My Stroke (Part VII)

According to the Centers for Disease Control and Prevention, every year more than 795,000 people in the United States have a stroke. Of these, about 610,000 are first-time strokes. Stroke has an eerie similarity to Russian roulette — drop a round into the cylinder of a six-shooter, give the chamber a good spin, hold the gun to your head, and pull the trigger. You have the same odds of blowing your head off as of suffering a fatal stroke over your lifetime: 1 in 6.

 

 

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MRI image taken in 2010 after my first stroke. The ability of the brain to forge alternate pathways compensated for the portion of my parietal lobe destroyed by the stroke. (Image is reversed)

I feel positively blessed that I can still teach, still drive (provided there’s no clutch involved), and still whip through crossword puzzles.
Here’s what I  can no longer do: play piano, wade trout streams, tie flies, tie my shoes, garden, hike any terrain more challenging than a gently sloping sidewalk — and, considering how much time I spend around the water, I can no longer swim.

I suffered my first stroke, a right carotid artery dissection (or tear) in 2010. The neurologist on call at that time, Dr M, promised a full recovery. His prediction was spot on. I spent three days in the hospital, breezing through a physical therapy evaluation, and generally feeling like I had been given a new lease on life.
To say I was euphoric would be an understatement. A month after my release,I played piano in the Jewish Child & Family Services All-Star Band, fronted by JCFS CEO Howard citron, who led us through a rousing rendition of “Sweet Home Chicago.” I made a couple trips up to Coon Valley where I waded trout streams to my heart’s content. I weeded, cut the grass, and on a couple of occasions, even took out the garbage.

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MRI taken in July 2012 after my second stroke. Roughly 75 percent of my right parietal lobe was destroyed, resulting in irreversible left-side damage. Also note the damage to my frontal cortex. I’m told the white blotch on the right is an “artifact” (a mechanical flaw as opposed to an accurate depiction.)

But then came the reckoning. Near the end of August, I had my first encounter with “diakaesis.” As Dr. M. had explained to me back on Easter Sunday, “A stroke is a violent, completely unexpected assault on your brain.” Consequently, he explained, it is not uncommon in stroke victims for the now shell-shocked brain to interpret events such as stress, lack of sleep, or respiratory illness as an impending stroke. The brain then responds by replicating the symptoms of a previous stroke.
How then, I asked Dr. M, will I be able to tell the difference between diakaesis and an actual stroke?
“If it is diakaesis, you will feel symptoms in the same areas where you had your stroke, and the symptoms will be of short duration.” he replied. However, he urged me to call 9-1-1 immediately if the stroke-like symptoms last longer than a couple of minute, or if I experience “stroke-like” symptoms in an area of my body not previously affected by my stroke.

When discussion turned to post-stroke treatment, Dr. M. mentioned, almost as an afterthought, the option of a stent insertion. Popular as a means of widening clogged arteries, stents also have been inserted in the vicinity of carotid artery dissections to seal off or block blood flow.

To perform the procedure, a “radiological  interventionist”  makes a small opening in a blood vessel in the groin, arm or neck. Through this opening, the interventionist  threads a thin, flexible catheter with a deflated balloon (the stent) at its tip. Using x-ray video, the interventionist  directs the catheter to the area of the dissection, where the stent is  inflated. The catheter is removed but the stent remains. Over time, arterial cells grow to cover the mesh of the stent, creating an inner layer that looks like the inside of a normal blood vessel.

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Illustration of brain, top view, with its three large divisions. A major stroke in the parietal lobe is bad news, A major stroke in either of the other two lobes is dire news.

But stent placement, or carotid angioplasty, has a downside, Dr. M. cautioned. “It’s not as invasive as, say, a carotid endarterectomy, but it carries about a six-percent risk of triggering a stroke during the procedure.”

Dr. M’s advice? “You could call me a conservative, I suppose,” he counseled, “but I put great stock in the body’s ability to heal itself, and dissections generally close on their own. I want you to check in with me in eight weeks for a CT scan, so we can eyeball it.”

I felt relieved and reassured. I took an immediate liking to Dr. M., who appeared to have quickly picked up on my quirky sense of humor and was only too eager to respond in kind.

Spoiler alert: Dr. M. eventually reached the conclusion that my stroke prevention protocol could be enhanced by a more invasive approach. He reached this conclusion In July, 2011, after I twice checked into the emergency room, convinced that I was suffering a full-blown stroke; after I repeatedly hounded Dr. M’s nurse (Dr. M. was never “available” to speak to me by phone) to please inform the good doctor that I was having episodes of diakaesis almost daily; after Dr. M. viewed MRI imagery taken six month after my stroke  and acknowledged that the tear still had not closed (“Not to worry, it doesn’t have to close.”)

Are you following me, gentle readers? Dr. M. concluded that my stroke prevention protocol could be enhanced by a more invasive approach right at the point when I was simultaneously suffering a second stroke. Three botched  carotid angioplasties and one botched carotid endarterectomy later, I was pretty much right where I started from.  Speaking as a layman, I can confidentially state that, if polled, most doctors would circle, “When the patient is actually having a stroke,” in response to the question:  “When is the worst possible time to  implement a stroke-prevention action plan?”

Incidentally, what I like to refer to as “the icing on the cake” occurred in post-op where I was recovering from  the botched endarterectomy (the surgeon had said he encountered too much turmoil in the vicinity of my stroke to risk attempting to stitch the tear.) Around 11:30 p.m., about 12 hours after my surgery, a malfunction occurred in the pump administering intravenous heparin, a powerful blood-thinner intended to discourage clotting around my carotid tear. Suddenly, I was receiving so much heparin that my blood was permeating through my surgical stitches in a sort of micro-mist and pooling in my neck .The only way I can describe the pain, which steadily grew worse, is that it felt like some force was inflating my face from within, and would continue doing so until my face burst open. I pushed the call button to no avail. Finally,  I worked my way out of my bed, and crawled to the door, where I beheld a hallway, deserted and dark but for the dimly lit nurses’ station about  100 feet distant.

