Stopping a Stroke

When the young mother of two passed out, a revolutionary surgery was her best hope. But the clock was ticking 
 
<P>Traci miller woke up to the sound of quick footsteps scampering toward her room. It was shortly before dawn on a rainy Saturday in April 2006, but her three-year-old daughter, Alexis, was up unusually early. Traci tucked the toddler back in bed, then checked on one-year-old Rylee, who was sound asleep in her crib. It would be nice to slide under the covers for a few more minutes. But the redheaded mom from Hackettstown, New Jersey, had a busy day planned. She and her husband, Michael, had an appointment with a real estate agent to look at larger houses for their growing family, and her parents would be visiting later in the day. “I’m going to take a shower,” she told Michael, who was still dozing. “I’ve stuff to do before Mom and Dad get here - and we need groceries too.”</P><P>Seconds later, Michael heard a thud. He didn’t know it, but a desperate race against time had just begun. He leapt out of bed to see what was wrong. In the bathroom, he found his wife of five years slumped against the tub. “I was screaming her name and asking if she was okay, but she just stared straight ahead and didn’t answer,” says the 36-year-old civil engineer. “She was moaning, kind of crying. I was terrified.” He carried her to their bed, then dialed 911. During the call, he noticed that Traci couldn’t move her right leg. “That scared me even more.” </P><P>Within minutes, police rushed in with their radios blaring. Since Traci couldn’t talk, they asked Michael what had happened. “Maybe she hit her head and got a concussion,” he replied. Before long, the bedroom was full of paramedics, who examined Traci, slipped a brace around her neck, and loaded her onto a stretcher. During the wait for the ambulance, which was delayed on another call, Michael asked a neighbor to come over and watch the kids until he could reach relatives.</P><P>Amazingly, baby Rylee slept through the commotion, and Alexis played quietly in bed, unaware of the emergency.<BR>By the time the ambulance finally arrived, Michael was frantic. The right side of Traci’s face had developed an alarming droop, and her mouth hung open. She was raced to a local hospital, then airlifted to a trauma center in Morristown, New Jersey. “I knew they wouldn’t do that unless her condition was very serious,” says Michael, who followed in his car. “I was crying as I drove. How could she have hurt herself so badly slipping in the bathroom? I panicked to the point that I thought about losing my wife, and our girls growing up without their mother.”</P><P>When michael reached Morristown Memorial Hospital at 7:40 a.m., he tried to get his emotions under control. During a brief visit with Traci, who was paralyzed on the right side of her body, he discovered that she could communicate with head motions. “Did you fall?” he asked. She nodded yes. “Do you remember how you fell?” She shook her head no. Then she was wheeled off for tests, including a CAT scan, while Michael prayed in the waiting room and called home to check on the kids. </P><P>Nearly an hour later, ER doctors returned with shocking news: Traci had suffered a stroke - loss of blood flow to part of the brain, usually caused when a vessel is blocked by a clot. Michael couldn’t believe it. How could this have happened? His wife, a slim, physically fit nonsmoker, was only 35. His mind raced from one terrifying scenario to another. One of his relatives had a stroke and was never the same afterward. Would that happen to Traci? Would she ever walk or talk again? Was she going to die? Strokes kill more than 157,000 Americans a year, about 60 percent of them women. Survivors can be left with paralysis, impaired vision, chronic pain, difficulty speaking, or cognitive or emotional problems.</P><P>The neurologist explained that it might be possible to reverse the stroke. But it all depended on whether Traci could be treated in time. The longer her brain went without blood flow, the greater the damage. Before the doctors could do anything, they needed to pinpoint when the symptoms started. There are only two FDA-approved therapies for stroke, and both had to be given within strict time limits. Michael hadn’t looked at a clock, but his best guess was that she was stricken at around 6 a.m., or possibly a little later.</P><P>The specialist checked his watch. It was 8:45 a.m. There were just minutes left to administer tPA (tissue plasminogen activator), a clot-busting drug that’s only approved for use within three hours of a stroke. But the doctor worried that the clot in Traci’s brain was too big to dissolve with tPA. If it didn’t work, she’d be left profoundly disabled, if she survived at all. Up to 50 percent of people with a blockage where Traci’s was die.</P><P>Traci also qualified for a newer procedure, then offered at only one facility in her state: Overlook Hospital, in Summit, New Jersey. A corkscrew-like device called the Merci Retriever (FDA approved in August 2004) is designed to pluck clots out of blocked vessels like corks from wine bottles. It’s more beneficial than tPA for large blockages and works for up to eight hours after a stroke, says Ronald Benitez, MD, Overlook’s director of endovascular neurosurgery. “Expanding the treatment window means many more patients will be spared death or disability, since most people don’t get to the hospital in time for tPA.” </P><P>The Merci treatment has serious risks, including punctured blood vessels (brain hemorrhaging), which could worsen the stroke or even be fatal. And since the hospital had recently acquired the device, Traci would be only the second patient in New Jersey to undergo the procedure, which is 54 to 69 percent effective at restoring blood flow, according to a 2006 study at University of California, San Francisco. Faced with a life-or-death decision, and a ticking clock, Michael didn’t hesitate. Scrawling his signature on a consent form, he shouted, “What are you waiting for? Let’s get her moved to the other hospital!”