What are the main challenges in treating these patients?
Dr. Amankulor: The treatment challenges relate to 2 things – one is how to stop the bleeding before you actually have a massive deleterious outcome neurologically. When a patient presents with headache, mild weakness, or visual disturbance, it may be that you can reverse the problem before it gets to a place where it’s necessary to operate.
Ways to do that can be manifold, depending on the hematologic malignancy and what it is destroying or diluting. Sometimes we have to give platelets and cryoprecipitate, and other times drugs that decrease clotting factors are warranted.
For an ischemic stroke, endovascular thrombectomy or intra-arterial tPA administered directly into the site of the clot may be indicated. The type and location of the stroke will determine the treatment approach.
Ultimately, the goal is to avoid operation, so we’ll do whatever we can to provide non-surgical intervention early. If it becomes necessary, we have to make sure the body is prepared to have an operation that the patient has sufficient factors to support healing postoperatively.
Then comes the hardest decision, when a patient has a cerebrovascular accident and you determine that there’s nothing you can do. Some of these events are clearly terminal. This may occur when there’s such a massive volume of blood that the brainstem has already been destroyed by the pressure, or it could be a patient with very late-stage disease that’s spiraling out of control, and going in [to operate] would be futile.
Making that determination is the hardest thing we have to do and can be extremely heartbreaking.
What are the most pressing remaining needs in this area?
Dr. Amankulor: I think the most pressing need is to develop universal guidelines for determining when surgical intervention is potentially futile in these patients and when it can be beneficial. There is currently enough data to inform these guidelines, mostly based on retrospective studies of which patients do well and which ones do not, based on their condition, coagulation factors, platelets, and other variables.
We really need evidence-based guidelines to tell us what chance a patient has of good or bad outcomes, and we need a predictive formula for when to intervene and what the intervention should be. Such recommendations are lacking for patients with hematological malignancies.
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