Skip to main content

Advertisement

SpringerLink
Log in

Ethical Considerations in the Treatment of Cerebrovascular Disease

  • Review
  • Published:
Current Treatment Options in Neurology Aims and scope Submit manuscript

Abstract

Purpose of Review

To care for patients with cerebrovascular disease (CVD), neurointerventionalists, intensivists, and other healthcare providers must be equipped to address associated ethical challenges. This review aims to delineate the applicability of fundamental bioethical approaches to CVD, highlight key ethical issues in CVD care, and delineate an ethical framework to streamline ethical decision-making for people with CVD.

Recent Findings

Three introductory cases are presented. The four key principles of principalism and the approach of narrative ethics are described with reference to CVD. Key ethical considerations include decision-making capacity and informed consent, uncertainty, and resource allocation. A categorization of CVD as emergent/nonemergent and the recommended management as intervention/no intervention helps frame the spectrum of CVD. A different six-pathway may then be taken based on which category the patient case corresponds to.

Summary

Physicians involved in the care of people with cerebrovascular disease must understand how the ethical issues manifest in individual patient cases to ensure appropriate care. The aforementioned ethical framework may aid physicians in providing ethically sound care. All decisions must involve a balance between clinical expertise and patient values and preferences or those articulated by a surrogate to properly respect the wishes of patients with CVD.

This is a preview of subscription content, log in via an institution to check access.

Access this article

Log in via an institution

Price excludes VAT (USA)
Tax calculation will be finalised during checkout.

Instant access to the full article PDF.

Institutional subscriptions

Fig. 1

Similar content being viewed by others

Data Availability

All relevant data are available in the article text.

References and Recommended Reading

Papers of particular interest, published recently, have been highlighted as: •  Of importance •• Of major importance

  1. Bamford J, Sandercock P, Dennis M, Burn J, Warlow C. A prospective study of acute cerebrovascular disease in the community: the Oxfordshire Community Stroke Project--1981–86. 2. Incidence, case fatality rates and overall outcome at one year of cerebral infarction, primary intracerebral and subarachnoid haemorrhage. J Neurol Neurosurg Psychiatry. 1990;53(1):16.

  2. Schoenberg BS, Mellinger JF, Schoenberg DG. Cerebrovascular disease in infants and children: a study of incidence, clinical features, and survival. Neurology. 1978;28(8):763-.

  3. Benjamin EJ, Virani SS, Callaway CW, Chamberlain AM, Chang AR, Cheng S, et al. Heart disease and stroke statistics—2018 update: a report from the American Heart Association. Circulation. 2018;137(12):e67–492.

    Article  PubMed  Google Scholar 

  4. Feigin VL, Norrving B, Mensah GA. Global burden of stroke. Circ Res. 2017;120(3):439–48.

    Article  CAS  PubMed  Google Scholar 

  5. Bravata DM, Ho S-Y, Brass LM, Concato J, Scinto J, Meehan TP. Long-term mortality in cerebrovascular disease. Stroke. 2003;34(3):699–704.

    Article  PubMed  Google Scholar 

  6. Portegies M, Koudstaal P, Ikram M. Cerebrovascular disease. Handb Clin Neurol. 2016;138:239–61.

    CAS  PubMed  Google Scholar 

  7. Gillon R. Medical ethics: four principles plus attention to scope. BMJ. 1994;309(6948):184.

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  8. •• Shlobin NA, Clark JR, Campbell JM, Bernstein M, Jahromi BS, Potts MB. Ethical considerations in surgical decompression for stroke. Stroke. 2022;53(8):2673–82. Comprehensive description of the ethical considerations of decompressive craniectomy for stroke by the author of this article.

  9. O’Neill O. Some limits of informed consent. The Elderly. Routledge; 2017. p. 103–6.

  10. Shlobin NA, Rosenow JM. Ethical considerations in the implantation of neuromodulatory devices. Neuromodulation: technology at the neural interface. 2021.

  11. Shlobin NA, Campbell JM, Rosenow JM, Rolston JD. Ethical considerations in the surgical and neuromodulatory treatment of epilepsy. Epilepsy Behav. 2022;127: 108524.

    Article  PubMed  PubMed Central  Google Scholar 

  12. Salwi S, Kelly KA, Patel PD, Fusco MR, Mistry EA, Mistry AM, et al. Neighborhood socioeconomic status and mechanical thrombectomy outcomes. J Stroke Cerebrovasc Dis. 2021;30(2): 105488.

    Article  PubMed  Google Scholar 

  13. • Regenhardt RW, Young MJ, Etherton MR, Das AS, Stapleton CJ, Patel AB, et al. Toward a more inclusive paradigm: thrombectomy for stroke patients with pre-existing disabilities. J Neurointerv Surg. 2020. Study indicated that individuals with pre-existing disabilities should not be systematically excluded from undergoing mechanical thrombectomy for stroke.

