 patients were evaluated by traditional EMS and 58 evaluated by MSTU. Time from dispatch to scene arrival was median 9 min (IQR 5.5 - 12min) in EMS group and median 12 min (IQR 8-16 min) n MSTU (p&lt0.01). Time on scene was 17 min (IQR 14 - 24min) in EMS group and median 42 min (IQR 36-48 min) in MSTU. There was no difference within the MSTU group in time on-scene among those treated with IV tpA (43 min) and those without (41 min, p=.08 ). After dispatch, patients arrived in hospital by EMS earlier (median 40 min, IQR 33-49min) than by MSTU (median 72 min, IQR 58-81min, p&lt.01), but patients on MSTU were evaluated by a physician at median 28 (IQR 21.5-34.5) min after dispatch. Conclusion: Early evaluation of ischemic stroke patients with MSTU, doubles the time on scene compared to municipal EMS.

Can the Use of Oral Minocycline Improve Ischemic Stroke Outcomes?

2008 ◽  
Vol 21 (2) ◽  
pp. 159-164
Author(s):  
Kathy B. Lee
Keyword(s):  
United States ◽  
Ischemic Stroke ◽  
The United States ◽  
Sudden Onset ◽  
Pharmacological Agents ◽  
Stroke Outcomes ◽  
Stroke Treatment ◽  
The Brain ◽  
Brain Ischemic Stroke

Cerebrovascular accident (CVA), also known as ischemic stroke, is the sudden onset of neurologic deficit attributable to a focal vascular cause.1 It is the third leading cause of death, with the death rate being reported as 50.0 (per 100,000 population) in the United States in 2004.2 It is also a leading cause for serious, long-term disability in the United States. While there are various causes, the large majority of strokes result from either global or focal ischemia of the brain. Ischemic stroke accounts for 87% of all strokes, while intracerebral and subarachnoid hemorrhage makes up the remainder. 2 Currently, the primary pharmacological agents used in stroke treatment are thrombolytics, not without limitations, however, and antiplatelet therapy. 3 Minocycline, a semisynthetic tetracycline antibiotic, has recently gained attention as a neuroprotective agent. A recent study evaluated the use of minocycline in the treatment of acute stroke and demonstrated promising results.4 A review of the mechanisms of action and data presented in past studies will be examined to evaluate the efficacy and clinical impact of minocycline in the treatment of acute ischemic stroke.

The ‘anthropologization’ of archaeological heritage

2009 ◽  
Vol 16 (2) ◽  
pp. 209-225 ◽  
Author(s):  
Jan Kolen
Keyword(s):  
Ethical Issues ◽  
Archaeological Research ◽  
Archaeological Heritage ◽  
Ethical Concerns ◽  
Archaeological Practice ◽  
The Past ◽  
Practice Method ◽  
High Degree ◽  
Transmission Of Values

AbstractWith the growing impact of postprocessual orientations, archaeologists have become increasingly aware that the production of values resides in all aspects of archaeological research. This awareness has also paved the way for a more encompassing concept of archaeological heritage, which of course not only includes the management of material traces but also the transmission of values through archaeological practice, method and theory. Many archaeologists and heritage managers now propagate the belief that reflecting on value production will better equip archaeology for ethical concerns or that it will improve its engagement with society, and that adopting anthropological perspectives and key notions may help to achieve this goal. This contribution explores the opposite proposition: that an anthropologically informed reflexive attitude is important to understand present-day heritage practices, but in most cases it is desirable for archaeologists to tell stories about the past, not about themselves, in order to be really engaged with public and ethical issues. Arguments for this proposition can be derived from the discipline's specific articulation of discovery, difference and time depth (including the ‘long term’), which traditionally shape archaeological research and narrative to a high degree, not only within academic discourse but also in a wider social setting.

scholarly journals Joinville stroke biobank: study protocol and first year’s results

2017 ◽  
Vol 75 (12) ◽  
pp. 881-889 ◽  
Author(s):  
Leslie Ecker Ferreira ◽  
Paulo Henrique Condeixa de França ◽  
Vivian Nagel ◽  
Vanessa Venancio ◽  
Juliana Safanelli ◽  
...  
Keyword(s):  
Risk Factors ◽  
Ischemic Stroke ◽  
Acute Stroke ◽  
Latin American ◽  
Classification System ◽  
National Institutes Of Health ◽  
Brain Images ◽  
Stroke Treatment ◽  
Stroke Registry ◽  
Acute Stroke Treatment

ABSTRACT Aiming to contribute to studies that use detailed clinical and genomic information of biobanks, we present the initial results of the first Latin American Stroke Biobank. Methods: Blood samples were collected from patients included in the Joinville Stroke Registry and four Brazilian cities. Demographic socio-economic data, cardiovascular risk factors, Causative Classification System for Ischemic Stroke, Trial of Org 10172 in Acute Stroke Treatment and National Institutes of Health scores, functional stroke status (modified Rankin) and brain images were recorded. Additionally, controls from both geographic regions were recruited. High-molecular-weight genomic DNA was obtained from all participants. Results: A total of 2,688 patients and 3,282 controls were included. Among the patients, 76% had ischemic stroke, 12% transient ischemic attacks, 9% hemorrhagic stroke and 3% subarachnoid hemorrhage. Patients with undetermined ischemic stroke were most common according the Trial of Org 10172 in Acute Stroke Treatment (40%) and Causative Classification System for Ischemic Stroke (47%) criteria. A quarter of the patients were under 55 years of age at the first-ever episode. Conclusions: We established the Joinville Stroke Biobank and discuss its potential for contributing to the understanding of the risk factors leading to stroke.

scholarly journals Neuroprotection from Stem Cell-Derived Human Adipose Extracellular Vesicles Intranasally Administered 24 Hours After Stroke in Rats. 

2021 ◽  
Author(s):  
Francieli Rohden ◽  
Luciele Varaschini Teixeira ◽  
Luis Pedro Bernardi ◽  
Pâmela Lukasewicz ◽  
Mariana Colombo ◽  
...  
Keyword(s):  
Ischemic Stroke ◽  
Extracellular Vesicles ◽  
Infarct Volume ◽  
Human Adipose Tissue ◽  
Long Term Memory ◽  
Infarct Core ◽  
Infarct Zone ◽  
Stroke Treatment ◽  
Administration Routes

Abstract Ischemic stroke is a major cause of death and disability, demanding innovative and accessible therapeutic strategies. Approaches presenting an optimal period for therapeutic intervention and new treatment administration routes are promising tools for stroke treatment. We evaluated the potential neuroprotective properties of nasally administered human adipose tissue stem cells (hAT-MSCs)-derived extracellular vesicles (EVs) obtained from healthy individuals who underwent liposuction. A single intranasal EV (200 µg/kg) was administered 24 h after a focal permanent ischemic stroke in rats. A higher tropism of EVs was observed in the peri-infarct zone surrounding the infarct core. In the same brain region, there was a significant decrease in the infarct volume, improvement of the blood-brain barrier, and re-stabilization of vascularization. In addition, EVs recovered the impairment of long-term motor and behavioral performance induced by an ischemic stroke. Surprisingly, one single intranasal EVs administration reestablished: i) front paws symmetry, ii) short- and long-term memory, and iii) anxiety-like behavior. In line with the findings, our work highlights hAT-MSC-derived EVs as a promising therapeutic strategy for stroke.

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