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Timely Stroke Treatment Saves Young Mother's Life

June 04, 2013

Hayley Iben, PhD, and her husband Pushkar Joshi, PhD, met while they were doctoral students in computer science at the University of California-Berkeley. Iben, who works on software development at PIXAR, and Joshi, a software engineer for Google, celebrated New Year's Day this year with the delivery of their newborn son, Ajay. Just one month later, on February 1, the 34-year-old mother suffered a life-threatening ischemic stroke - the result of a blood clot that blocked an artery in the left side of her brain.

Today, Iben is on the road to recovering nearly all of her normal function, thanks to the quick responses of Dr. Prabhjot Khalsa, a neurologist and clinical neurophysiologist, and Dr. Jeffrey Thomas, a cerebrovascular neurosurgeon and medical director of Interventional Neuroradiology at Washington Hospital.

"My mom, Betty Iben, had come out from Pennsylvania to help take care of the baby, so my husband and I decided to go out on a 'date night' since it was a Friday," she recalls. "We were just leaving our house in Fremont, and I was checking traffic conditions on my cell phone. We decided to take city streets to avoid the traffic congestion on I-880. Then all of a sudden, I couldn't move my right hand to turn off the phone. It didn't hurt, but I couldn't talk. Then I tried to smile at my husband, and he noticed that the right side of my face was drooping."

Iben's husband immediately recognized that the "drooping" on just one side of her face was a symptom of stroke.

"Luckily, we were already headed toward Washington Hospital," she says. "By the time we got to the hospital, I could talk a little. I tried to tell my husband that something was wrong with my hand, but I called it my foot, instead. I just couldn't use the right word."

After arriving at the emergency room, Iben was taken in immediately when her husband said he thought she had a stroke. A CT scan confirmed the stroke diagnosis. Dr. Khalsa showed up quickly and ordered an intravenous injection of tissue Plasminogen Activator (tPA), a strong "clot dissolving" medicine. This drug needs to be given within 4.5 hours after stroke symptoms begin to restore blood flow by dissolving the blood clot causing the stroke. Iben received her first dose of tPA within an hour of arriving at the hospital.

"After the tPA injection, my speech improved a bit, but I still couldn't move my right hand the way I wanted to," she says. "They performed additional CT scans that showed it was getting worse, so they called in Dr. Thomas. When he arrived, I was conscious, but I really couldn't understand what was going on."

Dr. Thomas notes, "I rushed to the hospital and raced into the operating room. I encountered her mother and husband on the way in and got informed consent. She had a blocked left internal carotid artery, so no blood was getting to the left side of her brain. She was awake, but her mental condition was compromised and worsening.

"The stakes are higher with a young person who suffers a stroke," he adds. "It could cause unimaginable disability that could be a huge problem for the rest of her life, and death is a very real possibility."

Iben was quickly put under general anesthesia and attached to equipment to monitor her brain wave activity. Then Dr. Thomas performed an interventional neuroradiology procedure (also known as endovascular neurosurgery) to open up the blockage.

"We made a tiny incision in the leg and inserted a microcatheter just under the skin, threading it through the bloodstream, going up through the leg, abdomen, chest, neck and into the brain," he explains. "Then we injected dye into the artery to get digital images of the blood vessels. The imaging showed the middle cerebral artery in the brain was completely blocked by a blood clot, and her left carotid artery in the neck was blocked, apparently by a disruption in its wall. The blood clot had migrated from the site of injury in the neck, into the vital brain artery.

"We had to be able to get around the obstruction in the left carotid artery in the neck, which was essentially a complete roadblock," he continues. "So I used the brain's alternative routes, called 'collateral circulation.' I went through the right carotid artery, and then crossed from the right side of the brain to the left. Then I went through the left vertebral artery to cross from the back of the left brain to the front. This allowed us to deliver tPA directly to the clot on the left side of the brain. We were able to do it all via the small leg incision using the microcatheter, and I knew it was going well because the neurophysiologist told me during the procedure that the electrical activity in that area of her brain had improved substantially. This is the area of the brain controlling speech and right-sided movement, among other things."

The entire procedure took less than two hours.

"The sooner you can administer the tPA, the better," Dr. Thomas says. "You want those neurons in the brain alive when the blood flow is restored. Strokes are very dramatic events. If you've 'won,' you've won pretty big. After the first few days, she was well on her way to being back to normal."

Iben woke up in the Critical Care Unit (CCU) of the hospital.

"At first, the nurse in the CCU tried to get me to squeeze her hand to indicate that I recognized things, but I was too drowsy," she says. "Later in the morning, though, when my mom and husband came in to see me, I tried to reach for him. He was so happy that I could recognize him!"

