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

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.The American Medical Association designates this journal-based CME activity for a maximum of 1 AMA PRA Category 1 Credit™ available through the AMA Ed Hub TM . Physicians should claim only the credit commensurate with the extent of their participation in the activity. CaseMr J is a 64-year-old man with metastatic non-small cell lung cancer (NSCLC), who, while eating, abruptly developed right hemiplegia and aphasia. He had been diagnosed 10 months earlier with NSCLC; his estimated life expectancy was approximately 1 year. After a course of chemotherapy with pemetrexed and carboplatin, Mr J started pembrolizumab, an antiprogrammed death-1 immune checkpoint inhibitor offered possibly to extend his life but not as a cure for his cancer. 1,2 Since diagnosis, Mr J has suffered multiple hematologic complications, including thrombosis and hemorrhage. When brought to an emergency department, he was confirmed as full code and intubated on arrival due to poor mental status and aspiration risk. Computed tomography (CT) imaging of his head and neck revealed normal brain parenchyma and occlusion of the proximal left middle cerebral artery (MCA), which supplies blood to most of the brain's left hemisphere, including areas critical for language and right-side sensorimotor function. 3 The mechanism of Mr J's left MCA occlusion was presumed to be thromboembolism, to which he was predisposed by hypercoagulability of malignancy, pembrolizumab, 4,5,6 and intracardiac hemostasis, given his known low left ventricular ejection fraction.

Outcomes of Mechanical Thrombectomy for Acute Ischemic Stroke in Cancer Patients

“…Therefore, the role of endovascular MT is expected to extend beyond palliative therapy. 28,29 Our institutional experience has limitations that include the retrospective nature; absence of 3-month clinical outcome data of 37% of the included patients; lack of detailed oncologic data about the cancer groups, including-and not limited to-the molecular types and the genetics of the tumors; possible selection bias in patients with severe morbid conditions; and the possible effect of the small number of patients in the AM group on the observed statistical differences. In addition, the institutional data for the HOM group did not encompass any patients with a history of metastatic disease.…”

Mechanical Thrombectomy in Acute Stroke Patients with Moderate to Severe Pre-Stroke Disability

“…For patients with pre-stroke disability due to other serious health conditions or even life-limiting conditions, MT may represent a measure to decrease their sum of harm and alleviate further suffering. Basic ethical principles of beneficence and nonmaleficence make these considerations of offering stroke interventions in those previously disabled or even in a palliative setting justifiable [ 19 ].…”