Wednesday, March 10, 2010

Surviving a brain stem stroke

How a Mass General patient overcame the near impossible

Barbara Collard with her husband Richard.

Even under the most challenging odds, patients can make remarkable, unexpected recoveries.

Barbara Collard is one such patient. After suffering a severe stroke in July 2008, she has made a recovery that would astound even the most seasoned of physicians. Collard suffered a serious brain stem stroke, a deadly condition that affects the blood supply to areas of the brain vital to the body's basic life support functions. Initial scans had indicated that this part of her brain was severely damaged, but some patients can recover neurologic function in the part of the brain if blood flow is re-established quickly.

Collard's seemingly miraculous recovery reminds physicians that standard protocols of therapy must be viewed in combination with individual patient circumstances.

"Every stroke patient has a unique lesion, medical condition and physiologic response," said Dr. James Rabinov, MD, an interventional neuroradiologist in the Massachusetts General Hospital Vascular Center. "We need to do our best to consider all of these within the algorithms we have established with our Neurology colleagues."
"I’m having a stroke"Despite her excitement about her granddaughter’s birthday party, Barbara woke up "feeling out of sorts." She spent the Sunday afterward in bed with fatigue. "I thought I had some sort of bug," she said.

On Tuesday Barbara was feeling better and went to her office at Bristol Community College. However, by mid-morning she recalls that her arms were shaking, and then she suddenly collapsed at her desk. Two EMTs who were nearby responded to a call for help and stayed with her until an ambulance arrived to rush her to Charlton Hospital in Fall River, Massachusetts.

Doctors at Charlton Hospital intubated Collard and quickly arranged for her to be airlifted to Mass General. A team of stroke neurologists and neuroradiologists, led by Dr. Natalia Rost, a neurologist with the Mass General Stroke Service, were waiting for her in the Emergency Department and immediately initiated a series of tests to diagnose the type and severity of stroke she was suffering.

An acute neurologic examination found that Collard was unresponsive to a variety of physical and verbal stimuli. This corresponded to score of 31 on the NIH Stroke Scale, a standardized method used by neurologists to measure the level of impairment caused by a stroke. Collard's high score indicated a severe impairment and possibly a poor prognosis. A CT angiogram revealed that Collard had a blockage of her left vertebral artery in the neck and that a clot had moved into the basilar artery, which supplies the brain stem. An MRI supported this potentially dismal prognosis. The tissue of the brain stem showed marked changes on diffusion weighted imaging (DWI) caused by the blockage of blood flow. Medical literature shows that with good reliability these images can predict the extent of neuronal death within an hour of onset.

"Embolic strokes in the posterior circulation are a life threatening situation," said Dr. Rabinov. "This area controls awareness and motor function, so we have to work efficiently."
Treatment OptionsStroke is one of the leading causes of serious, long-term disability in the United States. There are approximately 500,000 stroke cases each year. Two types can occur, hemorrhagic (when a blood vessel ruptures and blood leaks into the brain) and ischemic (when a vessel becomes narrow or blocked limiting blood flow to the brain).

Recognizing the signs of stroke quickly is critical because the treatments are time sensitive. According to the American Heart Association, warning signs of acute stroke can include:

  • Numbness or weakness of the face, arm or leg especially on one side of the body
  • Sudden confusion, trouble speaking or understanding language
  • Sudden trouble seeing with one or both eyes
  • Sudden trouble walking, dizziness, loss of balance or coordination
  • Sudden, severe headache with no known cause

Treatment with a clot dissolving drug called tissue plasminogen activator (tPA) has been found to be effective for ischemic stroke if the patient receives it intravenously (IV) within three hours of onset of symptoms. Endovascular treatment to deliver tPA in the artery at the site of the clot or retrieval of the clot are considered options for patients up to 9 hours following stroke onset. These procedures are performed by Interventional Neuroradiologists who are skilled at this delicate procedure.

For Collard, her diagnosis came too late for IV administration of tPA, so her doctors met with her husband of 24 years and her five daughters to explain their options. "The most dramatic aspect of the case may have been the discussion with the family on how to proceed with her care," said Dr. Rost. "No one is prepared to make these decisions for their loved ones, so we try to walk them through the treatment options."

"We talked with them about the range of possible outcomes. We were not sure if she would have much quality of life, but her situation was not hopeless," said Dr. Rabinov. "It was both a medical and emotional decision, and the family chose to give her every possible chance."
Intervention and RecoveryDr. Rabinov performed an endovascular treatment targeting the blood clot causing the severe stroke in the basilar artery. He navigated a catheter through her blood vessels to the site of the clot and used a variety of techniques, including the use of tPA within the clot, and eventually restored blood flow in the left vertebral artery and the basilar artery. Dr. Rost was working in parallel throughout the procedure, helping to make treatment decisions, monitoring the systemic indicators for her future neurological health, and keeping the family updated about the team's progress.

"We kept her asleep overnight, but the next day she began to regain strength very quickly," said Dr. Rabinov.

Collard spent the next seven days in the Neurointensive Care Unit at MGH and in total spent 16 days in the hospital. She was transferred to Rehabilitation Hospital of Cape Cod and the Islands where she continued her remarkable recovery.

"My whole right side was gone," she said. "I couldn’t walk, talk or eat, but the next week I was on my feet moving around. I worked hard because I wanted to talk again. I have too many grandchildren to enjoy, and I’m too young to be stuck in a wheelchair."

Collard says her husband was by her side everyday helping her toward each breakthrough at rehab.

"The biggest step forward was getting the tracheostomy removed," she said of the tube that was placed to help her breathe. "I really enjoyed tasting my first cup of coffee after that."

Collard was at the rehab hospital for another two weeks before returning home to New Bedford. After frequent rehab sessions for nearly a year, she is walking without a can and has no trouble with her speech.

"I didn’t recognize her the first time she came to my clinic for a follow up appointment," said Dr. Rost. "I was in the waiting room expecting someone in a wheelchair, and she was just standing there smiling at me. Moreover, she has continued to improve every time I have seen her since."
Learning From Her CaseDr. Rabinov explained that it is very rare that doctors are able to impact the outcome of a stroke patient as sick and close to death as Collard. Brain scans prior to her procedure show that most of the neurons in the brain stem appeared to be dead. This usually is a poor indication for recovery.

"If you look at our database, she is one of the most severely affected cases we have ever seen," said Dr. Rost. "You can open the blood vessels but if the brain tissue is dead, function will not return."

Follow up MRIs of Collard’s brain uncovered some unexpected surprises. The seemingly dead tissue appeared to have recovered once blood flow was restored.

"We postulate that her blood vessels helped her out with some collateral circulation. It may have allowed a small amount of oxygen supply to the ischemic tissue near the blockage. By opening the blockage some of the injured tissue could recover." The case study has been accepted for publication in a medical journal so that other doctors can learn from it.

"I’m amazed at how I came through it all; just amazed," said Collard. "I hope I can offer some hope that it is possible to survive a brain stem stroke. It can be done."

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