scholarly journals Case Report: Case report: Administration of anticoagulant therapy after neuro-anesthesia procedure for hemorrhagic stroke patients with COVID-19 complications and its ethical and medicolegal consideration

F1000Research ◽  
2021 ◽  
Vol 10 ◽  
pp. 1303
Author(s):  
Taufik Suryadi ◽  
Kulsum Kulsum
Keyword(s):  
Case Report ◽  
Intracerebral Hemorrhage ◽  
Hemorrhagic Stroke ◽  
Clinical Medicine ◽  
Ethical Dilemmas ◽  
Prima Facie ◽  
Ethical Principles ◽  
Recurrent Bleeding ◽  
Stroke Patients ◽  
Double Effect Principle

Background: Ethical dilemmas can occur in any situation in clinical medicine. In patients undergoing neuro-anesthesia for surgical procedure evacuation of intracerebral hemorrhage with a history of hemorrhagic stroke, anticoagulants should not be given because they can cause recurrent bleeding. Meanwhile, at the same time, the patient could also be infected with coronavirus disease 2019 (COVID-19), one of treatment is the administration of anticoagulants. Methods: A case report. A 46-year-old male patient was admitted to hospital with a loss of consciousness and was diagnosed with intracerebral hemorrhage due to a hemorrhagic stroke and was confirmed positive for COVID-19. Giving anticoagulants to patients is considered counterproductive so, an ethical dilemma arises. For this reason, a joint conference was held to obtain the best ethical and medicolegal solutions for the patient. Results: By using several methods of resolving ethical dilemmas such as basic ethical principles, supporting ethical principles, and medicolegal considerations, it was decided that the patient was not to be given anticoagulants. Conclusions: Giving anticoagulants to hemorrhagic stroke patients is dangerous even though it is beneficial for COVID-19 patients, so here the principle of risk-benefit balance is applied to patients who prioritize risk prevention rather than providing benefits. This is also supported by the prima facie principle by prioritizing the principle of non-maleficence rather than beneficence, the minus malum principle by seeking the lowest risk, and the double effect principle by making the best decision even in a slightly less favorable way as well as the medicolegal aspect by assessing patient safety and risk management.

Ethics of Incongruity: moral tension generators in clinical medicine

2019 ◽  
Vol 45 (4) ◽  
pp. 244-248 ◽  
Author(s):  
Nicholas Kontos
Keyword(s):  
Medical Ethics ◽  
Moral Philosophy ◽  
Ethical Dilemma ◽  
Clinical Medicine ◽  
Ethical Dilemmas ◽  
Ethical Principles ◽  
Right Action ◽  
Patients Experience

Affectively uncomfortable concern, anxiety, indecisionand disputation over ‘right’ action are among the expressions of moral tension associated with ethical dilemmas. Moral tension is generated and experienced by people. While ethical principles, rules and situations must be worked through in any dilemma, each occurs against a backdrop of people who enact them and stand much to gain or lose depending on how they are applied and resolved. This paper attempts to develop a taxonomy of moral tension based on its intrapersonal and interpersonal sources and expressions. The proposed ‘ethics of incongruity’ (EoI) outlines ways in which values, actions and needs can find themselves mismatched in morally relevant ways between patients and their clinicians, their own psychologies and their societies. Patient–clinician incongruities may manifest as discord, value misalignment and deception. Patient–patient (ie, intrapersonal) incongruities may manifest as incapacity, akrasia and self-deception. Patient–society incongruities may manifest as disenfranchisement, disaffiliation and disregard. Brief explanations of the incongruities in this scheme are provided, as are suggestions on working within them. Using concepts from moral philosophy when applicable, these suggestions may either ease direct resolution of problems arising from the incongruities, or make sense of the moral tension that arises from the human context of the ethical dilemma at hand. This presentation of content and resolution methods for the EOI is no doubt incomplete. Hopefully, refinement of this preliminary proposal will follow, particularly from clinicians, as the ones who, along with their patients, experience medical ethics in directly tension-inducing ways.

