By now, most of us have memorized the signs of a stroke: F-A-S-T for Face drooping, Arm weakness, Speech difficulties, and Time to get a person to the hospital. Mark Kroeze definitely knew the signs, but as a healthy 36-year-old who enjoyed fishing and cycling (he's completed three cross-country bicycle trips so far) and spent his days working as a forester in Texas, he wasn't expecting to suffer from a stroke anytime soon.
In the spring of 2020, Kroeze drove from Texas to Moab, Utah, to attend his sister's wedding in the picturesque setting of Arches National Park. He arrived a day early and was spending time with his eight-year-old son in the hotel pool when he felt like he was hit by a bolt of lightning. He got out of the pool and sat down, but several minutes later he was still feeling light-headed. He couldn't walk and couldn't speak.
He immediately thought it could be a stroke but wasn't sure because the symptoms were coming in waves. One minute, half of his body was significantly delayed, and he couldn't speak. The next, he felt almost normal. He knew something wasn't right and decided to go to the emergency room.
World-Class Stroke Care from Anywhere
Moab Regional Hospital is located in a rural part of southeastern Utah. It's a Level IV trauma center that serves a large geographic area of the state but only a population of around 35,000 residents and tourists who come to the area. The hospital doesn't have a neurologist or stroke specialist on staff. When University of Utah Health launched its telestroke program almost 20 years ago in 2003, it was specifically with facilities like Moab Regional Hospital in mind.
"Without a doubt, the partnership between the University of Utah TeleStroke program and Moab Regional Hospital was the difference between life and death in Mark's case," said Joe Christman, TeleStroke Coordinator at Moab Regional Hospital. "The ability to put Moab providers, University of Utah specialists, and the patient together rapidly enables the diagnosis and treatment plan to commence quickly and increased the patient's chance for survival."
The night that Mark went to the hospital, Dr. Jennifer Majersik, a professor in the Department of Neurology at U of U Health and TeleStroke director, was on call. She got on the phone with a physician's assistant who described a patient with strange symptoms that might be a stroke, but providers in Moab could not tell for sure.
A telestroke consultation begins with a conversation between the physician at the outreach facility and the neurologist over the phone. If the neurologist believes it is possibly a stroke, the next step is a video consultation with the patient and their family. A nurse from the outreach facility is also in the room to help facilitate the telemedicine visit. Since the neurology specialist isn't able to be in the same room with the patient, the nurse can help with certain parts of the exam. The nurse and the patient's family can also help provide important information specific to a stroke evaluation, such as neurological medical history and key medications. Once the exam is complete, the physicians and medical staff quickly review the assessment and determine next steps.
"We often say that 'time is brain' in stroke care," said Danielle Freeman, director of outreach and telehealth for the neuroscience service line at U of U Health. "Regional hospitals that don't have stroke neurologists working in them need rapid access to stroke experts who can quickly and accurately identify stroke, especially in life-threatening situations, and transfer the patient to a larger stroke center like U of U Health's Comprehensive Stroke Center."
"Time is Brain"
When someone experiences a stroke, time is the biggest enemy. To provide the best care and preserve brain function, a neurologist needs to start certain treatments within a very specific timeframe. Every minute lost is brain cells lost—brain cells that cannot be regenerated.
Because Mark didn't immediately know he was having a stroke, and because his symptoms were coming and going, he waited a little while before going to the hospital. He had already lost some time in his treatment window, and the distance from Moab to Salt Lake City would take too long to drive, even by ambulance. So Dr. Majersik ordered a helicopter to fly Mark to U of U Health's Comprehensive Stroke Center.
Mark remembers the helicopter flight after being diagnosed with a stroke. He thought about all the places he had traveled—first growing up in northern Minnesota, then attending graduate school at Mississippi State. From there he moved to Texas, then California, and even spent a year in New Zealand in his 20s. As a person who was always up for an adventure, it was hard to comprehend how his life might be different after a stroke.
"I was basically resigned to my fate," Mark said. "I thought I was going to be permanently paralyzed or permanently disabled. I wouldn't say I was ever really sad or mad about it, but I didn't really know of any treatments or anything you could really do for a stroke."
He arrived at University of Utah Hospital and felt his symptoms getting worse. His mind was completely lucid, but nothing else was working. His brain knew what he wanted to say and do, but his body wouldn't cooperate.
One of the neurology residents explained that he would probably need a mechanical thrombectomy. Mark was willing to do whatever was required. "When you're in that state of impairment, you really don't care what you've got to do to get out of it," he said. "Imagine the worst dream of your life—the worst nightmare. You'll do whatever you can to wake up."
The Six-Hour Window
The most common FDA-approved stroke treatment, called tissue plasminogen activator (tPA, or alteplase) has to be given within a few hours of the stroke onset. "Very few people get to the hospital within minutes of their stroke," Dr. Majersik said. "So even though you have a few hours total, by the time they get to the emergency room, you might only have 20 to 30 minutes left in the tPA window." In Mark's case, he waited too long to go to the ER, so the intravenous tPA, which is standard treatment for ischemic stroke, was not an option. It must be given within four and a half hours of stroke onset.
Instead, doctors got brain imaging to identify the clot location and saw that it was big enough to remove using a procedure called a mechanical thrombectomy. This procedure is an option for some patients for up to 20 hours after the stroke occurs.
Because the team at University of Utah Hospital knew Mark was on his way from Moab Regional Hospital, everyone and everything was already in place before he got there so they could get started immediately when the helicopter arrived.
