On November 22, 2020, Fred Fleming was driving home with his family from Idaho where his grandson had been playing basketball when he started slurring his words. “Pull off the road and park,” his daughter Jill told him. He exited the highway and came to a stop in a parking lot. Fred didn’t realize what was happening, but his family recognized the symptoms.
Fred, 71, was taken to the emergency department (ED) at Providence Sacred Heart Medical Center where it was confirmed that he had suffered a transient ischemic attack (TIA).
A TIA is a sudden, short-term loss of blood flow to the brain, disrupting oxygen supply. Although it’s not classified as a stroke, a TIA produces symptoms of a stroke, except they disappear within minutes to an hour. They also serve as strong indicators of a possible major stroke and other health issues, which is why they shouldn’t be ignored.
Carotid artery disease diagnosis
While undergoing tests at Sacred Heart, Fred’s care team discovered additional information – a complete blockage in his left carotid artery and 80% blockage in his right artery, the main blood vessels that send blood and oxygen to the brain.
This condition is caused by a buildup of cholesterol-rich plaque (fatty deposits and calcium) in the lining of the arteries. If the arteries become too narrow or a piece of plaque breaks off, blood flow to the brain is reduced or blocked, causing stroke.
With no lasting symptoms, the care team prescribed Fred an aggressive treatment plan that required a combination of medications to help reduce his risk of a stroke, as he prepared for an innovative vascular surgery to remove the blockage in both arteries.
Fred was confident in the treatment plan his stroke team had made for him, and he felt normal. Now, back home, he prepared for the Thanksgiving holiday as if nothing happened. “I was out doing my thing, like normal people do,” he said.
Thankful on Thanksgiving
On Thanksgiving Day, while loading the car with dishes to take to his son’s home, Fred fell and had difficulty getting up. He was able to get back into the house, and his wife Vicki knew something was wrong. “He was having a hard time using his right hand,” she said. Fred was experiencing similar symptoms he had before.
Fred couldn’t believe it was happening again. “I was in denial,” he said. “I didn’t think anything was wrong, but everyone around me knew.”
At the Sacred Heart ED, Fred was admitted to the hospital for further evaluation. The medical team located a new clot that had formed in the left middle cerebral artery. But the severity of his symptoms was still low on the National Institutes of Health (NIH) stroke scale, which uses a rating system of 1 (good) to 5 (severe). Fred scored a 2 out of 5.
The interventional radiologist, who later removed the clot, consulted with the other members of the neurohospitalist team. “Because the risks of removing the clot outweighed the benefits, the team made the decision to closely monitor him,” said Cynthia Murphy, M.D., lead neurohospitalist at Providence Sacred Heart Medical Center.
Fred’s symptoms worsened. He was having difficulty using his right side and his ability to speak had greatly diminished. “His stroke scale went up well past 5,” said Dr. Murphy. “At that point experts from endovascular, interventional radiology and neurohospitalist teams came back together, and the decision was made to take out the clot.”
In good hands
Fred recalls being wheeled into the interventional radiology (IR) lab for surgery. He can still see the machines and the care team surrounding him. He knew this was a serious surgery with risks, but he was ready and trusted the team. “Then it was lights out,” he said.
A catheter was inserted into Fred’s groin and directed through the blockage in his neck (left carotid artery) and into his brain where the interventional radiologist was able to grasp and remove a large clot. Blood flow was instantly restored to the left side of his brain. Then the interventional radiologist inserted a balloon in the left carotid artery, a temporary measure to allow blood flow in the artery until a stent could be inserted.
“The procedures went very well,” said Dr. Murphy. “It was a true team effort to get his arteries open.”
The next thing Fred remembered was being gently woken up in recovery. He wiggled his fingers. “I could use my hand perfectly,” he said. Fred’s surgeon showed him a photo of the clot, the biggest one he’d ever removed from a patient’s brain.
He credits the doctors, neurohospitalists and the interventional team for their skilled work, as well as the team of nurses and other caregivers who helped him. “It was like I had a little time bomb in my body, waiting to go off,” he said. “And when it did finally go off, I was in the absolute best care facility. The whole time, it was like having my immediate family taking care of me.”
