When Stroke Strikes, No Time to Waste: Rapid Recognition and Reaction Turn Tide
Chris McLachlin's survival story reads like the script for a Hollywood movie where, unbelievably but totally by chance, everything happens at just the right moment and in just the right place.
When he stopped talking in mid-conversation and slumped over the couch, one of the people in the room with him was someone who'd had a stroke, recognized the symptoms and immediately called 911. He was at a hospital within 15 minutes.
When physicians called his wife to get her permission to administer the gold standard, frontline clot-dissolving medication, she answered her phone just as she was about to step inside a movie theater where she would not have had phone reception for at least three hours.
I remember feeling paralyzed on my right side. I wasn't frightened because I didn't understand what was going on.
For McLachlin, as it is with anyone having a stroke, time is everything. No matter what the stroke's cause, every second that passes means more brain cells die of oxygen starvation and more capabilities lost.
Physicians and scientists know more about stroke than they ever have, and can reach inside the brain with more impact than was ever dreamed of, even three years ago. But stroke remains a leading cause of death in the US and the primary cause of adult disability. The direct and indirect costs in 2009 neared $69 billion.
Expert care quickly
McLachlin became a patient of the Stanford Stroke Center at Stanford Hospital & Clinics, considered a national leader in advanced stroke treatment. At Stanford, an innovative, streamlined protocol called the SIRS (Stroke Interventional Radiology Service) Rapid Access Program drives patient care, particularly for patients coming from other hospitals, delivered in the fastest fashion possible.
The protocol includes a rapid access transfer system that includes specific time goals for each step, a checklist, a simultaneous page to a full team of medical professionals to plan care ready as soon as the new patient arrives.
Quick care is important, but the risk of stroke can be reduced with changes in behavior that make other medical sense, too: quit smoking, eat a balanced diet and exercise regularly. For people with high blood pressure, diabetes and high cholesterol, medications can be very effective. "All of those things go a tremendously long way toward controlling risk," said Neil Schwartz, MD, PhD, who treated McLachlin at the Stanford Stroke Center.
Age, however, is one element that can't be altered. McLachlin had just retired after 37 years as a sports coach, teacher, counselor and administrator at the Punahou School in Honolulu, Hawaii. He coached the school's teams to 11 state titles in volleyball and three in basketball.
A healthy life derailed
From the time he was in middle school, McLachlin had been an athlete. Basketball and volleyball were his sports and when he arrived at Stanford as an undergraduate, he began a collegiate athletic career that concluded with the unusual post of player-coach on Stanford's volleyball team.
Throughout his adult life, he said, "my attitude about my health was pretty good. I was good at getting eight hours of sleep, my cholesterol was good, and I played steady tennis and golf. My blood pressure was a little high but not serious; I was taking medication for it."
Stanford's a big campus, so I do a lot of walking. I still play tennis and golf when I can.
He played master's class volleyball until he was 55; his father, at 89, still plays tennis five days a week.
McLachlin considered himself to be in great shape, and was looking forward to a trip that would take him to visit one son at Stanford, another son in Arizona and his daughter in Southern California. He flew from Hawaii and stopped in the Bay Area to visit a family that had helped him through graduate school at Stanford more than 40 years earlier.
He was sitting in their living room and talking with them when suddenly he noticed he couldn't speak. "I remember feeling paralyzed on my right side and falling over on my right onto the couch," he said. "I wasn't frightened because I didn't understand what was going on. I was in a kind of haze. I was not really aware of what was going on."
The Stanford Stroke Center has recently developed a ground-breaking protocol to expedite treatment for patients transferred from other hospitals. Called the SIRS (Stroke Interventional Radiology Service) Rapid Access Program, the protocol includes streamlined communications to ensure rapid acceptance to the Stanford Stroke Center for patients from outside hospitals, regardless of immediate bed availability.
SIRS also includes evaluation of the case by a collaborative, multidisciplinary team of stroke experts so a treatment plan is ready when a patient arrives. SIRS also includes a checklist that sets out specific times within which actions must be taken and completed; it also contains a list of information to be gathered. A simultaneous page goes out to mobilize responders from all over the hospital, including specialists in anesthesia, imaging, diagnostic radiology, critical care nursing, pharmacy, respiratory therapy and intensive care. SIRS's special interventional neuroradiology team care is available 24/7 to remove blood clots from a patient's brain if that procedure is required.
