What does lysis mean in medical terms

Therapy at any cost?

BERLIN. Germany now has a nationwide network of stroke units. Mechanical thrombectomy is celebrating its triumphant advance and can often cure patients with large vascular occlusions without permanent disabilities. All of these are great successes.

At the Neurological Intensive Care Workshop (ANIM) in Berlin, Professor Wilhelm Nacimiento from the Sana Clinics in Duisburg presented the example of an 82-year-old woman with an M2 lock. Two days after the thrombectomy, she was able to go home unhindered.

"This is what we strive for - a complete cure for the patient," said the neurologist. With modern intensive care medicine, this is often possible even with very old people. Old age alone is not a decisive factor for the prognosis, but old age together with many comorbidities, said Nacimiento.

However, such frequently cited successes are not the rule. Doctors often face a dilemma when deciding on further therapy for a patient with a severe cerebral infarction. Maximum intensive care treatment despite a poor prognosis? In many ways, this is the easier and more lucrative way.

Nacimiento made this clear with another example: In an 82-year-old woman with a carotid T-occlusion, the doctors were able to open the vessel via lysis and thrombectomy, but on the following day the patient suffered a large, space-consuming media infarction.

"In this case, a change of course from maximum therapy to palliative treatment is called for. We thought it was indicated and it was compatible with the patient's presumed wishes." The woman died after a few days.

Maximum therapy can be lucrative

However, the doctors could have made a different decision: transfer the patient to an intensive care unit, arrange for a hemicranectomy. "This gives the impression that you are practicing good medicine. At the same time, large revenues can be achieved, which is quite tempting." But this is precisely what is not indicated: "There must be no automatic mechanism to continue treating patients in a maximal curative way if there is no longer a sensible curative goal," said Nacimiento.

However, it is not always easy to identify those patients who are eligible for palliative therapy. There are very different points of view from those affected, relatives and doctors. From a medical point of view, it is primarily patients with extensive brainstem infarcts, space-occupying media ulcers, large multilocular infarcts, large intracerebral or massive subarachnoid hemorrhages, whereby age and comorbidities must be taken into account. Ultimately, according to Nacimiento, the target groups for palliative care after a stroke are poorly defined.

In addition, there is sometimes a low level of acceptance by doctors and relatives who regard palliative care as a surrender. The neurologist explained this using the example of a 70-year-old with a major media infarction. The doctors order a hemicranectomy, a few days later the patient develops a media infarction in the other hemisphere, is then tetraplegic, cortically blind and aphasic.

Nevertheless, it is not possible to convince the relatives that there is no longer any potential for rehab - they continue to insist on maximum therapy, which, however, cannot save the patient. He dies a few days after the heart attack.

Unexpected will to live

It can also be difficult to determine the will of the patient. Around 40 percent of stroke victims now have an advance directive, but that doesn't always help either. As an example, Nacimiento mentioned a 75-year-old man with extensive pons infarction and almost complete paralysis. Communication was initially only possible through eye movements. He was previously very independent, and there was a lot to suggest that he did not want to continue living in such a state.

Nevertheless, he shared his will to live with the doctors and showed a great deal of commitment to rehabilitation. "Some patients can recalibrate their quality of life expectations. That also depends on how well they are cared for at home." In a similar case, a patient with locked-in syndrome stated that there was no way he wanted to go on living like this. The PEG tube was then removed.

If the cerebral function is still completely intact, according to the neurologist, the patient can of course still make wishes and demands, but in the case of large hemispheric infarctions with severe cognitive and affective restrictions, the current will can hardly be determined.

So how should doctors proceed in borderline situations? Nacimiento initially advises a well-founded assessment of the prognosis based on clinical and neuroradiological findings. What are the chances of survival? How high is the risk of severe disabilities? What comorbidities are there?

If a clear prognosis is not possible, the therapy should be curative in the acute phase, everything speaks in favor of a poor prognosis, and much depends on the patient's stated or presumed wishes. Discussions should then take place with the patients, relatives and caregivers on an equal footing in order to make a joint decision on the therapy goals.

Doctors should make it clear to relatives that maximum therapy can lead to survival with severe disabilities. In such cases, palliative care is not a surrender, but a medically and humanly optimal therapy. However, the patient's will is always the top priority.

Since many patients die after consciously abstaining from maximum therapy, the mortality rate considered in isolation cannot be a quality criterion for stroke medicine for Nacimiento. "The palliative care of severely affected patients in hospitals must also be recognized as a therapy goal and core competence of progressive stroke medicine."