scholarly journals Resolution of Ethical Dilemmas Using Basic Ethical Principles in Cases of Pregnancy with Severe Symptoms of Coronavirus Disease 2019 Complications

2021 ◽  
Vol 9 (C) ◽  
pp. 267-272
Author(s):  
Taufik Suryadi ◽  
Sarjani Sarjani ◽  
Kulsum Kulsum
Keyword(s):  
Case Report ◽  
Pregnant Women ◽  
Ethical Dilemma ◽  
The Elderly ◽  
Double Effect ◽  
Prima Facie ◽  
Termination Of Pregnancy ◽  
Ethical Principles ◽  
Ethical Considerations ◽  
Pediatric Pulmonology

BACKGROUND: Coronavirus disease 2019 (COVID-19) can attack the entire population, but is more aggressive in vulnerable populations such as the elderly, patients with chronic diseases, and pregnant women. For pregnant women, the management of COVID-19 treatment provided must be in line with efforts to reduce maternal mortality. The method of this study was a case report. A pregnant woman aged 40 years who was confirmed with severe COVID-19 symptoms. This patient had severe symptomatic hypoxemia and had a hypercoagulable state. Termination of pregnancy in patients is considered for the sake of fetomaternal safety so that an ethical dilemma arises. For this reason, a joint conference was held to get the best solution for the patient and the fetus. CASE REPORT: Using several basic ethical principles such as beneficence, nonmaleficence, justice, and autonomy, which are supported by the principles of minus malum, double effect, and prima facie, it was decided for the patient to terminate pregnancy to reduce severe symptoms of COVID-19. Termination of pregnancy in pregnant women with confirmed COVID-19 with severe symptoms is still an ethical dilemma that needs to be discussed further. Therefore, ethical considerations in this patient were carried out by reviewing obstetric, pediatric, pulmonology, anesthesia, and internal medicine indications. CONCLUSION: Termination of pregnancy in this patient with confirmed COVID-19 with severe symptoms can be done. Although termination of pregnancy has not completely saved the mother’s condition, this decision has the potential to provide benefits and safety for the patient and the fetus.

scholarly journals Dynamic Process of Secondary Pulmonary Infection in Mice With Intracerebral Hemorrhage

2021 ◽  
Vol 12 ◽  
Author(s):  
Hanyu Zhang ◽  
Yingying Huang ◽  
Xiaojin Li ◽  
Xu Han ◽  
Jing Hu ◽  
...  
Keyword(s):  
Immune System ◽  
Intracerebral Hemorrhage ◽  
Dynamic Process ◽  
Barrier Function ◽  
Hemorrhagic Stroke ◽  
Pulmonary Infection ◽  
Intestinal Barrier ◽  
Intestinal Barrier Function ◽  
Immune Disorders ◽  
Stroke Patients

Stroke is a common central nervous system disease in clinical practice. Stroke patients often have infectious complications, such as pneumonia and infections of the urinary tract and gastrointestinal tract. Although it has been shown that translocation of the host gut microbiota to the lungs and immune dysfunction plays a vital role in the development of infection after ischemic stroke, the occurrence and mechanism of pulmonary infection at different time points after hemorrhagic cerebral remain unclear. In this study, the changes in the immune system and intestinal barrier function in mice during disease development were investigated at 1 day (M 1 d), 3 days (M 3 d) and 7 days (M 7 d) following hemorrhagic stroke to clarify the mechanism of secondary pulmonary infection. The experimental results revealed that after hemorrhagic stroke, model mice showed increased brain damage from day 1 to 3, followed by a trend of brain recovery from day 3 to 7 . After hemorrhagic stroke, the immune system was disturbed in model mice. Significant immunosuppression of the peripheral immune system was observed in the M 3 d group but improved in the M 7 d group. Staining of lung tissues with hematoxylin and eosin (H&E) and for inflammatory factors revealed considerable disease and immune disorders in the M 7 d group. Stroke seriously impaired intestinal barrier function in mice and significantly changed the small intestine structure. From 1 to 7 d after stroke, intestinal permeability was increased, whereas the levels of markers for intestinal tight junctions, mucus and immunoglobulin A were decreased. Analysis based on 16S rRNA suggested that the microflora in the lung and ileum was significantly altered after stroke. The composition of microflora in lung and ileum tissue was similar in the M 7d group, suggesting that intestinal bacteria had migrated to lung tissue and caused lung infection at this time point after hemorrhagic stroke. In stroke mice, the aggravation of intestinal barrier dysfunction and immune disorders after intracerebral hemorrhage, promoted the migration of enteric bacteria, and increased the risk of pneumonia poststroke. Our findings reveal the dynamic process of infection after hemorrhagic stroke and provide clues for the optimal timing of intervention for secondary pulmonary infection in stroke patients.

