Stroke Month: Cutting-edge treatment helps Casper man walk out of hospital after stroke
By Kristy Bleizeffer May 7, 2018
Chantel Balcerzak’s heart sank when she heard the word. To her, “stroke” meant disability, long hours of physical therapy, possibly relearning to walk or talk.
Her husband of 17 years, David Balcerzak, was at Wyoming Medical Center in the ICU. She felt traumatized as she texted their grown children. Their son, who was in Denver with a premature baby, drove back to Casper.
“I know a couple people who have had strokes and they never fully recovered. Strokes, as I always understood, are bad bad news,” said David.
Not so long ago, “stroke” too often meant long-term disability or at least long, hard-fought recoveries for survivors and their families. It is still the fourth-leading cause of death and the leading cause of long-term disability in the United States.
But thanks to Wyoming Medical Center’s multidisciplinary stroke team and emerging cutting-edge treatments, this is not the Balcerzaks’ story. Though David suffered a sudden and severe blockage in one of the main arteries feeding blood to the right side of his brain, he walked out of the hospital three days later with no residual side effects.
David, 50, has atrial fibrillation – an irregular and rapid heart rate – and has had heart failure in the past. On New Year’s Eve, he had trouble sleeping and woke up gasping. He gained 15 pounds in three days and went to see his cardiologist. He was admitted to Wyoming Medical Center on Jan. 4 after a short procedure to shock his heart back into rhythm. Mostly, his doctors wanted to see how he reacted to changes to his heart medication.
At about 3 a.m. Jan. 5, David felt an unexplained pain in his toe and pushed his call button: “The CNA came in and she could not understand what I was saying, my face was drooping and all of that. She knew I was having a stroke,” David said. “From there, it was kind of a whirlwind for me. I don’t remember much.”
The CNA alerted David’s nurse who activated the Wyoming Medical Center stroke team. The team is made up of members from nearly every department in the hospital including EMS, ER nurses and physicians, radiology, laboratory, pharmacy, ICU, neurology, therapies, case managers and more. The team meets monthly to analyze the latest data, collaborate on best care practices and troubleshoot areas that need improvement.
David Wheeler, M.D., was the neurologist on call that morning. He is also medical director of Wyoming Medical Center’s stroke program. Dr. Wheeler ordered an immediate stroke protocol CT scan to detect the amount of blood flowing into David’s brain as well as show his specific anatomy of arteries. Dr. Wheeler administered intravenous tPA – or tissue plasminogen activator, a protein used to break apart blood clots and, hopefully, restore blood flow to the brain.
Even three years ago, treatment for David’s stroke might have stalled there while doctors waited to see how he reacted to the clot buster. But in January 2015, the first of three major studies on the effectiveness of new-generation clot retrieval devices was published in the New England Journal of Medicine. The studies showed that physically removing clots from the brain, along with clot buster management, dramatically improved outcomes for certain stroke patients. The results were so convincing that a couple of the trials were stopped early, Dr. Wheeler said. The standard of care completely shifted.
Dr. Wheeler recognized that David was a good candidate for mechanical clot retrieval and called Michael Sloan, M.D. Dr. Sloan is an interventional radiologist, the type of specialist that makes this type of stroke treatment possible at WMC.
Sudden and severe
David’s stroke was sudden and severe, cutting blood flow through one of the main arteries feeding the right side of his brain. It was “embolic,” meaning the clot came from another source, presumably David’s heart. Cardiac arrhythmia can sometimes create small blood clots which can break free and travel to other parts of the body, including the brain.
Inside WMC’s interventional radiology suite, Dr. Sloan accessed the common femoral artery near David’s groin and inserted a small guide wire covered with a vascular sheath. Guided by real-time X-ray imaging, Dr. Sloan snaked the guide wire through David’s arteries and around a complex path to the artery in his neck. He then passed smaller tubes into the blocked artery in David’s brain and released a special device called a “stent retriever” to ensnare the clot and remove it. However, the device was unsuccessful after two attempts, so Dr. Sloan used the suction of the tube to “cork” the clot material in the tube and pull it out.
During the procedure, David’s condition worsened at first. He was combative and could not communicate. A CT scan taken just before the interventional treatment showed another, larger clot in an artery in his neck which would have likely caused another, much larger stroke. Dr. Sloan removed that clot as well.
After treatment, David’s condition improved dramatically. He was speaking and moving all his extremities the next day and his neurological exam was normal the day after that.
“This is an incredible success story for modern medicine,” Dr. Sloan said. “Before 20 years ago, a patient arriving in the emergency room with a stroke was treated with a watch and wait approach – there was no attempt to improve the symptoms or outcome of the stroke.”
'Gold standard treatment'
About 10 years ago, the cutting-edge treatment for David’s kind of stroke would have involved placing a tiny catheter near the brain or within the artery to drip the clot dissolving medicine near the clot. If he survived, he would have likely required many months of therapy or perhaps a stay in a rehabilitation hospital.
In the last several years, the clot retrieval devices have been developed and have improved rapidly. Clot retrieval, along with clot-busting medication, is now considered the gold standard treatment for patients that meet certain criteria -- that is patients who are suffering significant neurological deficit and whose symptoms started within the last four hours or so before the start of treatment. (More recent medical literature suggests clot retrieval is beneficial for some patients for up to 24 hours after the onset of symptoms.)
“Ultimately, whether or not a patient is good candidate for clot retrieval is a complex decision involving the patient's neurological symptoms, medical condition, timeline, etc. All of these factors are considered in detail by the neurologist and interventional radiologist caring for the patient,” said Dr. Sloan.
Wyoming Medical Center is the state’s first Primary Stroke Center certified by the Joint Commission. We are the only hospital with 24-hour coverage by an interventional radiologists, the specialists that make clot retrieval possible. We are working with emergency rooms at hospitals across the state to standardize care and identify more patients who could benefit from this type of treatment and transport them to Wyoming Medical Center in time.
“We are able to use cutting-edge stroke treatment techniques, including clot retrieval, at WMC around-the-clock, every day of the year,” said Dr. Sloan. “The frequency of these procedures is increasing as the public becomes more aware of the need to seek immediate treatment for neurological symptoms and as the referring physicians in Wyoming become aware of the success in treating acute stroke.”
'Blessing in disguise'
After his initial heart procedure, David was scheduled to leave the hospital on Monday, Jan. 8. His stroke did not delay his discharge. If anyone can call a stroke “lucky,” he and his wife think that the timing of his stroke was a blessing in disguise. Had the blood clot traveled to his brain while sleeping at home, would someone have caught it in time?
“I tell you what, I am thankful it happened as it did,” David said. “And I’m glad that it happened here in Casper, and that they had the specialists and expertise to treat it. I wouldn’t have wanted to be in Denver or somewhere else.”
“I guess we take the medical care in Casper for granted sometimes,” Chantel said. “He isn’t suffering from any sort of effects from his stroke. His speech is great. His movements are great. This has been a definite miracle from start to finish.”