Notes on a stroke

Last April we were about to celebrate the Passover Seder at my home. Just before calling the guests to the table, as the officiator of the celebration, I decided to take a quick look in the Passover guide, the Haggadah. I found that I could read no more than three or four words before the next, like some concrete traffic barrier, tripped up my progress. When I attempted to overcome this deficiency by uttering the words out loud, what came forth was an inchoate collection of muffled gibberish and gargles. It was clear that I was not going to be able to symbolically guide my family out of Egypt on the way to the Promised Land. It was all I could do to make my distress known to my wife and have her guide me to the nearest emergency room. At the age of 84, I was having a stroke. During the 10-minute drive to the hospital, my articulation worsened and I began to experience numbness and tingling in my hands. I was able to walk into the emergency room. When I informed the clerk that I believed I was having a stroke, within minutes I was rushed to the back into the hands of the stroke team. Intravenous lines were inserted and a medical resident was right on the scene. Looming over her shoulder on a two-way television set-up was the neurology attending physician at her home assisting in examining me and making critical decisions. A computed tomography (CT) scan ruled out cerebral bleeding, which would have ruled out the administration of tissue plasminogen activator (t-PA). Since some of my symptoms were persisting, an infusion of the clot-dissolving agent was begun. Within 15 minutes all symptoms had disappeared. The time delay between the onset of symptoms at home and the administration of t-PA was between 2 and 3 hours. Magnetic resonance imaging (MRI) was performed before I was admitted to the neurology intensive care unit. No specific arterial occlusion was seen, but there were multiple changes in the brain consistent with aging as well as old embolic-related small infarctions. The carotid vessels were clear. A transthoracic echocardiogram was normal. A Holter-like electrocardiographic monitoring device was attached to me to detect any episodes of asymptomatic atrial fibrillation over a 2-week period. (None found.) Prior to this episode, I had been taking a regular aspirin (365 mg) daily along with atorvastatin for hypercholesterolemia. The aspirin dose was lowered to 80 mg, and clopidogrel was added to my medical regimen on discharge. Twelve days following discharge, there were new cerebral rumblings. I felt the sudden onset of moderately severe lightheadedness with a transient unilateral facial droop. The 911 team delivered me to the hospital, where another CT and MRI were performed. These were unchanged from the previous studies. My symptoms rapidly abated and I was admitted for further observation and testing. This included electroencephalographic monitoring for 3 days, which was nondiagnostic. A transesophageal echocardiogram revealed a patent foramen ovale. A “bubble study” indicated shunting of blood across the defect from the right to left atrium, indicating this course of small thrombi reaching the heart from the systemic veins and lodging in the brain instead of the lungs, where they could not do as much damage. The aspirin and clopidogrel were discontinued, and I was placed on an oral anticoagulant (rivaroxaban). I emerged from this episode remarkably free of sequelae. Motor and sensory functions are intact. I do have a slight unsteadiness of gait but can walk without assistance of any kind. I believe I am still mentally acute but, as a writer, I cannot escape the feeling that, on occasion, I find it more difficult than previously to retrieve just the right word from the memory bank inside my brain. By any measure, one can say that I received the very best care that 21st century medicine can provide. So why did I have this lingering sensation that my care was somehow incomplete? It had to do with the performance of the neurological examination by nearly a dozen or more physicians and other health care workers during the course of my hospitalizations. Not one person checked my deep tendon reflexes. Examination of the cranial nerves was cursory and incomplete. I was checked for sensation of light touch but not pain or temperature perception. No one even attempted to elicit a positive Babinski sign! Even a second-year medical student would have been expected to perform better than this. When I began the practice of medicine over 50 years ago, its technological revolution was just getting into full swing. At that time I and my contemporaries were not too far removed from the teachings of the towering figures like Austin Flint and William Osler, who epitomized the ideals of the profession. Their keen interpretation of symptoms and signs of disease often put them on the right diagnostic track. No wonder they were often called “diagnosticians.” And, at a time when little could be done to alter the outcome of most diseases, they were quite adept at predicting the course of a disease in any patient they attended. Even when the outcome was death, their ability to foresee how and when it would occur gave the patients’ families a kind of comfort in knowing what to expect. Walter Alvarez encapsulated this skill in the lines, “Blessed be the physician who takes a good history, looks keenly at his patient and thinks a bit.” Modern technology has dimmed the lights of the past. Nowhere has this been more marked than in the management of stroke, where time to treatment is so critical. If doing a full neurological examination adds nothing to this, should it still be performed? My neurologist assured me that the abbreviated neurological examination has become standard for all stroke teams such as his. Why waste time ascertaining the level of flooding in the valley when, upstream, a crack in the dam can be found and possibly be repaired? However, there are many clinical scenarios that allow for a more cognitive approach. My harping on the history and physical examination might not just represent foolish nostalgia. Osler's aphorism still has the ring of truth: “Listen to your patient. He is telling you the diagnosis.” He is also telling you much else about himself and, as you persist in your bedside attention to him, you are responding in kind.