Diagnosis of cerebral hemorrhage before the era of computed tomography

2013 ◽  
Vol 154 (44) ◽  
pp. 1743-1746
Author(s):  
Gergely Hofgárt ◽  
Rita Szepesi ◽  
Bertalan Vámosi ◽  
László Csiba
Keyword(s):  
Computed Tomography ◽  
Cerebrospinal Fluid ◽  
Positive Predictive Value ◽  
Predictive Value ◽  
Hemorrhagic Stroke ◽  
Cranial Computed Tomography ◽  
Cerebral Stroke ◽  
Daily Routine ◽  
Stroke Patients ◽  
The Difference

Introduction: During the past decades there has been a great progress in neuroimaging methods. Cranial computed tomography is part of the daily routine now and its use allows a fast diagnosis of parenchymal hemorrhage. However, before the availability of computed tomography the differentiation between ischemic and hemorrhagic stroke was based on patient history, physical examination, percutan angiography and cerebrospinal fluid sampling, and the clinical utility could be evaluated by autopsy of deceased patients. Aim: The authors explored the diagnostic performance of cerebrospinal fluid examination for the diagnosis of ischemic and hemorrhagic stroke. Method: Data of 200 deceased stroke patients were retrospectively evaluated. All patients had liquor sampling at admission and all of them had brain autopsy. Results: Bloody or yellowish cerebrospinal fluid at admission had a positive predictive value of 87.5% for hemorrhagic stroke confirmed by autopsy, while clear cerebrospinal fluid had positive predictive value of 90.7% for ischemic stroke. Patients who had clear liquor, but autopsy revealed hemorrhagic stroke had higher protein level in the cerebrospinal fluid, but the difference was not statistically significant (p = 0.09). Conclusions: The results confirm the importance of pathological evaluation of the brain in cases deceased from cerebral stroke. With this article the authors wanted to salute for those who contributed to the development of the Hungarian neuropathology. In this year we remember the 110th anniversary of the birth, and the 60th anniversary of the death of professor Kálmán Sántha. Professor László Molnár would be 90 years old in 2013. Orv. Hetil., 154 (44), 1743–1746.

KUALITAS HIDUP PASIEN STROKE DI POLIKLINIK RAWAT JALAN RUMAH SAKIT SWASTA YOGYAKARTA

2019 ◽  
Vol 7 (3) ◽  
pp. 232-237
Author(s):  
Hana Larasati ◽  
Theresia Titin Marlina
Keyword(s):  
Quality Of Life ◽  
Social Relations ◽  
Hemorrhagic Stroke ◽  
Poor Quality ◽  
Social Dimension ◽  
Stroke Patients ◽  
Sampling System ◽  
Post Stroke ◽  
Psychological Dimension

Background: stroke is a disorder of nervous system function that occurs suddenly and is caused by brain bleeding disorders that can affect the quality of life physical dimensions, social dimensions, psychological dimensions, environmental dimensions. Based on the result of Lumbu study (2015) the number of samples were 71 people collected data using the (WHOQOL-BREF). There were 56 people (78,9%) had the poor quality of life of post stroke. The mean of post-stroke quality of life domain was physical domain (45,27%), psychological domain (49,87%), social relations domain (48,15%) and environmental domain (50.01%). Objective: the purpose of the study was know the quality of life of the stroke patients in Outpatient Polyclinic of Private Hospital in Yogyakarta. Methods: used descriptive quantitative by using questionnaire test of purposive sampling system based on patients who have been affected of ischemic or hemorrhagic stroke before, number 30 respondents. Result: quality of life of stroke patient of medium physical dimension (67%), psychological dimension (71%), social dimension (67%), dimension good environment (63%). Conclusion: the quality of life of stroke patients of physical dimension, psychological dimension, and moderate social dimension, while the quality of life of stroke patients were good environmental dimension.   Keywords: Hemorrhagic stroke, ischemic stroke, quality of life