For the next three days, Iben was confined to bed because the catheter was still in place in case another procedure had to be performed. Once she had the catheter removed, she had no trouble walking, and the hospital staff started her on speech therapy, physical therapy and occupational therapy until she was able to leave the hospital on February 8.

"At first, I couldn't talk much at all," she notes. "My husband's and baby's names were my first words. After I left the hospital, I went to an outpatient rehabilitation center for a week for physical, occupational and speech therapy. Afterward, I still had pain in my right hand, so I did more occupational therapy. I'm still waiting for the pain to go away in the right hand, but I have no trouble using the hand. I also currently am in ongoing speech therapy to address the aphasia - a common speech problem resulting from the location in the brain of the stroke I had."

The procedure Dr. Thomas performed on Iben is not "standard of care" at any American hospital and, if offered, is most often done in large university medical centers. Washington Hospital is among a very small number of community hospitals nationwide that provide this type of procedure. Dr. Thomas joined Washington Hospital in November 2011 to lead the development of a Comprehensive Center for Cerebrovascular, Neurointerventional and Stroke Surgery. He is one of only about 120 neurosurgeons in the United States with dual expertise in microscopic brain surgery and interventional neuroradiology. He previously had spent eight years at California Pacific Medical Center in San Francisco, leading the development of their Neurointerventional and Cerebrovascular Surgery Program.

"We are in the midst of building an advanced stroke program at Washington Hospital," says Dr. Thomas. "It is one of the missions of the hospital to expand and improve our care of stroke patients. This is a great service to people in the East Bay. Patients don't have to cross over the bay to a university hospital, which is important because time is critical in treating stroke victims. It is unusual to have neurosurgeons who perform these types of procedures at a community hospital."

Iben certainly appreciates her good fortune in having such advanced stroke care so close to home.

"We were very lucky," she remarks. "I didn't even know Washington Hospital was a stroke center. I also didn't realize how bad my stroke was - or how bad it could have been if I hadn't gone to Washington Hospital."


Recognizing the Risk Factors and Symptoms for Strokes

Hayley Iben did not fit the profile of a "typical" stroke victim.

She was young (age 34) and healthy, while most strokes occur in people over age 65. She had no known family history of stroke. She had no history of high blood pressure or high cholesterol. She never had any symptoms of cardiovascular disease. She did not have diabetes, and she was not a smoker.

"I had carefully monitored my blood pressure and cholesterol during pregnancy," she says. "When I had my stroke, my cholesterol was slightly above normal, which I understand sometimes happens with childbirth. I have always been healthy, and there was no indication of anything that would be a risk factor for stroke. After I had my stroke, though, I learned that women may be at a slightly higher risk for a stroke after having a baby."

Dr. Thomas explains: "Childbirth is known for producing big fluid shifts in the mother's body, and that may have contributed to her stroke, but we can't say for sure. Also, after her stroke, Dr. Khalsa discovered by means of a blood test that Hayley had an inherited trait known as Factor V Leiden that makes blood have a tendency to coagulate and clot more easily. In either case, the event that is believed to have resulted in the initial blockage of her carotid artery in the neck was likely a spontaneous disruption of the vessel wall called a 'dissection.' It is a common cause of stroke in young healthy persons with no other stroke risk factors."

In Iben's case, she was extremely fortunate that her husband recognized her drooping face as a possible symptom of a stroke. According to the American Stroke Association, it is important to "Spot a Stroke F.A.S.T." with these stroke warning signs and symptoms:
* Face Drooping - Does one side of the face droop, or is it numb? Ask the person to smile.
* Arm Weakness - Is one arm weak or numb? Ask the person to raise both arms. Does one arm drift downward?
* Speech Difficulty - Is speech slurred, are they unable to speak, or are they hard to understand. Ask the person to repeat a simple sentence, like "The sky is blue." Is the sentence repeated correctly?
* Time to call 9-1-1 - If the person shows any of these symptoms, even if the symptoms go away, call 9-1-1 and get the person to the hospital immediately.

Other possible symptoms of stroke might include:
* Sudden numbness or weakness of a leg.
* Sudden confusion or trouble understanding.
* Sudden trouble seeing in one or both eyes.
* Sudden trouble walking, dizziness, loss of balance or coordination.
* Sudden severe headache with no known cause.

For more information about strokes, visit www.strokeassociation.org. For information about stroke services provided at Washington Hospital, or to find a physician who specializes in treating strokes, visit www.whhs.com.

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