SIRS was created to gain every second possible between a stroke and treatment. Some medications are only effective if administered within a certain time frame, and the speeded transfer process improves the odds that such medications will be effective in reducing stroke damage.
Within minutes of getting to a hospital and being administered tPA, tissue plasminogen activator, the go-to clot-dissolving medication, McLachlin regained some movement in his right leg and arm.
Trouble starts small
McLachlin's stroke began with a clot in his left internal carotid artery caused by a tiny bit of plaque. The clot travelled up into a smaller vessel within the brain, producing the stroke symptoms McLachlin experienced.
Plaque is a combination of cholesterol, fatty acids and fibrous tissue that gathers along the lining of an artery. Plaque makes it harder for blood to get through the artery, making it more likely to clot. The body's chemistry includes natural clot-dissolvers, but sometimes clots are too big, jamming arteries closed.
The brain works on oxygen carried to it by blood, and when that blood stops coming, oxygen-deprived tissues begin to die. The sooner the clot can be dissolved or removed, the more likely it is that significant recovery can take place.
We have imaging tools that allow for rapid and real-time elucidation of information that tells us just what's happened to the brain.
Stanford's physicians take information from CT and MRI scans and process it through a Stanford-invented computer software program that builds an image of great sensitivity and specificity that includes speed, volume and location of blood flow throughout the brain. That visual map may serve first as a guide for making treatment decisions, and then serves to confirm the effects of treatment.
McLachlin was again lucky, because his clot dissolved without further treatment. In other cases, physicians called interventional neuroradiologists may have to thread a narrow tube, called a catheter, into an artery in the groin and push it up into the brain, carrying miniature treatment tools. Those tools can either grab a clot to extract it or vacuum it out.
New options to advance care
Modern, high-tech imaging, including techniques developed at Stanford, allow for a very detailed look inside the brain. "We have imaging tools that allow for a rapid and real-time elucidation of information," Schwartz said, "that tells us just what's happened to the brain tissue, what's salvageable and what's not."
Stanford researchers are also investigating other methods of stroke treatment and neuro-protection, Schwartz said. Those include everything from lowering the temperature of the body and brain of a stroke patient to using special lasers. There are also treatments under study using stem cells, he said, that may stimulate the brain to repair its damaged parts.
Even though McLachlin's stroke was quickly treated, he spent a year in therapy, working to regain not only mobility but strength, too. He was surprised at how quickly he did recover, but Schwartz was ever cautious. "Don't get too full of yourself," McLachlin recounts him saying, "You had a severe stroke and your body needs at least a year to get over the trauma."
McLachlin still lives in Hawaii, but has spent a lot of time at Stanford, too. He's been filling in as an assistant coach for the University's men's volleyball team for the last two years. It's meant he's been coaching his younger son, who's now a senior and team captain. It's also meant he gets good workouts. "I work out with the team," he said, "and Stanford's a big campus, so I do a lot of walking. I still play tennis and golf when I can."
He also watches his diet but does allow himself the occasional burger. "Dr. Schwartz told me, 'You don't need to be torturing yourself. You don't have to beat yourself up – just don't do anything to excess.'"
He does check his blood pressure twice a week, before and after workouts. And he gets his cholesterol checked regularly, too. "These are not things that would disrupt anybody's life," he said, "and they could save your life."
He does spend as much time as he can speaking to groups about stroke prevention. Even when he travels, he said, he sometimes delivers his "one-minute spiel about how to save somebody's life from stroke."
About Stanford Health Care
Stanford Health Care, located in Palo Alto, California with multiple facilities throughout the region, is internationally renowned for leading edge and coordinated care in cancer, neurosciences, cardiovascular medicine, surgery, organ transplant, medicine specialties and primary care. Stanford Health Care is part of Stanford Medicine, which includes Lucile Packard Children's Hospital Stanford and the Stanford University School of Medicine. Throughout its history, Stanford has been at the forefront of discovery and innovation, as researchers and clinicians work together to improve health, alleviate suffering, and translate medical breakthroughs into better ways to deliver patient care. Stanford Health Care: Healing humanity through science and compassion, one patient at a time. For more information, visit: StanfordHospital.org.