Monday, March 25, 2019

So Here's What Happened ...


For those of you who don't already know, I spent a couple of days in the ICU over the weekend as a result of collapsing during one of the performances of a play (it happened at intermission, in the green room). It turns out to be physiologically a bit interesting ...

So the events transpired thusly:

On Thursday, March 21, I was performing as Verges in the Steel River Playhouse production of William Shakespeare's "Much Ado About Nothing." Verges is a tiny role, so I only have four scenes in total: two in act I and two in Act II (I'm talking about the acts as set up by the director, not by Billy Shakes ... he had six acts in this play).

About halfway through my first scene, my right foot abruptly went completely numb. At the time I wasn't too concerned; this had happened before as a result of the costume not being a perfect fit (hey, it's a volunteer gig, so it's not like there's a professional seamstress on staff to attend to the costume alteration requests of seventeen people). However, when I came off stage and sat down, it didn't go away.

I figured that the first scene was my biggest one, I only had one more to go before intermission, and the final two scenes basically involved me standing there and reacting to Dogberry, so I could just power through and get a good night's sleep and everything wold sort itself out.

I was wrong.

During intermission, in the green room, I was leaning up against a counter. My arms started shaking, then my right leg announced that it was no longer happy with its working conditions and therefore was going on strike. I collapsed. I was still somewhat lucid, but my entire right side had become pretty much useless, there was significant facial drooping -- all the classic signs of a stroke.

I had suffered two strokes pervious to this: one on February of 2017 that was centered in the pons (a region of the cerebellum that, my neurologist informed me, was arguably one of the best places to have a stroke). The second was in June of 2017 and was rather inconclusive ... the neurologist at the hospital described the MRI as "fuzzy" and that as best as she could figure out it was something that happened in the white matter in the brain.

And here's where it gets interesting. But first, a little anatomy lesson.

The vertebral artery
In the diagram above, you can see the aortic arch. The aorta, as you are undoubtedly aware, is the main artery coming from the heart. It loops up by the collarbone (from whence the carotid artery splits off) to supply blood to the arteries of the head, face, and neck, before descending into the lower part of the body. In the diagram above, you can see the vertebral artery (in red) emerging from the aortic arch and ascending along the spine -- not inside the spinal column itself, but tucked into the spinal processes. There are actually two vertebral arteries, one on each side.

Diagram of the vertebral arteries at the base of the brain
Above is a sort of schematic of the vertebral artery system. These arteries are located at the base of the brain, as shown below.

The vertebral arteries in relation to the brain.
As you can see, these things are tucked right up against the underside of the brain in an area that is virtually impossible to get to surgically (this will become relevant later).

Given my symptoms both in June of 2017 and this past Thursday, it looked for all the world like I was having a stroke or, at least a TIA (transient ischemic event). The difference between the two? A stroke leaves permanent footprints on the brain, whereas a TIA is just what it sounds like: a temporary blockage of an otherwise healthy blood vessel that leaves no residuals.

My stroke in February of 2017 left me with a 5-10% strength deficit on my right side. Most of the time it's not at all apparent, but when I get tired (say, if we've spent the day at Longwood Gardens walking a lot) I will develop a limp and my right eyelid will droop. Other than that I was extremely lucky in that there were no other permanent effects.

For the these last two events, though, they didn't quite fit either classification. They couldn't be considered actual strokes in that there were no marks left in the brain, but they couldn't necessarily be thought of as TIAs either due to the severity and the fact that TPA (Alteplase IV r-tPA, a clot buster drug) reversed symptoms (as far as I know, tPA has no effect in a TIA situation).

On Saturday I met with the neurologist on staff. I was curious as to why it took two days to see the guy, but this became clear when he presented his hypothesis.

His thinking is that one of the vertebral arteries at the base of the brain, where the spinal cord enters the medulla, is malformed (a birth defect) as shown in the amateurishly photo-shopped diagram below:

The hypothesized arrangement of the arteries in my brain.
According to the doc, what has been happening is that this artery, being undersized and with narrower walls, really isn't sturdy enough to hold itself open; it relies on my blood pressure to do that. However, after the first stroke, I was prescribed medication to reduce my blood pressure -- which, let's face it, wasn't really that bad off to begin with, but it is accepted practice to prescribe blood thinners to stroke patients.

What this did was to reduce the blood pressure enough so that it was right on the cusp of being insufficient to support this artery. The doctor's hypothesis is that, both in June 2017 and on Thursday, my blood pressure dropped enough to pass that threshold. As a result, blood flow to that portion of the brain was cut off, and stroke symptoms emerged. However, with the administration of tPA, my blood became thin enough that it could squeeze through this artery and force it back open, restoring blood flow.

In retrospect, this makes a whole lot of sense. Several times over the past coupe of years -- too many to count, to be honest -- I have noticed that my right side weakness would become a little more severe, or I would notice facial drooping in the mirror, etc. In all of these situations my reaction was "Oh, crap. Not again" and I would started getting a little torqued up ... which would (presumably) elevate my blood pressure, open the artery back up, and the symptoms would subside.

At this time my only course of treatment is to stop taking the blood pressure meds. I will be consulting with my neurologist, at which point there may be other options. Based on everything I have been told, though, it doesn't look like a surgery to go directly at it and expand the artery is possible based on its location. It may be possible to have a stent put in via catheterization, but then again I'm not a doctor and really have no idea what the hell I'm talking about.

So this was my weekend. How was yours?

I gotta lie down. Literally.

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