!nsights

Editor's Note: It has been quite a while since we had a contribution to the !nsights section.. This month, Dr Rasmiranjan Pathi, I.R. Specialist highlights how it is possible to achieve mighty success despite measly access... 

And 'a stroke so grievous' desperately needed 'a stroke of genius!'..

She was a 27-year-old woman who had her whole life ahead of her. A driven IT professional, she was known for her ambition, social energy, and love for adventure. She lived life on her terms with a love marriage against the will of her family. That is, until the morning when everything changed...

It was a Sunday in the early Autumn, and she had woken up with a strange heaviness in her right arm. She brushed it off as nothing—she had been working long hours and figured her body was just telling her to slow down. But as she tried to walk she could not lift her leg off the floor. Panic set in when she realized she couldn’t speak. Words formed in her mind but refused to leave her mouth. A strange, slurred sound escaped her lips, and she fell to the ground. Her body felt disconnected, like a puppet with its strings cut. Her husband knew immediately that something was wrong. Her face was drooping on one side & eyes filled with confusion and fear. He immediately shifted her to GKNM hospital & she was in the emergency room within an hour, diagnosed with a major ischemic stroke.

The fight to save a young life..

She was imaged by CT cerebral angiogram which showed occlusion of all major blood vessels arising from arch of aorta with a clot in the major blood vessel (Middle cerebral artery) in the left side of brain which supplies 2/3rd of her brain. This stroke is not usual. Something unusual has happened here.. She was given a clot buster drug intravenously in the Radiology department itself without much delay & we ensured our door to needle time of 60 minutes. The next few minutes passed in a blur. Her right side was still paralyzed, her speech was impaired. “What to do next, doctor ?” a confused voice was heard from behind. It was her husband, desperate to get the love of his life back to normal. As Neuro-interventionist, over the last decade, we have treated many major stroke patients with a procedure called mechanical thrombectomy which helped them get back to normalcy. But, for the first time we were seeing a young female with Takayasu arteritis (No previous symptoms) with a clot in M1 segment of MCA as her first presentation.

We were equally tensed as her fiancée. But as doctors we should appear calm in the face of storm even if it threatens to uproot the tree called life. We held our nerves, took him to the counselling room & typed mechanical thrombectomy in Takayasu arteritis in google. Few results popped up. As he is also an IT professional we showed him that only few people across the globe have done mechanical thrombectomy in Takayasu arteritis. She may deteriorate, she may go into coma , her brain may swell, there might be a major bleed in the brain…We told him. But he wanted to try the  maximum for her. "Doctor, We are ready for the risk…" a confident voice was heard from her husband. We thought he might back out, but after getting the consent, our heart started racing. How to reach the left MCA clot ?

We put her under general anesthesia as it calmed down both of us, the patient & the doctor! After brainstorming about the pros and cons of different access routes, we finally decided to go ahead with direct carotid puncture. Direct carotid puncture mechanical thrombectomy in patients with occluded inflamed arch vessels save time as each minute we delay, the brain loses 2 million neurons,14 billion synapses and 12kms of myelinated fibres. For her it was risky as she was thrombolysed, her entire left common carotid artery was occluded except for a stump just proximal to bifurcation. We took help of ultrasound to puncture the CCA stump. Everything went fine. We could retrive a dark red monstrous linear clot from the MCA which had just tried to kill or incapacitate a young soul. We prayed to God to help us make our hands steady and he listened to us. Few days in hospital & she was back in her feet and with normal speech.. There were moments when we wanted to give up. But there was something in her that refused to let go.

Life After stroke..

She joined her duty. She followed up with her Neurologist & the Rheumatologist. She was put on steroids & other immune suppressants. A year after the stroke during our routine OPD days she visited us with her husband. We failed to recognise her. She was all smiles. I enquired about her well being. They were planning pregnancy and they wanted to know about the safety of starting a family. She had survived, and in doing so, she had found a version of herself that was more resilient than she had ever imagined. Her story was one of grit & transformation. 

Stroke can happen to anyone at any age & all might not be lucky like her to lead an independent life after a major stroke. Let us cherish each moment as we do not know what may happen in the next second.