A few weeks ago, my brother-in-law was feeling a bit off.  It’s not surprising; he’d invited friends over for Oktoberfest.  It was a late night of beer and bratwurst.  As we get older, staying up late does not feel so great.  While he’s young, he’s not so young that staying up and then waking up at the break of dawn with kidlets is something that he’s going to survive as well as he might’ve in his partying years.  Regardless, he rallied to go to the Container Store and price out closet organization systems with a designer.  It was a planned appointment, and though he’d felt rough earlier, he felt good enough by noon to go on the 20-minute jaunt to the store.

While there, he felt increasingly awful and told my sister that he wanted to go lay down in the car.  She quickly finished up and decided to take him home.

A couple minutes into the drive, he insisted she pull over because he was going to be sick.  She did and after he emptied his stomach, he put the car seat down to rest while she drove home.

On the way home, my sister noticed that he was rigid, unbreathing, and unresponsive.  He started breathing again in snoring, irregular grunts, and gasps while his limbs twisted bizarrely.  She called me since I was watching the kids and went directly to the emergency room that was about 5 minutes away.  Luckily for her, there was a paramedic standing in the emergency parking lot who saw her run into the lobby and ask for help.  The medic and about six people were able to get BiL on the gurney and back into the ER.

They did a CT scan without contrast and eventually discovered that he had a serious stroke.

My brother-in-law is a fit 45-year-old.

With administration of tenecteplase (TNK) IV, part of the clot was dissolved and he regained consciousness for a period of time.  They took him into interventional radiology to see if they could retrieve more of what turned out to be multiple large clots in his brain, but since they had migrated into smaller vessels as they dissolved, it would be more dangerous than helpful to go further.  He came out of anesthesia and was responsive, coherent, and capable of moving all his extremities.

During a stroke, the goal is to get into the ER as soon as symptoms present, if not, then no longer than three hours after symptoms start.  From the door, the goal is to get someone into a CT scan within 20 minutes of arriving in the ER, with treatment starting less than 60 minutes post arrival.  The patient is scored on something called the NIH Stroke Scale, which guides practitioners as to where the stroke is, the severity of the stroke, and often the recoverability of a stroke.  It is a consistent and reproduceable score that can help demonstrate any neurological changes, complications, or re-occlusions.  My BiL’s NIHSS was a 9.  Not awful, but when you find out that the NIHSS is heavily weighted toward anterior circulation strokes with posterior circulation strokes being very lightly scored, it starts to make more sense.

NIHSS scoring scale.

His score of a 9 was due to slight dysarthria, some LOC issues, ataxia, and visual deficits.  Upon discharge, with optimal treatment, he was down to 4 scoring for slight dysarthria (slurred speech) and significant visual changes including blurred central vision and complete omission of entire visual fields in both eyes.  This makes sense given that he had multiple strokes: a basilar artery occlusion, bilateral thalamic stroke, bilateral occipital lobe strokes, and bilateral cerebellar strokes.  Post-treatment and radiology, the basilar artery occlusion dissolved, moving a smaller clot into the posterior cerebral artery’s more distant reaches (and out of safe radiological retrieval), and the remaining damage was unchanged, in some cases the ischemic zone measuring up to 1 cm in diameter (which is not insignificant).

Figure 2 from Posterior circulation ischaemic stroke. | Semantic Scholar

Overall, BiL was very lucky to have survived.  The basilar artery occlusion mortality rate is >90% much of the time due to the sudden onset and how important the posterior circulation is to supplying the brainstem, which allows for respiratory and cardiac functioning.  Regardless of his luck and his blessings in merely surviving, much less surviving with as much functionality intact, at 45 years young, the loss of visual function is career-threatening for many people.  Reductions in the ability to read, a prohibition on driving, and then baseline visual function and spatial awareness reductions tend to bring a somber note to recovery.

While it isn’t all bad news, strokes in the occipital lobe only have about a 50/50 chance of total visual recovery over the span of a year.  For some people, this is not awful news.  It truly is cup half-full/half-empty with a long period of recovery and potential for recovery.  Once again, no one expects to have a stroke at 45 years old when the worst that they do is enjoy a drink once a week (literally once a week).

The neuropsychiatric ramifications of strokes in young people, however, are much more serious.  Post-stroke depression is not uncommon.  How could it be when it is so life-altering?  How would it be when the brain’s neurotransmitters are inherently damaged and depleted from loss of adequate perfusion to the brain tissue?  It’s generally expected that people who have strokes will have some amount of depression.  As one might imagine, the rate of depression is much higher in those who have strokes when they are young.  Resources abound for the elderly who have strokes due to aging, lifestyle choices, genetic factors, etc.  Those resources and relatable support groups thin out considerably when we correct for age and bring the age limit to 50 or even 60.  How easy is it to relate to someone with atherosclerosis who has been battling high blood pressure, diabetes, and high cholesterol when you just finished running a 10K with friends and you’ve never had to take medication in your life?

I wish I could say that technology is making it easier and that young people having strokes will be a thing of the past.  However, research indicates that more young people than ever are having strokes due various factors (too many to mention and some still controversial).  But treatment is improving constantly, therapies are being tested, validated, and furthered in areas where specialists could not reach before the advent of the internet and telehealth.  Strokes are being recognized more often and more quickly than they were in the past, leading to reduced mortality and morbidity.

I have hope that strokes will be recognized more easily in the future, that those who are at genetic risk of stroke will receive counseling early on in life (teenage years onward), and that treatments will consistently improve.  I have hope that the more we learn about brain functionality, the more long-term rehabilitation will improve and techniques to retain brain function will improve.  I have hope that people will learn not to crack their necks, as this one of the leading causes of stroke in young people(10-25%, and the likely culprit in BiL’s case).  I have hope that treatment for addiction can be advanced and the pervasive psychological issues that contribute to drug use can be mitigated in the future, reducing many more of the strokes in young people (under 65).

Most of all, I have hope that my brother-in-law will regain much of his visual functioning, will find some amount of peace with what has happened to him, and will eventually find his way together with his family back into a life with joy.  I have hope that he will eventually be able to accept what has happened and will be able to, with certain adjustments, continue in his career that has been 20+ years in the making.

I would be remiss if I did not end a post like this with stroke education.

Anyone can have a stroke at any time.  Young or old.  It is an emergency.  This is not something where one should take a nap and see if things improve.  Strokes are life-threatening.  If any of these symptoms are present, please, please, call 911 and have an ambulance take you to the hospital.  Please do not drive yourself (yes, this occurs frequently).  Ambulances can drive faster and medics can frequently get things started so that no time is wasted when you or your loved one arrives to the hospital.  Remember this mnemonic:

With thanks to Campbell County Health for this beautiful graphic.