Emergency protocol delivers fast, lifesaving stroke care

It was six days before Christmas when Richard “Dick” Boshart, 84, tried to connect to the livestream of his granddaughter’s holiday concert. His wife, Annie, was busy preparing breakfast in the kitchen. The couple, who live in an independent living community in Lititz, Pennsylvania, had no idea this quiet morning would soon take a sudden, life-altering turn.

Dick suddenly rose from his seat and began wandering around their home. His movements lacked any clear purpose, and when he sat back down, Annie noticed the right side of his face was drooping. She alerted a nurse. The nurse quickly assessed Dick’s condition, recognized the signs of a potential stroke, and called 911.

In addition to the facial drooping, Dick was also struggling with aphasia, a condition that affects a person's ability to speak and comprehend language. He vaguely remembers a paramedic asking him questions as they worked to stabilize him, but he was unable to respond. The moments that followed were largely a blur, as the EMS team raced against time to get Dick the medical help he urgently needed.

It turned out that quick action in those critical moments would prove to be the key to Dick's successful recovery.

Timely assessment by paramedics expedited care

Paramedics believed Dick was having an ischemic stroke, which occurs when vessels supplying blood to the brain are blocked by a blood clot. They recommended taking him to Penn Medicine Lancaster General Hospital, the only hospital in Lancaster County that performs mechanical thrombectomy, an advanced procedure for physically removing a blood clot from a brain vessel. As soon as Annie gave permission, one of the paramedics called ahead and activated the hospital’s stroke alert.

This set in motion a protocol that expedites a patient’s assessment and treatment upon arrival. The faster a stroke is recognized and treated, the better the chances of preserving brain function and reducing the likelihood of disability.

Nicole Chiota-McCollum, MD, chief of the Division of Neurology for Lancaster General Health, received Dick in the emergency room. She examined him and determined the severity of his stroke.

He then underwent a computed tomography (CT) angiogram, a noninvasive test that uses X-rays and a special dye to create images pieced together to form three-dimensional reconstructions of the area of concern.

The test revealed a blockage of the middle cerebral artery, the most common artery involved in a severe stroke. It consists of four main branches that extend from the internal carotid artery. These vessels supply blood to parts of the frontal, temporal, and parietal lobes of the brain, as well as deeper structures.

With the discovery, Chiota-McCollum administered Tenecteplase via an IV injection. This medicine can restore blood flow by dissolving the blood clot causing the stroke. She then notified Sedeek Elmoursi, MD, a vascular neurologist and neurointerventional surgeon at Lancaster General Hospital, who would remove the remainder of the clot through mechanical thrombectomy.

Racing against the clock

In a nearby suite dedicated exclusively to stroke care, Elmoursi made a tiny incision on the left side of Dick’s groin and inserted a microcatheter, threading it through an intricate network of blood vessels to the blood clot in his brain. His progress was slow because of the clusters of entangled vessels, a result of Dick’s age. He often had to double back and find a new route.

“This was very hard because we had a timeline,” Elmoursi said. “We had to reach the clot as soon as possible to prevent more damage from being done to the brain.”

Once he reached the clot, Elmoursi attempted to suction it out, but the clot didn’t budge. He quickly turned to another technique, inserting a stent retriever—a thin mesh tube—into the catheter and expanding the walls of the middle cerebral artery, restoring blood flow to the brain. He was then able to reposition the blood clot further down the artery with the stent retriever, which enabled him to suction it out with an aspiration catheter.

Annie and their daughter, Carolyn Fitzkee, rejoined Dick in the intensive care unit after the procedure. Within a couple hours, Dick was raising his arms and legs, wiggling his toes, and squeezing the nurse’s hand at their request. By that night, he was drinking water, eating applesauce, and talking in short sentences.

“Every hour he seemed to improve,” Carolyn said.

Elmoursi checked on Dick and Annie the next day. Dick’s ability to communicate was continuing to improve, and he was gradually returning “to his normal level of neurological function,” Elmoursi said.

Dick was discharged five days after his stroke.

An important discovery in the ICU

The day after Dick’s procedure, while he was in the ICU, a nurse observed he was in atrial fibrillation (AFib), an irregular and often very rapid heart rhythm. Before that moment, Dick said he had never had any heart trouble. For many people, AFib may have no symptoms.

Elmoursi said AFib is one of the leading risk factors for stroke because it can lead to blood clots. As many as a quarter of all strokes after age 40 are caused by AFib, according to one estimate.

Left untreated, Dick would be at high risk of having another stroke. But he’s since started taking a blood thinner specifically formulated to prevent clots and stroke in people with AFib. The medication, Elmoursi said, has significantly reduced the chances of Dick having another stroke, allowing him to continue enjoying retirement on his terms.

Therapy to regain capabilities

Dick followed up with Romy Styer-Slogik, PA-C, a neurology physician assistant at Lancaster General Health Physicians Neurology. He worked with a speech therapist to redevelop his thinking and understanding around certain tasks, like using his computer. And he did physical therapy twice a week for balance and strength training.

Although he was able to get around without assistance, in the weeks immediately following his stroke Dick was noticeably weaker, but said he felt generally “okay.”

His stamina returned little by little. When Styer-Slogik gave Dick permission to start driving again at the end of January, Fitzkee said it was a “turning point” in his comeback.

Hitting the right notes again

Eight months after the stroke, Dick had made a complete recovery and was exercising regularly. His weekly routine consisted of a low-impact aerobic exercise class and a bodyweight strength-training class, both of which are offered at the fitness center in his community. In nice weather, Dick also enjoyed riding his bike around the campus. And every two weeks, he tended to the bluebird houses scattered throughout his community.

Perhaps most importantly to Dick, he returned to singing, a longtime passion. Before retiring, he was a music teacher. In May—National Stoke Awareness Month—he and Carolyn were invited back to the hospital to share Dick’s story at a large conference. Carolyn wrote the script and did much of the talking, cutting to her father for the occasional musical interlude.

“It was pretty emotional,” she said.

It was a powerful reminder of how far Dick had come, thanks to early action by his wife, paramedics, and the team at Lancaster General Hospital.