Search

There 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.

Innovative strategies are needed to reduce the hypertension epidemic among African Americans. Reach Out was a faith-collaborative, mobile health, randomized, pilot intervention trial of four mobile health components to reduce high blood pressure (BP) compared to usual care. It was designed and tested within a community-based participatory research framework among African Americans recruited and randomized from churches in Flint, Michigan. The purpose of this pilot study was to assess the feasibility of the Reach Out processes. Feasibility was assessed by willingness to consent (acceptance of randomization), proportion of weeks participants texted their BP readings (intervention use), number lost to follow-up (retention), and responses to postintervention surveys and focus groups (acceptance of intervention). Of the 425 church members who underwent BP screening, 94 enrolled in the study and 73 (78%) completed the 6-month outcome assessment. Median age was 58 years, and 79% were women. Participants responded with their BPs on an average of 13.7 (SD = 10.7) weeks out of 26 weeks that the BP prompts were sent. All participants reported satisfaction with the intervention. Reach Out, a faith-collaborative, mobile health intervention was feasible. Further study of the efficacy of the intervention and additional mobile health strategies should be considered.

Background: Clinical trials of patent foramen ovale (PFO) closure for stroke prevention have produced controversial results. We investigated differences in presenting the net benefits of PFO closure or description of the PFO in a randomized vignette-based internet survey. Methods: Adults aged 18 to 60 inclusive were recruited via Amazon’s Mechanical Turk. Participants read a vignette asking them to imagine that they had a minor stroke. The vignettes included three randomized factors in a 2 x 2 x 3 factorial design: a) benefit of PFO closure (no proven benefit versus ~3% absolute risk reduction, analogous to difference in individual trials versus subsequent meta-analysis); b) normalization intervention (PFO described as very common and benign for most individuals versus no such description); and c) labeling of the PFO (?PFO? versus ?hole in the heart? versus ?difference in heart structure?). Participants were then asked their choice of treatment (PFO closure or aspirin). Secondary outcomes included self-perceived stroke risk and level of anxiety about the PFO diagnosis. Regression analysis was used to assess predictors of treatment choice (logistic) and secondary outcomes (linear). Results: 2157 participants completed the survey (54.6% female, 76.2% non-Hispanic white, median age 32 with IQR 27 – 41). Participants shown data suggesting 3% absolute risk reduction for PFO closure were more likely to choose PFO closure (30.9% vs. 7.5%, p < 0.001). The normalization intervention decreased anxiety about the PFO. The labeling intervention increased self-perceived stroke risk and had differential effects on patient anxiety (see Table for details). Conclusion: Differences in how information is presented can influence choice of treatment, perceived stroke risk, and level of anxiety surrounding PFO-associated stroke. Future work should address the impact of information presentation on potential variability in use of PFO closure and patient psychological outcomes.

Obstructive sleep apnea (OSA) is common after stroke and predicts poor outcomes. Continuous positive airway pressure (CPAP) treats OSA but is generally poorly tolerated by stroke patients. We assessed whether nasal expiratory positive airway pressure (EPAP), an alternative to CPAP, may be an effective option after acute stroke.We conducted a randomized, controlled, two-period crossover study in which each acute ischemic stroke patient received 1 night of EPAP and 1 night without EPAP while OSA was monitored with a validated device, the Watch-PAT 200. Linear repeated- measures analyses were conducted. Sample size calculations indicated that 18 subjects would be required to detect a 10-point or larger average reduction in the apnea-hypopnea index (AHI, the primary outcome), with use of EPAP, with power ≥ 80% and α = 0.05.Among the 19 subjects who completed the protocol, nasal EPAP treatment was associated with a nonsignificant absolute difference in AHI of -5.73 events/h in the primary analysis (p = 0.183, 95% confidence interval -14.4, 2.97) and a nonsignificant absolute difference in AHI of -5.43 events/h in the subgroup of patients who used nasal EPAP for ≥ 3 h (p = 0.314, 95% confidence interval -16.6, 5.76).This study suggests that EPAP is not an effective alternative to CPAP in acute stroke patients with OSA. Further work is needed to identify other more effective alternatives.ClinicalTrials.gov, ID: NCT01703663.

Introduction: Stroke Core Measures are intended to ensure that patients receive high quality, guideline-concordant acute stroke care. Compliance data is collected and reported to the public and to regulatory agencies for benchmarking and for reimbursement. Hypothesis: Core Measures noncompliance within one academic institution will often reflect ambiguous or incomplete documentation instead of true failure to provide medically appropriate care. Methods: We retrospectively reviewed Core Measures data for all ischemic and hemorrhagic stroke patients discharged from the University of Michigan between January 2013 and May 2014. Core Measures data was collected and reported per routine practice and contemporaneously reviewed by the institutional team. For this study, Core Measures failures were cross-referenced with the full medical chart and classified as “true failures” when care was not compliant with the Core Measure standard or “documentation failures” when chart review revealed poor documentation of otherwise appropriate care--for example, where a normal neurological examination was not explicitly linked with a decision to defer assessment for rehabilitation. Determinations of the basis for noncompliance on chart review were made by two different reviewers, with 100% agreement. Results: A total of 40 failures in 872 patients were identified and reviewed. Core Measures failures were documentation failures in 20 patients. Additional details are provided in Table 1. Conclusion: The high number of documentation-based failures in our experience illustrates potential problems in the use of administratively-defined measures as a marker of the quality of clinical care.