Carmen lives in La Belle, Fla., with her husband, Jose, an agricultural worker, and their 13-year-old son and 17-year-old daughter. She’s young—only 40. She eats right and doesn’t smoke. Is she knitted into a web of positive relationships? You bet. She’s the development coordinator at the Redlands Christian Migrant Association in LaBelle. She and Jose are active in church and enjoy spending time with their large extended family and friends. Something else in her favor? She strives to stay active. Carmen tries to walk four miles a day, several times a week. Our story begins on one of these days.
It was Nov. 12, 2009, the day after her daughter’s birthday. Carmen took a long, early morning walk with a friend. She remembers feeling slightly weak—but not enough to worry about. She had planned to meet her sister later that morning. When Carmen got back home, she got ready to take a quick shower. But something wasn’t quite right.
“It was the strangest thing,” she says. “I found myself struggling to take off my shirt and pants. Everything felt tight—as though my arm and leg had swollen up. I didn’t know what was happening.”
Then she began having trouble breathing. Even so, Carmen wasn’t overly alarmed. She remembers thinking maybe it was an allergy attack. She doesn’t remember calling her husband and falling to the floor.
Thankfully, her sister arrived and found Carmen lying there. “She told me my mouth was drooping to one side,” says Carmen. Her sister called 911. By the time the paramedics got there, Jose had arrived. Carmen remembers him whispering in her ear: “Please don’t go, I can’t live without you,” in Spanish.
The paramedics immediately realized Carmen was exhibiting signs of a stroke. Instead of taking her to a hospital in Fort Myers, they rushed her to Sarasota Memorial Hospital (SMH) by helicopter. The hospital’s Comprehensive Stroke
Center features a multidisciplinary stroke team, which is exactly what Carmen needed.
SMH’s emergency room doctor agreed with the paramedics and ordered a sophisticated type of CT scan that looks at blood flow to various regions of the brain. He also called in one of the stroke team’s neurologists, Dr. Donald Negroski.
“I was at her side within 10 minutes,” says Negroski. “Despite her young age, it was obvious she was having a stroke. She was unable to move her left arm and had weakness in her left leg. She was conscious but appeared confused. When her family arrived, I was able to get further history.” The CT scan confirmed Negroski’s conclusion; it revealed a clot in one of the brain’s arteries, which supplies blood to a vital area of her brain. Negroski knew the clock was ticking.
Negroski explains the danger Carmen faced. In his words, “A stroke is basically a brain attack—analogous to a heart attack. It should be treated with the same degree of urgency.”
What’s the danger? Think of the brain as an organic computer that runs on blood. A stroke cuts off blood supply to the brain. When that happens, brain cells die—two million a minute. The sooner a patient gets treatment, the better his or her odds of escaping serious disability. “Our first opportunity to work effectively is within three hours after a stroke,” says Negroski. “If we act in time, the patient may have a better chance of a full recovery.”
Some 90 percent of strokes are ischemic—strokes in which the blood vessel is blocked. Doctors treat this kind of stroke by removing the clot that’s blocking blood flow to the brain. For an ischemic stroke, the most promising treatment is a Tissue Plasminogen Activator (tPA), a clot-busting drug which, if given intravenously, must be administered within three hours to work effectively. Unfortunately, the team didn’t know exactly when Carmen’s stroke had begun. Negroski knew he had to move to his next best option.
He called in Dr. Nasser Razack, a neurointerventionalist. Interventional neuroradiology was pioneered in the 1980s, exploiting startling advances in computer imaging technology and the miniaturization of medical devices. In this procedure, the neurointerventionalist inserts a microcatheter in the region of the groin. Guided by X-rays, the neurointerventionalist threads the catheter through the arteries and up into the brain. This technique allows neurointerventionalists to deliver tPA directly to the site of a stroke victim’s blockage and/or to use a variety of other procedures to remove the clot. When tPA is administered this way, it’s still effective up to six hours after a stroke event.
Razack sums up his specialty in layman’s terms.
“I’m basically a plumber,” he says. “Instead of working with pipes and drains, I work with blood vessels. I do one of two things: I either close them or open them.”
Pushing the plumbing analogy a little further, he says, “We can unplug an ischemic clot with TPa, which is basically Drano for the brain. Or I can use a Merci Retriever device, which is exactly like a plumbing snake—it corkscrews its way through the clot. I can also use a vacuum device that sucks up the blood clot and restores blood flow to the brain. Finally, I can use a stent, which uses a fine, tubular wire mesh to keep the vessel open.”
The best option depends on the nature of the problem. Better information leads to better decisions. Once Razack threaded the microcatheter through Carmen’s body and up into her brain, he located her clot with advanced 3D angiogram imaging technology. He quickly decided that a stent would work best.