TCAR procedure addresses cause of strokes
Less than a month after the clot was removed from his brain, Fred returned to Sacred Heart for a TCAR procedure on his left carotid artery to address the cause of the strokes. A TCAR (transcarotid artery revascularization) is a minimally invasive procedure that requires opening the artery through a small incision on the base of the neck. A stent is put in place to trap plaque, keeping the pathway open for blood flow to the brain.
Providence vascular surgeon, Luke X. Zhan, M.D., Ph.D., performed the procedure on Fred’s left carotid artery, and then his right carotid artery a month later.
TCAR is a recently developed procedure and a unique offering in the region. “We are the first group of high-volume stroke centers in the nation to get trained and implement this procedure,” said Dr. Zhan. “We have the experience. Our case volume is top ten in the nation.”
Fred quickly recovered from both procedures and noticed a marked difference in his health. “When I got the second one [TCAR], it was like I had a new lease on life,” he said.
Although the stents will remain in Fred’s arteries, they need to be monitored over his lifetime for the underlying cause. “The typical protocol is a yearly checkup,” said Dr. Zhan. “We’ll perform a carotid duplex ultrasound as a way to measure whether there is a recurrence of stenosis [plaque buildup] and to what degree.”
Carotid artery disease: Silent health risk
Before the strokes, Fred didn’t have any symptoms to suggest he had carotid artery disease. As a seed farmer, ambitious gardener, father and grandfather, Fred has been physically active – dawn till dusk – nearly every day of his life. He’s never smoked, doesn’t drink and didn’t have diabetes – all risk factors for carotid artery disease.
But Fred’s father had a debilitating stroke at age 62. A person’s risk for carotid artery disease and stroke is also closely linked to family history, as well age and gender. Men are at higher risk for carotid artery disease than women.
Other risk factors for the disease and stroke include being overweight, high blood pressure, high cholesterol and a diet high in fat, which contribute to plaque buildup. Adults over age 40 need to be aware of these risk factors and the potential for plaque buildup in the carotid arteries. The disease can sneak up over time without symptoms.
The best way to check for carotid artery disease is to be screened by your primary care physician. This is especially important for adults with a personal or family history of plaque buildup elsewhere in the body, such as the heart.
Understanding your risks for carotid artery disease and getting screened by your provider are the first lines of defense against stroke.
Signs of stroke: Minutes matter
Fred is grateful to his family for knowing what to do at the first sign of stroke and his care team for seeing him through the experience. “My guardian angels, my daughter, my wife, all these people around me have allowed me to continue on life unimpaired.”
No matter what type of stroke, time is of the essence. Delaying care can increase the risk of death or permanent brain damage, which is why it’s important to seek help at the first sign of stroke.
“The people around you are the first line of defense,” added Vicki.
Learn the symptoms of stroke, and have your family members learn them, too. If you think you are having symptoms of stroke, call 9-1-1 immediately. If you have risk factors for carotid artery disease and stroke, see your health care provider for a screening and diagnosis.
A robust program and collaborative team
Providence Sacred Heart Medical Center has the largest stroke care program in the region, offering a multidisciplinary team approach. We care for approximately 1000 stroke patients a year with the majority of those treated for ischemic stroke.
“Fred’s case illuminates the importance of having a robust stroke center with a complete and highly trained stroke team able to respond quickly and offer the best solution to any condition,” said Kenneth Isaacs, M.D., regional director of the Providence Spokane Neuroscience Institute. “Our team of neurohospitalists, neurosurgeons, vascular surgeons, interventional radiologists, and specialty trained nurses are a highly collaborative group, ready around-the-clock, seven days a week to care for stroke patients.” From our first responders, through treatment and rehabilitation, we provide a smooth, continuous care pathway, demonstrating why we are the regional leader in stroke intervention and care.
Additionally, the Institute supports multiple hospitals throughout Washington that may need to transfer patients for more advanced treatment. Patients can be evaluated within minutes through the Providence TeleStroke program, with vascular neurologists providing remote consultation and decision as to need to transport to Sacred Heart Medical Center.
For additional information about the Providence Spokane Neurosciences Institute, visit Sacred Heart Medical Center Neuroscience Institute.
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