The Nurse's View

Hi everyone. This is Heidi, Ed's sister and I am a nurse. Ed and Gwen's kids asked that I add my few cents here, and I am happy to do so. First, a few disclaimers. I practiced as a pediatric nurse when I practiced years ago. Now, my specialty is signing purchase orders and dealing with educational "adminis-trivia", so I do not hold myself out as an expert on strokes, or any other "adult" malady. However, I have had the chance to review Gwen's medical records with her permission and have a bit of a sense of the medical issues. Clint and Clay have done a great job of accurately reporting her condition, and I share their joy at seeing her progress since the early phase of her stroke. So, now for the physiology lesson:

We may never know what caused Gwen's stroke. The most likely "cause" may be an irregular heartbeat. I'll explain why in a bit. But first, you might be wondering what a stroke is. We use that term a lot, but in my experience I find that most people really don't know what that means.

Stroke
The term "stroke" just refers to a a sudden impairment of brain function. This can be caused by:

• a blood clot (we call that an "embolus")
• some other substance, like plaque from a diseased artery (we call that a "thrombus")

This is called an "ischemic stroke" and is caused by a blockage in a blood vessel. Ischemia means "restriction in the blood supply". An embolus or a thrombus can travel along in larger blood vessels, but eventually can get caught in the very small blood vessels and cause the blood flow to that area to stop (just like a dam in a river). When this happens, the oxygen rich blood cannot move on into the surrounding tissues and the cells that are fed by that blood vessel are then damaged. This appears to be the type of stroke that Gwen suffered. More on that later.

Another type of stroke is called a "hemmorhagic" stroke. This is when a blood vessel ruptures, like with an aneurism, and causes bleeding in the brain. That causes the brain tissue to be pressed against the skull, and that pressure causes the blood flow to that area of the brain to be decreased and the cells to be damaged. This does NOT appear the be the type of stroke that Gwen experienced. We know this because there was no sign of hemorrhage on any of the MRI scans that were performed.

So, Gwen has probably had an Ischemic Stroke that my have been caused by an embolus (blood clot) or by a thrombus (some other material like a plaque). All of her artery and vein studies in the neck (carotid arteries and jugular veins) have been evaluated and are clear, meaning there was no plaque inside those blood vessels, which would appear to mean that it was most likely NOT a thrombus, or plaque, that caused the stroke. We are left, then, with the most probable cause being a blood clot, or embolus.

So, what does her heart beat have to do with this?

You may remember from your biology classes that the heart has four chambers. There are 2 atria and 2 ventricles. The atria are on the top part of the heart and are smaller than the ventricles. The atria act like the "waiting room" for the blood before it goes into the ventricles, which are the work horses or "pumps" that squeeze the blood out into the lungs and the rest of the body. The right side of the heart, meaning the right atrium and the right ventricle, collect the unoxygenated blood from the body and push it into the lungs to get oxygen. After the blood gets oxygen in the lungs, the blood goes through the left atrium, then goes to the left ventricle to be pushed out into the body with every heart beat.

The atria and the ventricles are separated by heart valves. Think about the old irrigation ditches and how we would move water forward in the ditch by using "gates" and dams. Or think about moving cattle through the working chutes to the squeeze chute. You have to have some way to stop the water, or the cows, from moving backwards....everything has to move forward. It is the same way with blood in the heart. When the blood is squeezed forcefully out of the ventricle to move forward in the system, something has to stop the blood from going backwards into the atrium. That is the purpose of the heart valves. The heart valves act like dams or gates to prevent the blood from moving backwards in the circulatory system.

A heart murmur is heard when the valves do not close sufficiently to keep the blood from moving backwards when the ventricle pumps the blood to the next "station". Since the valve does not close completely, the blood is kind of turbulent at the valve and it creates a swooshing sound. Think of a river flowing...it makes noise because of the turbulence that is created when it goes around stones, branches, etc.

When Gwen came in, her neurologist said that he heard a heart "murmur". However, her heart studies did not show any problems with her valves, so that is good news. Perhaps it was a temporary problem related to the stroke? Who knows. Then, she began to have an irregular heart rhythm. One possible reason for this could be atrial fibrillation. By its name you can tell that this condition happens in the atria (plural for atrium...the top chambers of the heart, or "waiting rooms" for the blood). Fibrillation means that they are vibrating or "jiggling like a bag of worms". Different things can cause this situation, and I do not know what caused Gwen's irregular heartbeat. However, when this happens, the atria are "jiggling" instead of "pumping". The atria normally do not pump as forcefully as the ventricles do, but they do have a little pump to them to help get the blood down into the ventricles. When blood is not moving, it coagulates, or clots. So, if the blood is kind of stagnant in the atria and not moving forward, it can clot and become an embolus that can then travel through the system until it gets lodged in a tiny blood vessel in the brain and cause a stroke. This is the most likely cause of Gwen's stroke, though, frankly, it is hard to say if the stroke was caused by a clot formed by an irregular heart rate or if the irregular heart rate was caused by the stroke which happened for some other reason. That will probably remain a mystery. As Clay mentioned in an earlier posting, Gwen's heart rate converted on it's own to a regular beat a few days ago, and to my knowledge, continues to be regular.

Now, as for the location of the stroke. The neurologist indicated in one of his notes that he thought the stroke occurred in the left midbrain. The midbrain is the smallest region of the brain and it acts as a relay station for sound a visual information. In the brain, injuries to the left side of the brain show themselves on the right side of the body, and vice versa. The doctor referred early on to a "lacunar stroke". A lacunar stroke is the name given to a stroke that involves very small blood vessels at the end of larger vessels. The location of the stroke deep in the midbrain, and in very small vessels, may explain why all of her brain studies have come back essentially normal.

Now, as for treatment...

Gwen has already received the treatment one would expect. The most important element of her treatment is to prevent further strokes. This is being done by giving her medications that thin the blood to decrease the chance of further clotting.

Now, the focus is on rehabilitation, physical therapy, speech therapy and occupational therapy. These activities will be on-going and will be focused on getting her as independent as possible. We can all expect a hit of a roller coaster in terms of her abilities, but their should be fairly general, overall improvement as time goes on. There may be day-to-day ups and downs, and often these will be determined by her fatigue level. She is working VERY HARD....every physical movement, spoken word and attention to conversation is taking a lot of her energy. Things that were automatic for her before the stroke are now things that may have to be concentrated on, and that takes energy. She needs her rest as much as she needs her therapy. It is fine to encourage her, but do not over tax her. Take the lead from the therapists on how much she should do.

Finally, two things for you all:

• take one baby aspirin a day (81 mg). Aspirin is well documented as a good preventative against strokes and heart attacks caused by blood clots...it thins the blood a bit. This is one case where more is not better. 1 baby aspirin is all you need; more can cause stomach bleeding, so don't take more than that every day. Report that you are taking baby aspirin as part of your regular medications when you go to the doctor or the hospital.
• I recommend the book, My Stroke of Insight: A Brain Scientist's Personal Journey written by Jill Taylor (no relation!). She suffered a stroke herself and offers a compelling first hand account and good advice for dealing with this difficult experience. You can find it on Amazon and it costs around 15.00

Love to all....Heidi