Ischemic stroke

Victoria and familyVictoria Devorak was still celebrating the recent birth of her youngest son when an unexpected ischemic stroke gave her and her family the shock of their lives. Victoria, then a 30-year-old home care nurse and mother of four didn’t know what to make of her sudden symptoms. One minute she was changing her one-month-old baby’s diaper, the next minute her vision was completely blurred, and one side of her body felt paralyzed.

On any other day, Victoria would’ve been home alone with her sons, all of whom were under the age of seven at the time. Luckily, her husband, Billy hadn’t left for work yet that morning and was there when Victoria made a call for help.

“I yelled down to my husband to come up and help me because I didn't know what was going on,” she recalled. “I couldn’t see a thing. When he came upstairs, I asked him to help me stand up and that’s when I realized I’d lost all feeling in my right side.”

Billy called 911 and an ambulance rushed Victoria to nearby Virtua Hospital in Mount Holly, N.J. where doctors confirmed her sudden loss of strength and vision was due to a stroke. The Virtua team determined that less than four hours had passed since Victoria’s stroke had occurred, making her eligible to receive a clot-busting medication called Alteplase, which began the process of disintegrating the blood clot that caused the stroke. But her imaging also revealed that a major blood vessel in her brain was blocked, for which Alteplase is often at best partially effective. So, doctors rushed Victoria to the Penn Medicine Comprehensive Stroke Center at the Hospital of the University of Pennsylvania where she would undergo a procedure to have the blood clot removed.

At Penn, doctors performed a mechanical thrombectomy for Victoria using continuous x-ray as they carefully guided instruments through an artery in her leg, up through her neck and into her brain to successfully remove the clot.

But the question remained, why had she had a stroke in the first place?

Multidisciplinary Care For a Unique Case

Victoria’s case was unique in every way. Most people who suffer strokes are 60 years or older. Victoria was only 30. She was otherwise very healthy and didn’t have any of the common risk factors for stroke. Yet, here she was, at the hospital, having a blood clot removed from her brain. And it all unfolded on World Stroke Day, a global day set aside to raise awareness of the serious nature and high rates of stroke. “Young people, 30 years-old don't have strokes, and when they do, it's such a rarity that it just draws attention, appropriately, to figuring out why this is happening to them,” said Elizabeth Neuhaus-Booth BSN, a stroke coordinator at the Hospital of the University of Pennsylvania. “She was a healthy woman. From what we could see at the outset, there was no reason for this to happen. So, as a team, we really wanted to find out why.”

The stroke team ran a battery of tests to ensure they hadn’t overlooked any risk factors that could’ve caused Victoria’s stroke. Initially, doctors thought her stroke may have been caused by a hypercoagulable state or increased tendency for blood clots brought on by the post-partum period. To confirm the cause, the stroke team brought in experts from multiple disciplines to assess all potential factors for Victoria’s stroke. Team members from the cardiology division later discovered Victoria had a Patent Foramen Ovale (PFO), a hole in the wall tissue between the upper chambers of the heart that had gone undetected since she was born.

According to Neuhaus-Booth, a PFO in a young person could result in a blood clot forming in one part of the body, traveling to the heart, moving through the hole and up to the brain.

“All these things were pointing in the direction that these may be the reasons why she had a stroke,” she said. “So, we were thinking, now that this happened and we've gotten her through it, let’s see what we can do to make sure it doesn't happen again.”

The Path to Recovery

Victoria returned home from the hospital on November 1, 2019, just three days after her surgery. After several weeks of physical therapy, Victoria was walking and even driving again with few residual symptoms. She has yet to return to work but says she feels like herself again. The stroke team has since presented Victoria with options for having her PFO closed to prevent a stroke from reoccurring.

Scott Kasner, MD, director of Penn’s Comprehensive Stroke Center, added that the goal of the stroke team is provide patients and their families with explanations and options so that they may make the best-informed decisions. This, along with an expert stroke team, helps patients receive the most advanced treatments for their condition.

“Victoria is exemplary because she was treated with two devices, one for reversing her stroke, and another for preventing future strokes. Both of these approaches were proven effective only in the last few years, and Penn’s multispecialty teams helped lead the trials that brought them into clinical practice.”

Victoria said she appreciates the fact that Penn was able to bring experts from so many disciplines together to ensure every aspect of her care was attended to with great detail and scrutiny.

“They were so thorough in making sure that they removed the clot and making sure there were no other issues within my heart, just to give us some reassurance because of course, having this happened just completely rocked our whole world,” she said. “I’d never had surgery in my life or any issues. So, this was just earth shattering in our little world and they did everything to make sure that we felt confident that this was a hurdle that we we’re going to have to overcome, but that I would be okay.”

“It’s one of my privileges to work at Penn where this happens so routinely. It is expected that teams will work together, in interdisciplinary teams, across services, from cardiology, maternity, neurology, neurointerventional, neuro critical care, all collaborating to develop a comprehensive care plan for patients like Victoria,” Nehaus-Booth said.

Beyond the expertise, it was the little things that really resonated with Victoria. The way her multidisciplinary care team went out of their way to make sure her family, who live in New Jersey, stayed informed of her treatment progress in Philadelphia. Or how the stroke team worked with maternal health to ensure that, as a new mom, she was given the right medications and the support of lactation consultants who provided breast pumps so she could continue feeding her newborn son. But more than anything, it was the kindness and concern of her care team that Victoria says she’ll never forget.

“When you have something especially catastrophic happen to you, what you want more than anything is to know that you're in good hands and that you're being taken care of and listened to,” she said. “They were so attentive and sensitive. Even the nurses at Virtua and Penn, I’ll never forget how patient they were with me. I felt important. I felt taken care of. I couldn’t have asked for more.”

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