scholarly journals Adrenomedullin Is a Diagnostic and Prognostic Biomarker for Acute Intracerebral Hemorrhage

2021 ◽  
Vol 43 (1) ◽  
pp. 324-334
Author(s):  
Francisco J. Julián-Villaverde ◽  
Laura Ochoa-Callejero ◽  
Eva Siles ◽  
Esther Martínez-Lara ◽  
Alfredo Martínez
Keyword(s):  
Hemorrhagic Stroke ◽  
Prognostic Biomarker ◽  
Characteristic Curve ◽  
Area Under The Curve ◽  
Nitroso Compounds ◽  
Healthy Controls ◽  
Stroke Patients ◽  
Important Health ◽  
Acute Intracerebral Hemorrhage ◽  
Changes Over Time

Hemorrhagic stroke remains an important health challenge. Adrenomedullin (AM) is a vasoactive peptide with an important role in cardiovascular diseases, including stroke. Serum AM and nitrate–nitrite and S-nitroso compounds (NOx) levels were measured and compared between healthy volunteers (n = 50) and acute hemorrhagic stroke patients (n = 64). Blood samples were taken at admission (d0), 24 h later (d1), and after 7 days or at the time of hospital discharge (d7). Neurological severity (NIHSS) and functional prognosis (mRankin) were measured as clinical outcomes. AM levels were higher in stroke patients at all times when compared with healthy controls (p < 0.0001). A receiving operating characteristic curve analysis identified that AM levels at admission > 69.0 pg/mL had a great value as a diagnostic biomarker (area under the curve = 0.89, sensitivity = 80.0%, specificity = 100%). Furthermore, patients with a favorable outcome (NIHSS ≤ 3; mRankin ≤ 2) experienced an increase in AM levels from d0 to d1, and a decrease from d1 to d7, whereas patients with unfavorable outcome had no significant changes over time. NOx levels were lower in patients at d0 (p = 0.04) and d1 (p < 0.001) than in healthy controls. In conclusion, AM levels may constitute a new diagnostic and prognostic biomarker for this disease, and identify AM as a positive mediator for hemorrhagic stroke resolution.

scholarly journals Effect of COPD on the Hospital Outcomes and Mortality among Hemorrhagic Stroke Patients. Sex Differences in a Population-Based Study

2021 ◽  
Vol 10 (11) ◽  
pp. 2491
Author(s):  
Javier de Miguel-Diez ◽  
Marta Lopez-Herranz ◽  
Rodrigo Jiménez-García ◽  
Valentín Hernández-Barrera ◽  
Isabel Jimenez-Trujillo ◽  
...  
Keyword(s):  
Sex Differences ◽  
Decompressive Craniectomy ◽  
Hemorrhagic Stroke ◽  
Population Based ◽  
Stroke Patients ◽  
National Hospital ◽  
Population Based Study ◽  
Factors Associated ◽  
Adjusted Incidence ◽  
Discharge Database

