Wednesday, September 02, 2009

Bless You

I witnessed the most bizarre stroke I have ever seen a few weeks ago. A nice woman, relatively young, came in by ambulance with a terrible stroke.

She had her eyes locked off to the right. With this she had 'hemineglect' for the left side of her body... Couldn't see me on her left side or hear me. That's a stroke phenomenon and it's very bizarre when you see it. She couldn't move her right side, upper or lower, and while she could understand speech, she couldn't speak. She was either going to die from this or we were going to fly her to a stroke center or we were going to give her thrombolytics right there.

Enter the family. No, we would not fly her, she was staying with us. Still don't understand that, but those were the rules.

About ten minutes into our evaluation and after the head CT showed a small basilar artery thrombosis, the patient vomited, partly on me and partly on my nurse and a lot on herself. And the patient was cured in the space of three seconds. Eyes back to midline, speech returned to normal, and only a few residua of the initial massive stroke.

The neurologist explained that the patient, with this forceful 'valsavla' maneuver, had split the clot in two and sent it higher in the cerebral circulation allowing for meaningful blood flow to most of the previously ischemic brain. The clerk reminded me that this patient had a lot of people praying for her. Interesting. Miraculous. One in a million.

21 comments:

  1. Sounds like a logical explanation, except for the "Neurologist" part which means its totally bogus...Doesn't a valsalva increase Intracranial Pressure? anyway, glad shes doin better.
    Think you're ward clerk is closer to the truth

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  2. So since I'm aspiring to med school, I really try to understand stuff like this. Was hoping if somebody can tell me if I'm correct in how I'm reading this.

    So with an ischemic stroke, she basically has a blood clot bleeding blocking flow of blood to her brain or a blood vessel ruptured and she's bleeding into her skull/brain. You'd be giving thrombolytics thinking its the first one, which, in essence is like plunging a toilet; hoping to push the clot through.

    Is that correct? If she were actually bleeding into her brain, would thrombolytics potentially make things worse?

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  3. Anthony, I'm only a lowly Biologist, but have taught Human Anatomy and Physiolgy. I think you are confusing an aneurism and the bleeding, with a clot/stroke and the clogging. The thrombolytic would be a clot dissolver, so more like Drano than a plunger.

    Of course, Frank would tell me to go sit in the corner with the Neurologists.

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  4. Frankie, can't you see it?!?!?
    Kinda like some of your stories....boy meets girl, boy likes girl,sexual tension building, building, building...sudden release of tension...nothing left but the angles singing!!!

    Steve

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  5. There you have it!!! Valsalva, instead of thrombolytics for stroke.

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  6. Great story and IMHO the two explanations are not mutually exclusive.

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  7. So, is Genentec working on a $3,000 bottle of Ipecac?

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  8. erdoc85...best response of the day!

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  9. Valsalva / violent retching / vomiting would increase the intrathoracic pressure, hence increase intra-arterial pressure in the Basilar artery, which could potentially dislodge an acute embolus/thrombus. Pretty far-fetched. But like most of us know, truth is stranger than fiction in medicine. Great story.

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  10. Anonymous said...

    There you have it!!! Valsalva, instead of thrombolytics for stroke.
    ===================
    I'm no Doc, but I have a pretty solid grasp of anatomy and hydraulics.

    All joking aside - is this not worth a shot, once a bleed has been ruled out?

    I'm convinced that in many, many cases we DO have the capacity to heal ourselves, as this woman demonstrated!

    /not as goofy as it seems...

    DD

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  11. Did you find out what was the cause of the clot? I am not a doctor, nor a biologist, but isn't that an odd finding for a 'relatively young' girl?

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  12. @JohnDoe,

    I'm no doctor, but I do know that birth control pills have a propensity to cause clots, especially if one smokes.

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  13. 911DOC'S Scribe11:10 AM, September 03, 2009

    Pink,

    if my memory serves me right, birth control was not on her med list. but it really was amazing. like 911DOC said, the patient vomited, eyes went back to midline and i'm quoting the patient immediately after she vomited, "Boy do I feel better!" now i'm just starting my medical career and i believe that i witnessed a true phenomenon. that patient definitely has someone to be thanking!

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  14. Aspirins an effective OCP if used correctly...

    One 81/mg aspirin HBK daily


    HBK= "Hold Between Knees"

    Frank

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  15. Ohhh! Is that why they call the little chewable aspirin "baby aspirin"? I guess it makes sense ... the smaller the tablet, the tighter you have to hold your knees. It is an amazingly versatile drug. What other off-label uses does it have?

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  16. hope to answer all here...

    the clot was likely from the heart but i do not recall the patient being in atrial fibrillation which would predispose one to forming clots which could then travel.

    a 'patent foramen ovale', hole in the heart, would, conceivably, allow lower extremity clots to migrate across the heart and up to the head but very rare.

    an atherosclerotic embolus... a piece of plaque from an artery is another possibility.

    no thrombolytics indicated here for two reasons... 1. the patient was nearly cured with the sneeze-vomit (snomit as we say in the ER) and 2. evidently, basilar artery thromboses tend to bleed with lytics... don't know why, but they are high risk.

    as it turned out this patient was placed on heparin to prevent further clotting, and was 'tanked up' with fluids to allow for expansion of the diameter of the arterial vessels in the brain.

    the whole think was spooky, in a good way. once in a lifetime.

    in terms of trying a 'valsalva' with every acute stroke i think the neurologists and neurosurgeons would kill me because i would probably, if i could get the patient who is completely gorked, to follow my commands, cause a 'dry stroke' to bleed, and then we are UTCWOAP. ("up the creek...)

    last aside, met a cardiologist who claimed that all VFib arrest patients do better in the cath lab than non VFib arrest patients, presumably due to this same phenomena... huge valsalva with 300J, clot either broken or moved distally, more heart survives. just goes to show i do not, in fact, know it all.

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  17. ooooOOOOOOOOoooooh, cool.
    -SCNS

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  18. Snomit?! My boys will love that!

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  19. I am a neurologist, and in my view the correct answer is: who the hell knows?

    Maybe the Valsalva pressure dislodged and broke up the embolus.

    Maybe the imposing presence of the awesome ER doc scared the clot shitless and it shattered.

    Maybe the clot was breaking up on it's own anyway.

    Maybe the patient had migrainous basilar vasospasm that relaxed.

    Maybe aliens used a laser beam from Alpha Centauri to dissolve the clot.

    The bottom line is that, whatever the reason, this lady is lucky. And lucky is good, no matter where the luck came from.

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  20. Grumpy, just curious what made you go into Neurology??? A fetish for tickling quadriplegics feet? You could pronounce "Amyotrophiclateralsclerosis" with one breath? and why do most Neurologists seem to suffer from a Neurologic condition?? C'mon!
    "Time is Brain"!!

    Frank

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