</P><P>While doctors scrambled to make the arrangements, Michael called Traci’s parents. “I hoped I’d made the right decision,” he says. “I would have agreed to anything if it gave Traci a better chance at getting back to normal. She didn’t seem to be suffering, but when the doctor asked her to stick out her tongue, she couldn’t even do that.” Michael sped to Overlook Hospital so fast that he actually beat the ambulance there. When Traci arrived, about 10 a.m., he kissed her and promised that the surgeons would help her. “I must have said ‘I love you’ a hundred times before they pulled me away. I was bawling my head off.”</P><P>Four and a half hours after the stroke began, Traci was put under general anesthesia. Dr. Benitez threaded a tiny tube into an artery in her leg. Using x-ray images as a digital road map, he navigated through a maze of blood vessels to her brain. When he reached the blocked vessel, he squirted tPA directly into the clot, a still experimental use of the drug. “That loosens the clot up so it’s easier to extract,” the surgeon explains. The next step was inserting the Merci Retriever into the tube. The Retriever is a flexible wire made of metals that have “memory.” When the nickel and titanium tip comes out the other end of the tube, it “remembers” to curl into a corkscrew. If all goes well, it snares the blockage when pulled back through it. </P><P>But Dr. Benitez’s first attempt only captured a few fragments - just enough to start a trickle of blood through the obstructed vessel, like water spilling from a leaky dam. Not good enough. The process was carefully repeated. “Traci’s being so young and having two kids added to the urgency,” Dr. Benitez says. The device was slowly extracted. To the doctor’s relief, a huge clot was tangled in its coils. X-rays showed blood surging through the vessel at the normal rate. Two much smaller vessels, though, were still clogged. Dr. Benitez squirted in more tPA and they slowly regained flow, except in one tiny area. He’d done all he could to bring her back. </P><P>Soon after the 90-minute procedure, Traci could wiggle her right leg. When she saw Michael in the recovery room, around 1 p.m., her first words were, “I love you.” He was amazed and ecstatic. It seemed like a miracle that she could speak so soon after the procedure. She was moved to the neurology ICU, where several anxious relatives were waiting to see her. A nurse explained after such a severe stroke, they’d have to monitor Traci’s progress one day at a time. It was too soon to predict whether she’d regain all of her former abilities, even with extensive rehabilitation. Michael sat at his wife’s bedside, holding her hand. “You’re going to be just fine,” he promised. “You’re a fighter and can overcome this.” Traci nodded slowly, then drifted off to sleep.</P><P>Over the next 24 hours, he rejoiced at each new milestone. Although her speech was soft and slurred, she whispered simple words, such as “yes,” “no” and “hi.” She also recognized friends and relatives who dropped by, and even greeted her brother-in-law by his nickname, “Dupe.” On Sunday afternoon, a day and a half after the stroke, she took her first steps, with the aid of a walker. “I was very excited, relieved and hopeful,” says Michael. Even though Traci seemed dazed, and had limited use of her right arm, he was convinced that over time, she’d recover 100 percent.</P><P>The next day, however, there was a setback. When a doctor checked her vision, she didn’t react when he shone a flashlight into her left eye. “I was devastated that I couldn’t see on that side,” says Traci, who was struggling to understand what had happened to her. “I didn’t get the whole stroke thing, or why something was wrong with my left eye, when the other problems were on the right side of my body.” The doctor thought that a fragment of the clot might have blocked flow to a vessel in that eye during the stroke, but he held out hope that her vision might eventually return. By the end of the week, she could see shadows. </P><P>She graduated from a walker to a cane, and began to speak in complete sentences. “I’m going to be okay,” she told her parents. They were helping Michael care for the kids. Rylee was too young to talk, but Alexis kept asking to see her mom. She had to wait until Traci was moved from the ICU to a regular hospital room. Before the visit, Michael explained that Traci used Play-Doh to exercise her hand. Alexis rifled through her toy box until she found a container of pink Play-Doh, the little girl’s favorite color. “This will help Mommy get better,” she proclaimed. Traci was so happy to see the children that she burst into tears,then put Alexis in her lap while they squeezed and molded the Play-Doh together.</P><P>After a week, Traci was transferred to a rehabilitation center, where she received physical, occupational and speech therapies. Two weeks after the stroke, she was well enough to go home and begin outpatient treatment. Before long, she was walking without a cane, though her right foot dragged, causing her to stumble frequently. She gradually learned to walk normally, and her right arm gained greater strength and flexibility, though it remains weaker than the left. Learning to write again was a struggle. At first, she could barely print her name, but eventually, her penmanship was nearly perfect.</P><P>As her physical skills returned, her thinking also got sharper. “About four weeks after the stroke, it finally hit me how serious this was. I wanted to know, Why me?” Tests revealed a previously undiagnosed birth defect: a small hole in her heart that made her more prone to stroke. However, doctors decided to postpone repair until she was further along with her recovery. Meanwhile, sight gradually returned to her left eye, though her vision is blurry on that side. She fumbles for a word occasionally but has no other speech problems.</P><P>In early July, she returned to her job at a pharmaceutical company. “I’m amazed that I had a 50-50 chance of dying, but I’m still here,” says Traci, who had a cardiac repair operation in September. She’s also had an emotional change of heart. “I’ve cut back on my hours at work, and I take more vacations. My life is here at home with my girls and my husband, and I want to enjoy it to the fullest.”</P>
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