  14. Leker RR, Gavriliuc P, Yaghmour NE, Gomori JM, Cohen JE. Increased risk for unfavorable outcome in patients with pre-existing disability undergoing endovascular therapy. J Stroke Cerebrovasc Dis. 2018;27(1):92–6.

    Article  PubMed  Google Scholar 

  15. Howard G, Roubin GS, Jansen O, Hendrikse J, Halliday A, Fraedrich G, et al. Association between age and risk of stroke or death from carotid endarterectomy and carotid stenting: a meta-analysis of pooled patient data from four randomised trials. The Lancet. 2016;387(10025):1305–11.

    Article  Google Scholar 

  16. Brody H, Clark M. Narrative ethics: a narrative. Hastings Cent Rep. 2014;44(s1):S7–11.

    Article  PubMed  Google Scholar 

  17. Daou B, Hammer C, Mouchtouris N, Starke RM, Koduri S, Yang S, et al. Anticoagulation vs antiplatelet treatment in patients with carotid and vertebral artery dissection: a study of 370 patients and literature review. Neurosurgery. 2017;80(3):368–79.

    Article  PubMed  Google Scholar 

  18. Investigators CT. Antiplatelet treatment compared with anticoagulation treatment for cervical artery dissection (CADISS): a randomised trial. Lancet Neurol. 2015;14(4):361–7.

    Article  Google Scholar 

  19. Hachem LD, Bernstein M. Ethical issues in geriatric cranial neurosurgery. Neurosurg Focus. 2020;49(4):E3.

    Article  PubMed  Google Scholar 

  20. Shlobin NA, Sheldon M, Lam S. Informed consent in neurosurgery: a systematic review. Neurosurg Focus. 2020;49(5):E6.

    Article  PubMed  Google Scholar 

  21. McGehrin K, Spokoyny I, Meyer BC, Agrawal K. The COAST stroke advance directive: a novel approach to preserving patient autonomy. Neurol Clin Pract. 2018;8(6):521–6.

  22. Bryant J, Skolarus LE, Smith B, Adelman EE, Meurer WJ. The accuracy of surrogate decision makers: informed consent in hypothetical acute stroke scenarios. BMC Emerg Med. 2013;13(1):1–6.

    Article  Google Scholar 

  23. Alonso A, Dörr D, Szabo K. Critical appraisal of advance directives given by patients with fatal acute stroke: an observational cohort study. BMC Med Ethics. 2017;18(1):1–9.

    Article  Google Scholar 

  24. Spokoyny I, Cederquist L, Clay B, Meyer BC. COAST (coordinating options for acute stroke therapy): an advance directive for stroke. J Clin Ethics. 2015;26(3):206–11.

    Article  PubMed  Google Scholar 

  25. Klein A, Kuehner C, Schwarz S. Attitudes in the general population towards hemi-craniectomy for middle cerebral artery (MCA) infarction. A population-based survey. Neurocritical Care. 2012;16(3):456–61.

    Article  PubMed  Google Scholar 

  26. Creutzfeldt CJ, Schubert GB, Tirschwell DL, Longstreth Jr W, Becker KJ. Risk of seizures after malignant MCA stroke and decompressive hemicraniectomy. Am Heart Assoc. 2012.

  27. Hamilton MG. Daily neurosurgical experiences with ethics and the elderly. Neurosurg Focus. 2020;49(4):E4.

    Article  PubMed  Google Scholar 

  28. Qureshi AI, Gilani S, Adil MM, Majidi S, Hassan AE, Miley JT, et al. Pattern of informed consent acquisition in patients undergoing emergent endovascular treatment for acute ischemic stroke. J Vasc Interv Neurol. 2014;7(2):21.

    PubMed  PubMed Central  Google Scholar 

  29. Rosenbaum JR, Bravata DM, Concato J, Brass LM, Kim N, Fried TR. Informed consent for thrombolytic therapy for patients with acute ischemic stroke treated in routine clinical practice. Stroke. 2004;35(9):e353–5.

    Article  PubMed  Google Scholar 

  30. Shlobin NA, Huang J, Lam S. Health literacy in neurosurgery: a scoping review. World Neurosurg. 2022.

  31. Shlobin NA, Clark JR, Hoffman SC, Hopkins BS, Kesavabhotla K, Dahdaleh NS. Patient education in neurosurgery: part 1 of a systematic review. World Neurosurg. 2020.

  32. Shlobin NA, Clark JR, Hoffman SC, Hopkins BS, Kesavabhotla K, Dahdaleh NS. Patient education in neurosurgery: part 2 of a systematic review. World Neurosurg. 2020.

  33. Stein J, Brady Wagner LC. Is informed consent a “yes or no” response? Enhancing the shared decision-making process for persons with aphasia. Top Stroke Rehabil. 2006;13(4):42–6.

