Timing Is Critical When It Comes to Care for Stroke Patients

A summer evening. Dinner at home with friends. That was the plan for Jim and Carol Miceli.

But as the couple shared vacation snaps over wine with their West Bend neighbors, something happened.

“I was sitting at the dining table when suddenly I felt I was going to faint,” Carol said. “I leaned over toward my husband and collapsed.”

Seven minutes later, Carol was in an ambulance on her way to Froedtert West Bend Hospital. Carol, a retired first-grade teacher, had suffered a stroke and the decision to call an ambulance, rather than drive her the mile and a half to the hospital, was critical.

“The benefit of calling 911 is that first responders can screen people for stroke and alert us before the patient gets here,” said Mary Lewis, MD, the emergency medicine physician who treated Carol that July night. “We knew from paramedics that Carol could not move the left side of her body and had trouble speaking, so we had a CT scanner ready to determine if there was any bleeding in the brain.”

At the hospital, which is part of the Froedtert & the Medical College of Wisconsin health network, Carol was also assessed with the National Institutes of Health Stroke Scale. It quantifies the cognitive, verbal, visual and motor deficits the person is experiencing.

“Carol’s score put her at a catastrophic level,” Dr. Lewis said.

Timely Treatment

After a CT scan indicated there was no bleeding in Carol’s brain, Dr. Lewis administered tPA, or tissue plasminogen activator, which is derived from a naturally occurring protein found on endothelial cells, the cells that line blood vessels. Delivered intravenously, tPA is used to loosen a clot that interrupts blood flow to the brain.

Just like that ambulance ride, time was of the essence. “Brain cells die quickly when deprived of blood flow and oxygen, so patients eligible for tPA must get it within four and a half hours from the time their symptoms start, sometimes sooner for elderly patients,” Dr. Lewis said. “Our team of physicians, nurses, pharmacists, lab technicians and radiologists work together to make sure we can assess the patient accurately and swiftly.”

After consulting with Ann Helms, MD, MS, critical care and vascular neurologist and MCW faculty member, Dr. Lewis transferred Carol to the Comprehensive Stroke Center at Froedtert Hospital for any needed interventions.

“In large strokes like this, tPA is not usually effective unless it’s followed with a catheter-directed therapy like a thrombectomy, in which we remove the softened clot,” Dr. Helms said.

Likely because of the early therapy she received with tPA and some luck on her side, Carol’s stroke responded well. She did not need a thrombectomy because she began to recover quite quickly.

“They took me for an MRI around 3 a.m. and I could already lift my left arm,” Carol said. Two of Carol’s daughters work at Froedtert West Bend Hospital (one is a pharmacist, the other an anesthesiologist) and her son-in-law is an emergency medicine physician at Froedtert Hospital. All three were on hand at the time and took this development as a hopeful sign.

An Extraordinary Recovery

Carol walked out of the hospital three days later. Following her discharge, she did three weeks of physical, occupational and speech therapy. Her quick recovery was atypical of someone who experienced the severity of stroke she did. The cause of her stroke was never pinned down.

“It looked like it was probably from her heart, what we would call a cardioembolic stroke,” Dr. Helms said. “But she fell into a category called ESUS, or embolic stroke of undetermined source. This is the case with 10 to 20% of all strokes.”

As a slender nonsmoker who walked up to 100 miles a month, Carol might not seem like a likely candidate to have a stroke. However, strokes can happen to anyone, and it is important to know the signs and symptoms.

“Because her family acted quickly and knew the signs of a stroke, they were able to get her the best care possible,” Dr. Helms said. “Everything that could go right did go right,” Carol said. “I progressed at an awesome rate.”

While the COVID-19 pandemic keeps her from seeing her 12 grandchildren as much as she’d like, Carol rejoices in the ability to enjoy a full, purposeful life. “I am just so thankful, every day,” she said. “Every single day.”