I could go no farther because my IV tubing was stretched to the limit, so I just lay on the floor, crying and screaming. At some point I caught the attention of  a nurse. “You absolutely should not be out of bed,” she scolded as she approached me.”Something’s wrong!” I croaked. “I’m in unbearable pain!”

“I’ll be right back,” the nurse responded, and then she left!

I was deep within the palace of pain when the nurse returned with the ER resident on call. “The Heparin monitor malfunctioned, ” he informed me.  “You were getting an excessive amount, so we cut it off.”  He spoke in a soft cadence with a British inflection.  He had a courtly manner remarkably similar  to that of a former co-teacher of mine, an emigre from Ghana.

Several medical personnel hovered around the doctor. He turned to one and said, ” Two milligrams of hydromorphone, IV, please.”

Then he turned to me and said, “We’re giving you diluadid, a powerful painkiller. Soon, your pain will become more bearable.”

“Mgeto” was the name engraved on the the doctor’s ID badge. As the narcotic  moved like a soft mist through my body, enveloping and then smothering the jagged shards of pain,   I made a vow: Should I last the night, I will  do all in my power to ensure Dr. Mgeto’s canonization into sainthood.   

But, my dear and patient  readers, I have been digressing! So please allow me to take you back to where we last left off: I’m referring to my post, “My Stroke, Part VI), at which point Dr. M urged me to make my way to the Evanston Hospital Emergency Room post haste.

As a “second-timer,” I knew the drill: Tell the security guard at the ER entrance that you think you’re having a stroke, at which point you will be whisked through the waiting area,  where you’ll  attract the mild curiousity of the two-or-three-dozen souls who won’t be going anywhere soon. The big curtain will be pulled open and you will enter the inner sanctum, where you will be wheeled into one of the partitioned alcoves, at which point it will occur to you that, akin to those jerks who, entering construction zones, drive all the way up to the the point where the two lanes funnel into one, and then commence trying to bully their way back into traffic, you, too, have come barreling out of nowhere to bump everyone else down a notch.

Within seconds, you will find yourself in the company of nurses and technicians whose smiles and well wishes are unforced because this is just another day at the shop for them. By the time Central Registration shows up to formally admit you, it’s probable that you’ve already been hooked up to the monitoring machine, along with an IV drip, and that you’ve undergone the stroke assessment protocol (“Do you know where you are?” “Give me a big smile.” “Squeeze my finger as hard as you can.”)

Next came a CT (or computer tomography) scan, the quickest means of getting a sense of what exactly was going on inside my head.

My acknowledgement (which, I suspect, in the minds of the assembled hospital staff was tantamount to a confession) that I had waited nearly a week before seeking medical help for what the MRI images from the previous evening clearly confirm was a stroke, ruled out  an  injection of a “clot buster.” Alteplase, the only drug approved by the FDA for stroke treatment, is a tissue plasminogen activator that hones in on blood clots anywhere in the body and “busts” them up. However, altiplase is only effective if administered within three to four hours after a stroke.

Consequently, all my assembled stroke team could do was to fit me with inflatable, plastic socks designed to promote circulation in my feet, and withhold my blood pressure medication, based on the premise that increased blood flow discourages blood clotting.

I was admitted to my room to get what rest I could, and to await my visit with Dr M, who was expected at about 4:00. It was now about noon. My roommate,  a gentleman who looked to be in his sixties, in the company, I assume, of his wife, was already eating lunch. Judging by his wife’s slender frame and fashionable garb, I assumed they hailed from Wilmette, an upper income community just north of Evanston.  The couple studiously ignored me, seemingly immune to the racket created by the orderly wheeling in my bed and by the nurse-on-call as they got me settled in.

“Looks like lunchtime,” I ventured. Actually,  I was famished. Aside from the fact that I was wearing plastic “socks” that rhythmically (and rather nosily) inflated and deflated, and that I was horizontal with a cluster of IV tubing snaking from my forearm to various monitors, I felt completely okay. And, as I mentioned previously, I was seriously hungry.

So far, no response. I gave it another shot. “Excuse me,” I said rather loudly, “Does having a stroke cause an increase in appetite?”

The nurse-on-call, who was stooped over beside my bed  jiggling with one of the controls, popped her head up and said in a cheerful voice, “It certainly seems true in your case! What would you like, sweetie?”

I knew exactly what I would like: “A pepperoni-and-sausage personal pizza, a strawberry shake and a Chocolate Lover’s brownie.” Those menu offerings were the highlight of my previous stay.

The nurse-on-call flashed an almost-cartoonish pout. “Oh, honey, your doctor would like you to order from the Healthy Heart menu until he gets the chance to meet with you.

Now you decide to get proactive, Dr. M., I muttered under my breath. Take away the one thing that could have brightened up this totally shitty day.

While enjoying my baked-chicken sandwich, mashed potatoes sans butter, bowl o’fruit, Mountain Dew (How did soda pop slip through the cracks?), and Berrylicious pudding, I found myself glued to the overhead television, slowly getting sucked into what I overheard one of the  nurses refer to as the “Cayley  Anthony Trial.” When Dr. M. strode into the room four hours later, I was almost annoyed. The stepfather had just taken the stand.

 

 

 

 

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