A mechanical thrombectomy is a minimally invasive procedure where a neurointerventional surgeon uses a specialized instrument to extract the clot from the blood vessel where it's blocking blood flow. A small catheter is inserted into an artery, then threaded through the patient's body to reach the clot. Along the way, the radiologist uses x-rays to advance the tools to the correct location.
Dr. Matthew Alexander, a neurointerventional surgeon in the Departments of Radiology and Imaging Sciences and Neurosurgery, performed the procedure to remove the clot. Mark remembers being prepared for the procedure while Dr. Alexander told him that he would use a small device to grab the clot and pull it out. It's a low-risk procedure but still involves inserting a device into an artery in the brain. So it comes with some risks.
Mark remained awake for the entire procedure with a local anesthetic, something Dr. Alexander prefers so the patient's brain remains active. He described it like the feeling of going underwater when scuba diving and experiencing some pressure in your nose and ears. He could hear a metal sound as the device deployed to grab the clot. When they pulled the clot out, it felt like a flickering lightbulb that was suddenly screwed in all the way and fixed.
"Instantly I just started crying because I knew that he got it," Mark said.
"Watching Mark's reaction was a moving experience," Dr. Alexander recalled. "He was so calm and quiet throughout the procedure. It was the middle of the night, so I assumed he had gone to sleep. It wasn't until we were finished that he told me he knew exactly what was happening at every step and knew the procedure was successful before I took the pictures to confirm that the vessel was open."
Stroke Prevalence Increasing at All Ages
The case of a seemingly healthy man in his mid-30s having a stroke was a mystery to Mark's doctors. As he recovered from the thrombectomy, they ordered some tests to figure out what happened. Since it was early 2020, they thought he may have contracted COVID-19 and the stroke was a side effect of the virus. But he was negative for COVID.
Instead, they discovered that Mark had a congenital heart defect—a patent foramen ovale (PFO), or a hole in his heart—and were surprised he could be as active as he was for so long without symptoms. It's a common defect that occurs in about 25 percent of people, and it put Mark at higher risk of developing a clot that could lead to a stroke. Three days after his mechanical thrombectomy, Dr. Anwar Tandar, a professor in the Department of Cardiology, repaired the hole to prevent future clots. This is often done as an outpatient procedure, but Mark had a long drive home to Texas, so the team felt it would be safest to repair it while he was still in the hospital.
While Mark's stroke was likely the result of the hole in his heart, the prevalence of stroke is increasing in younger patients. "There is a definite increase in the past 10 to 20 years of young people having stroke," Dr. Majersik said. "Some of that might be that we're smarter about diagnosing stroke. But it may be because of the national rise in diabetes, hypertension, and obesity in young persons." For that reason, it's even more important that people of all ages understand the symptoms of a stroke and where to go for care if or when you experience them.
The Miracle of Medicine
Stroke treatment happens quickly—it has to in order to save a patient's life—and doctors must be prepared to make split-second decisions about what the best course of treatment will be for each patient. In Mark's case, Dr. Majersik had a little bit of time to work with the team as he traveled from Moab via helicopter—but very limited time once he arrived in person and they rushed him to the operating room. In those few precious minutes, she and Dr. Alexander had to confirm whether mechanical thrombectomy would be the best treatment and prepare Mark for the procedure. It turned out to be the exact right decision.
"It was instantaneous," Mark said. "I started talking right when they pulled the clot out. It was just crazy. It was a very special moment for a lot of people because we got to see the miracle of medicine, how [doctors] can just make one right treatment decision and totally change somebody's life."
"The most important thing is to get help to the patient as quickly as possible, which is why telestroke programs are so beneficial," Dr. Alexander said. "With these programs, someone experiencing a stroke doesn't need to worry about whether they are going to a hospital that has a whole team for coordinated stroke care with a neurologist, neurosurgeon, radiologist, emergency room doctors, nurses, and others who can provide top-notch care. They don't have to spend extra time or drive a longer distance to find that type of facility. Patients can just go to the nearest hospital in the telestroke network and still have access to stroke specialists."
"Telestroke is increasingly common all over the country," Dr. Majersik said. "University of Utah Health provides more than 1,000 telestroke consultations a year at 26 hospitals in six states throughout the Mountain West region. It's a fantastic way for rural and even urban sites that don't have the kind of expertise that we have at [UofU Health], but they can share in that expertise despite being smaller. It's essential for overcoming geographic and transportation barriers, and it ensures that every patient can get the best care no matter where they live or where they experience a stroke."
The state of Utah actually has a plan that outlines how a hospital facility can become a designated Stroke Receiving Facility. For patients, it's important to know that you can request an ambulance to take you to one of these facilities when you think you are experiencing a stroke. To qualify, the facility must have an emergency department that operates 24/7 and either a dedicated stroke unit on staff or anytime access to telestroke specialists like those at U of U Health.
Mark also recommends that young people learn the signs of stroke so you can be your own advocate if you know something isn't right. Some of his initial stroke assessments were inconclusive at Moab Regional Hospital, but luckily he had access to an expert in Dr. Majersik and her team through telestroke. That helped him advocate for his treatment better because he knew the signs.
Today, Mark is back in Texas spending time with friends, colleagues, and family. "My life now is enjoying the moment more than before," he said. "I used to think that if you're alive today, odds are pretty good you'll be alive tomorrow. I really learned that your body can change instantaneously. I really try to be more mindful of the moment and enjoy every day."