(1) Background: It is not well known whether there is an association between COPD and hemorrhagic stroke (HS). We aim to analyze the incidence, clinical characteristics, procedures, and outcomes of HS in patients with and without COPD and to assess sex differences. Secondly, to identify factors associated with in-hospital mortality (IHM). (2) Methods: Patients aged ≥40 years hospitalized with HS included in the Spanish National Hospital Discharge Database (2016–2018) were analyzed. Propensity score matching (PSM) was used to compare patients according to sex and COPD status. (3) Results: We included 55,615 patients (44.29% women). Among men with COPD the HS adjusted incidence was higher (IRR 1.31; 95% CI 1.24–1.57) than among non-COPD men. COPD men had higher adjusted incidence of HS than COPD women (IRR 1.87; 95% CI 1.85–1.89). After matching, COPD men had a higher IHM (29.96% vs. 27.46%; p = 0.032) than non-COPD men. Decompressive craniectomy was more frequently conducted among COPD men than COPD women (6.74% vs. 4.54%; p = 0.014). IHM increased with age and atrial fibrillation, while decompressive craniectomy reduced IHM. (4) Conclusions: COPD men had higher incidence and IHM of HS than men without COPD. COPD men had higher incidence of HS than COPD women. Decompressive craniectomy was more frequently conducted in COPD men than COPD women and this procedure was associated to better survival.

P-OT021. Intracerebral hemorrhage in infective endocarditis, with dramatic response to dexamethasone: A case report

2021 ◽  
Vol 132 (8) ◽  
pp. e127
Author(s):  
Distya Nugrahening Pradhani ◽  
Ismail Setyopranoto ◽  
Indarwati Setyaningsih ◽  
Sri Sutarni
Keyword(s):  
Case Report ◽  
Infective Endocarditis ◽  
Intracerebral Hemorrhage

Abstract WP418: Characteristic of Intracerebral Hemorrhage Related to Direct Oral Anticoagulant versus Warfarin: Results From the PASTA Registry

Stroke ◽  
2020 ◽  
Vol 51 (Suppl_1) ◽  
Author(s):  
Satoshi Suda ◽  
Yasuyuki Iguchi ◽  
Shigeru Fujimoto ◽  
Yoshiki Yagita ◽  
Takayuki Mizunari ◽  
...  
Keyword(s):  
Intracerebral Hemorrhage ◽  
Oral Anticoagulant ◽  
Hematoma Expansion ◽  
Direct Oral Anticoagulant ◽  
Registry Study ◽  
Stroke Patients ◽  
Hematoma Volume ◽  
Imaging Characteristics ◽  
Warfarin Treatment ◽  
Patient Enrollment

Background and Purpose: The characteristics of direct oral anticoagulant (DOAC)-related intracerebral hemorrhage (ICH) have not been fully clarified. We planned to recruit patients prospectively and to investigate the characteristics and outcomes in patients with ICH receiving direct oral anticoagulant (DOAC) and warfarin treatment. Methods: The prospective analysis of stroke patients taking anticoagulants (PASTA) registry study is an observational, multicenter, prospective registry of stroke patients receiving OAC. Patient enrollment started in April 2016 at 25 tertiary centers across Japan. We compared imaging, clinical characteristics, and discharge modified Rankin Scale (mRS) between DOAC- and warfarin-related ICH patients with atrial fibrillation (AF). Results: A total of 154 patients (51 women; median age 77 [quartiles 69-87] years) were analyzed. Of these, 111 patients (72%) received prior DOAC treatment and the remaining 43 (28%) received prior warfarin treatment (Fig. A, B and C). There were no relevant differences in clinical and hematoma characteristics between DOAC- and warfarin-related ICH regarding baseline hematoma volume (median [quartiles]: DOAC, 11 [5-23] mL vs. warfarin, 12 [5-30] mL; P =0.95), rate of hematoma expansion (DOAC, 12/111 [11%] vs. warfarin, 4/43 [9%]; P =0.80), rate of subcortical hemorrhage (DOAC, 15/111 [11%] vs. warfarin, 10/43 [9%]; P =0.80) and the proportion of patients with unfavorable outcome (mRS, 4-6: DOAC 76/108 [70%] vs. warfarin 23/38 [61%]; P =0.26). Cerebral microbleeds (CMBs) were detected more frequently in DOAC group than in warfarin (47/76 [62%] vs. 11/32 [34%]; P <0.01). Subgroup analyses showed that type of DOAC agent did not result in relevant differences in imaging characteristics or outcome (Fig. D and E). Conclusions: Our results showed that there were no significant differences in hematoma characteristics and functional outcome among AF patients with DOAC- or warfarin-related ICH.

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