“I elected to use a stent for two major reasons,” says Razack. “First, a stent has a 90 percent chance of opening a blood vessel. Second, it works within minutes. We needed to open up the vessel and restore blood to the brain as soon as possible.”
The procedure took 30 minutes. “When Carmen came to us, she had suffered a significant stroke,” says Razack. “At the end of the procedure, the level of intensity had been reduced to almost zero. A few days later she was discharged from the hospital with minimal effects from the stroke. She is a perfect example of everything going right.”
At the time, Carmen had no idea of how wrong things could have been. Today, she only remembers waking up in the hospital and feeling mildly confused. “I couldn’t remember the date. But I remember moving my arm and leg without any problem.” Carmen says that the doctors had told her husband to be prepared. “They said he would have to wait and see,” she says. “Although he was worried, he said, ‘Whatever it is, we’ll face it.’”
During her hospital stay and for weeks after during rehab and occupational therapy, Carmen’s and Jose’s family gathered near her. “We’re very much believers in prayer,” says Carmen. “They had hundreds of people in LaBelle and around the country praying for my recovery. I don’t know if that is why I survived, but I can say that throughout the entire experience I never felt that I was dying or would die.”
Carmen believes in miracles—and she doesn’t ask why she had the stroke in the first place. Negroski does. From a scientific perspective, he’s forced to ask the question: What caused a healthy, 39-year-old woman to have a stroke?
He suspects a disorder of the blood vessels called fibromuscular displasia. “It’s very uncommon,” he says, “but it can occur at any age—from two to 80. It’s also more prevalent in women than in men.” Negroski explains that the condition causes a narrowing or stenosis of arteries supplying blood to the brain. Was there any way that Carmen could have known about it beforehand? No.
Razack agrees. “The condition was something she was born with,” he says. “But in most cases, the cause of a stroke isn’t hidden. It’s right out there in plain sight. There’s a wide range of risk factors we do know about.” He lists the usual suspects, including hypertension, high cholesterol and smoking. These risk factors are a matter of lifestyle and diet. But the No. 1 cause isn’t.
“The highest risk factor for stroke is age,” he says. “Whatever causes many of our diseases accumulates over time.”
It’s a complicated point, but Razack wants to be clear. Age acts as a multiplier for all other risk factors. Alcohol, smoking, bad diet and a lack of exercise create ongoing damage in the body. The damage not only adds up, it multiplies. Think of it as compound interest for bad behavior.
The body’s cumulative damage has many causes and one common effect: inflammation. Razack believes inflammation is the true culprit behind Alzheimer’s disease, heart disease, strokes and a range of other diseases and conditions.
“The blood vessels in the heart and brain are exactly the same on a molecular level,” he says. “Inflammation of the blood vessels is the silent killer—whether in the heart or the brain. We need to treat disease on a more holistic level. All of these diseases have common links to inflammation; and by treating inflammation as a whole, we can treat every major age-associated inflammatory disease, including heart disease, stroke and Alzheimer’s.”
According to Razack, Carmen is one of the unlucky few who have a stroke despite a healthy lifestyle. But she’s also one of the lucky few who survived a massive stroke without massive damage.
Thanks to the expertise and quick thinking of the medical team, from the paramedics who found her to SMH’s stroke center team, and the cutting-edge techniques of interventional neuroradiology, Carmen was out of the hospital within a week—and back to normal functioning within months.
But the experience has not left her unchanged. She says her faith is stronger, and so is her appreciation for life. “I thank God for the little things,” she says. “I used to be a perfectionist; now I realize it’s OK not to be perfect. I look out at the beauty of the world, nature, and am happy. I refuse to live in fear. I’m going to enjoy every day and thank God I’m alive.”
Until very recently, a stroke’s impact on a patient’s life was usually devastating. Medical advances have offered a window of full recovery for some patients—if action is taken in time. Even so, strokes are still deadly and destructive. Stroke is the leading cause of serious, long-term disability in the United States, with up to 30 percent of stroke survivors left permanently disabled. Three months after onset, 20 percent still require institutional care. In 2003, stroke-related medical costs in the United States exceeded $50 billion.
Stroke is the third leading cause of death in the United States, behind high blood pressure and cancer.
Every 45 seconds someone in the United States has a stroke.
Every three minutes someone dies from a stroke.
Stroke is not just an older person’s disease—28 percent of strokes occur in people under age of 65.
More men than women have strokes—although more women die from them.
African-Americans are at much higher risk for stroke. In part, this is because African-Americans are at increased risk for obesity, high blood pressure and diabetes, which increase the risk of stroke.
May is Stroke Awareness Month.
Dr. Donald Negroski: Negroski, Stein, Sutherland, and Hanes Neurology, 1921 Waldemere St., Suite 701, Sarasota;
Dr. Nasser Razack: Neurointervention Associates; (727) 289-7139