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Sandor Miko: Minute-by-Minute During a Massive Stroke
A lot can happen in a few hours.
In the case of Sandor Miko, a few hours were all it took to go from watching television in his living room to recovering from an unexpected brain surgery at Hennepin County Medical Center.
On July 14, 2007, Sandor suffered a massive stroke. A combination of a quick-thinking spouse, fast-acting Hennepin paramedics, and a highly experienced stroke team at Hennepin County Medical Center helped give Miko a shot at recovery.
Here's how it happened:
Sandor watches television in his St. Anthony home while his
wife, Judith, prepares dinner. "I was peeling potatoes,"
recalls Judith. "He walked up to me and I realized he wasn't |
Judith and Sandor Miko
share a moment together |
normal. His eyes didn't focus, and he was trying to tell me
something, but he was mumbling." Judith calls 911.
.
The ambulance arrives at the Mikos’ home. Hennepin paramedics Denny Combs and Kim Stueve immediately assess Miko's vital signs and evaluate his ability to talk, raise his arms, and move the
muscles in his face. Problems with any of these three abilities indicate a stroke.
Hennepin paramedics rush a patient to the
Emergency Department. |
Miko has trouble with all three. Combs and Stueve prepare their patient for a rapid transport to the hospital.
"They asked me if I had a preference for hospitals and I said no," says Judith. "They discussed it and said they thought they should bring him to HCMC. The whole thing took maybe 10 minutes. It was very fast."
On the way to the hospital, the paramedics call Hennepin staff members to let them know they
are en route with a possible stroke patient.
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Around Hennepin County Medical Center, special stroke team pagers begin to beep. Team members head to the emergency department.
"The stroke team here is highly specialized," says Mary DuPlessis-Tchida, RN, clinical coordinator for Hennepin Stroke Center. "We have so many subspecialties in-house -- neurology, vascular neurology, radiology, neurosurgery, interventional neurology -- that the bottom line is, when we treat a stroke patient, there's an incredible amount of training and experience in the room."
One example of this training and experience is Vallabh Janardhan, MD, who treated Miko. He is one of several interventional neurologists who, through a partnership with the University of Minnesota Medical School and University of Minnesota Physicians, provide 24/7 service to Hennepin County Medical Center.
An interventional neurologist is a physician whose stroke training includes an extra residency in neurology as well as two subspecialty fellowships of four or more years in length. The word "interventional" means that these physicians have extensive experience in performing minimally invasive surgical procedures that can treat strokes.
Just a few hundred physicians in the U.S. have achieved this subspecialty.
Also at Hennepin County Medical Center are specialists receiving training through the stroke
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Robert Taylor, MD (left) and other Hennepin staff observe an interventional neurology procedure at Hennepin
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fellowship program. Two other physicians on Miko’s team,
Gustavo Rodriguez, MD and Qaisar Shah, MD, are examples. Both are completing stroke and interventional neurology fellowships at HCMC. "The fellowship program available through HCMC give us access to some of the best and brightest physicians in the U.S.," says Duplessis-Tchida. "These are physicians who have years of practicing under their belts but they're the type who never want to stop learning."
The ambulance crew unloads Sandor's stretcher. Almost immediately, physicians Shah, Rodriguez, and Janardhan wheel Miko to the room where a CT scan can be performed. The test confirms it -- Sandor is having a massive stroke due to a clot in a blood vessel in his brain. The clot is preventing brain cells from receiving oxygen or nutrients.
Every minute the stroke continues, Sandor loses two million brain cells.
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Physicians Gustavo Rodriguez, MD,
and Qaisar Shah, MD, prepare for
an interventional procedure.
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The stroke team decides to treat Sandor with a clot-busting drug called TPA (tissue plasminogen activator.) TPA has received recent media coverage because of its ability to dissolve blood clots in the brains of certain stroke patients. However, the drug must be administered within three hours of the start of a stroke. "TPA has been a miracle drug for many stroke patients," says Vallabh Janardan, MD. "When patients are good candidates and when they get to the hospital on time, TPA can often be a very effective treatment. Thanks to his wife's quick action, Sandor got to the hospital quick enough." The team begins infusing the drug into Sandor's bloodstream.
Janardhan, Shah, and Rodriguez are concerned. While TPA works for most patients, it doesn't work for everyone. The clot in Sandor's brain is very large, and the drug doesn’t appear to be having a significant effect on it. It’s time to consider other treatments.
At Hennepin County Medical Center, a state-of-the-art catheterization lab is available 24/7 to patients who need procedures to treat their strokes. Janardhan calls the lab and tells them to get ready for a patient. Then he turns to Judith Miko to tell her about the minimally invasive procedure he and the team think would be best for Sandor.
Janardhan and the team begin Sandor's procedure by inserting a tube, called a catheter, into a blood vessel in Sandor's neck. Slowly, Janardhan works the catheter through the blood vessels in Sandor's head until he reaches the spot where the clot is blocking blood flow.
He inserts a device into the tube that temporarily blocks off blood flow so he can work on the clot. Then, he inserts another device that looks like a corkscrew attached to a wire. By twisting the wire, the team maneuvers the coil around the clot like a lasso. When the clot is secure, they pull slowly on the wire until out pops the blood clot with the coil still wrapped around it. |
Interventional neurologist Vallabh Janardhan, MD, explains Sandor Miko's procedure. |
A scan confirms it - all the regions of Miko’s brain are again receiving blood. While the team monitors Miko, Janardhan steps out of the catheterization lab to find Judith Miko and give her the good news.
In the few days since his stroke, Miko's wife, Judith, has rarely left his side. Today, Judith is by his side as Dr. Janardhan tests Sandor's brain function. "Look at my finger," Dr. Janardhan instructs. "Look to the right, left, up and down." Sandor follows Janardhan's finger as it moves in each direction.
When Janardhan finishes the exam, he pats Sandor on the leg and smiles. "You are making a great recovery," he said. "You're going to do well."
Judith, Sandor's wife, is ecstatic. "I am so happy about this procedure – I am amazed," said Judith Miko. "He's alive, he's better, and he has a new life."
"Sandor was lucky that his wife called 911 so promptly," says Janardhan. "The faster he got here, the faster we could treat him and the fewer brain cells he lost."
"I want people to know, if you think something is wrong and it could be a stroke, call 911," says Judith. "Don't hesitate.”
Cincinnati Pre-hospital Stroke Scale for EMS Providers
*72% of patients who have one abnormal finding on these
three exam points may be experiencing an acute stroke.
Cincinnati Pre-hospital Stroke Scale (CPSS)
| Sign/Symptom |
How to test |
Normal |
Abnormal |
FACIAL DROOP |
Patient shows teeth or smiles |
Both sides of face move equally well |
One side of face does not move as well as the other |
ARM DRIFT |
Patient closes eyes and extends both arms straight out for 10 seconds |
Both sides move the same or both arms do not move at all |
One arm does not move or one arm drifts down compared to the other |
| SPEECH |
Patient repeats, "The sky is blue in Cincinnati" |
Patient says correct words without slurring |
Patient slurs, says wrong words, or is unable to speak |
Reference: Cincinnati Pre-hospital Stroke Scale (CPSS), Kothari, et. al.,
Annals of Emergency Medicine, Volume 33, April 1999
If you are a patient and would like to make a clinic appointment, call (612) 873-2515.
If you are a physician and would like to request a consultation or refer a stroke patient, call (800) 424-4262 or (612) 873-4262.
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