    Article  PubMed  Google Scholar 

  34. Clark JR, Shlobin NA, Batra A, Liotta EM. The relationship between limited English proficiency and outcomes in stroke prevention, management, and rehabilitation: a systematic review. Front Neurol. 2022;13:77.

    Article  Google Scholar 

  35. Schwamm LH. Acute stroke: shifting from informed consent to informed refusal of intravenous tissue-type plasminogen activator. Am Heart Assoc. 2015;S69-S72.

  36. Creutzfeldt CJ, Holloway RG. Treatment decisions after severe stroke: uncertainty and biases. Stroke. 2012;43(12):3405–8.

    Article  PubMed  Google Scholar 

  37. Schwarze ML, Sayla MA, Alexander GC. A comparison of patient and physician beliefs about infrainguinal bypass operation: what role should surgical optimism play? Surgery. 2007;141(2):239–44.

    Article  PubMed  Google Scholar 

  38. Fargen KM, Leslie-Mazwi TM, Chen M, Hirsch JA. Physician, know thyself: implicit and explicit decision-making for mechanical thrombectomy in stroke. J NeuroInterv Surg. 2020.

  39. Aghabarary M, Nayeri ND. Medical futility and its challenges: a review study. J Med Ethics Hist Med. 2016;9.

  40. Emanuel EJ, Fuchs VR. The perfect storm of overutilization. JAMA. 2008;299(23):2789–91.

    Article  CAS  PubMed  Google Scholar 

  41. Frick S, Uehlinger DE, Zenklusen RMZ. Medical futility: predicting outcome of intensive care unit patients by nurses and doctors—a prospective comparative study. Crit Care Med. 2003;31(2):456–61.

    Article  PubMed  Google Scholar 

  42. Venermo M, Wang G, Sedrakyan A, Mao J, Eldrup N, DeMartino R, et al. Editor’s choice–carotid stenosis treatment: variation in international practice patterns. Eur J Vasc Endovasc Surg. 2017;53(4):511–9.

    Article  CAS  PubMed  Google Scholar 

  43. Kelly AG, Hoskins KD, Holloway RG. Early stroke mortality, patient preferences, and the withdrawal of care bias. Neurology. 2012;79(9):941–4.

    Article  PubMed  PubMed Central  Google Scholar 

  44. Cox AM, McKevitt C, Rudd AG, Wolfe CD. Socioeconomic status and stroke. Lancet Neurol. 2006;5(2):181–8.

    Article  PubMed  Google Scholar 

  45. Addo J, Ayerbe L, Mohan KM, Crichton S, Sheldenkar A, Chen R, et al. Socioeconomic status and stroke: an updated review. Stroke. 2012;43(4):1186–91.

    Article  PubMed  Google Scholar 

  46. Maruthappu M, Shalhoub J, Tariq Z, Williams C, Atun R, Davies AH, et al. Unemployment, government healthcare spending, and cerebrovascular mortality, worldwide 1981–2009: an ecological study. Int J Stroke. 2015;10(3):364–71.

    Article  PubMed  Google Scholar 

  47. Saposnik G, Menon BK, Kashani N, Wilson AT, Yoshimura S, Campbell BC, et al. Factors associated with the decision-making on endovascular thrombectomy for the management of acute ischemic stroke. Stroke. 2019;50(9):2441–7.

    Article  PubMed  Google Scholar 

Download references

Author information

Authors and Affiliations

  1. Department of Neurological Surgery, Northwestern University Feinberg School of Medicine, 676 N. St. Clair Street, Suite 2210, Chicago, IL, 60611, USA

    Nathan A. Shlobin BA

Authors
  1. Nathan A. Shlobin BA
    View author publications

    You can also search for this author in PubMed Google Scholar

Contributions

NAS wrote the manuscript and prepared the table and figure.

Corresponding author

Correspondence to Nathan A. Shlobin BA.

Ethics declarations

Conflict of Interest

Nathan A. Shlobin declare no conflict of interest.

Additional information

Publisher's Note

Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.

Rights and permissions

Springer Nature or its licensor (e.g. a society or other partner) holds exclusive rights to this article under a publishing agreement with the author(s) or other rightsholder(s); author self-archiving of the accepted manuscript version of this article is solely governed by the terms of such publishing agreement and applicable law.

Reprints and permissions

About this article

Check for updates. Verify currency and authenticity via CrossMark

Cite this article

Shlobin, N.A. Ethical Considerations in the Treatment of Cerebrovascular Disease. Curr Treat Options Neurol (2024). https://doi.org/10.1007/s11940-024-00789-4

Download citation

  • Accepted:

  • Published:

  • DOI: https://doi.org/10.1007/s11940-024-00789-4

Keywords

Search

Navigation