By: Emily Wallis
Dr. Ramesh Grandhi, an endovascular neurosurgeon and surgical co-director of the Stroke Center at the University of Utah Hospital, had performed the procedure hundreds of times, but never on a patient like this.
In a rare pediatric stroke case, eight-year-old Addison Wright came into the hospital with a large-vessel occlusion (LVO) and needed a life-saving intervention immediately. The team invested in Addison's care, Dr. Grandhi, Dr. Adam de Havenon, adult vascular neurologist, and Dr. Christina Trandafir, pediatric neurologist, decided the best chance for survival and recovery would be a highly advanced, minimally invasive technique known as an endovascular mechanical thrombectomy—a procedure revolutionizing stroke care in which doctors use a catheter and a small retrievable stent to remove the potentially fatal blockage in the brain.
In a mechanical thrombectomy, a catheter is threaded into an artery in the groin and is run through the torso up the neck and into the brain using continuous X-ray guidance, until it reaches the blood clot. Then, the physician inserts a stent into the catheter and places the stent into the clot. As the stent expands, it pushes the clot against the walls of the artery and temporarily restores blood flow to the affected area. After a few minutes, the stent is pulled back into the catheter and both are removed, effectively eliminating the clot.
"We knew this was a critical case. This type of blockage carries a high potential for significant life-long disability, and even death." Dr. Grandhi
Despite Addison's age, and the intricacies of the procedure, Dr. Grandhi felt confident in his ability to carry out his task.
"I didn't think of her as any different from an 80-year-old patient whose life is at risk from a similar clot," says Dr. Grandhi. "My greatest concern was making sure we did a good job explaining the situation to Addison's parents, reassuring Addison we were going to take the very best care of her, and do our job to get the clot out as quickly as we could."
That reassurance is what Alyssa Wright, Addison's mother, remembers most about the treatment her daughter received with Dr. Grandhi and the entire U of U Health team. Addison's stroke was a terrifying ordeal for the Wright family, particularly for Alyssa, who was with Addison as each critical decision unfolded. Although the incident occurred in February (2019), Alyssa can still recall each gut-wrenching detail as if it were yesterday.
Alyssa had just started a quick lunch break at her fast-paced job, when she received a call from Addison's school with the news that Addison may have had a seizure. Alyssa was concerned, but had experienced febrile seizures (a non-fatal, impermanent condition) with her older son, so her initial assumption was that Addison was also affected with the condition. As Alyssa rushed to a local hospital in Provo, she couldn't shake the growing sense that something deeper was wrong. As soon as Allyssa saw Addison in person, her deepest fears were confirmed.
"I knew she was having a stroke," recalls Alyssa. "She couldn't focus her eyes, and the right side of her face was drooping. I understood the severity."
Desperate to find a solution, Alyssa quickly conferred with doctors who agreed to run tests. When a CT scan revealed Addison's blood clot, Alyssa and her husband, Justin, were faced with a nearly impossible choice. They were presented with the option to administer an intravenous clot-busting medication known as tissue plasminogen activator (tPA). However, because instances of pediatric stroke are so rare, the drug has not been well studied in children, and carries the risk of—possibly fatal—bleeding.
Feeling as if they held Addison's fate in their hands, Addison's parents chose to allow the administration of tPA before Alyssa and Addison boarded a helicopter that would take them to Primary Children's Hospital, with direct access to the University of Utah Health's expert neuroscience team.
On board the helicopter, Addison began to complain of excruciating head pain and started to vomit red foam in uncontrollable, violent spurts. Alyssa could only watch as the nurses battled to keep Addison stable.
"I thought I had made the wrong choice," says Alyssa quietly, her voice shaking. "It looked like we were losing her."
Upon landing, Alyssa and Addison were met by a large team of physicians and nurses, who immediately discussed a treatment plan for Addison using mechanical thrombectomy, with Dr. Grandhi at the helm.
Although the treatment team needed to move quickly, the three doctors carefully calculated risks and outcomes for this rare case. According to Dr. Grandhi, the use of mechanical thrombectomy has been thoroughly researched in adult patients and boded well for Addison.
"In most adult patients with similar large vessel occlusions, administering intravenous tPA is a reasonable first step, but does not always break up the clot. Thus, getting the patient to a center where further imaging can be performed to confirm whether the clot is still present and where mechanical thrombectomy can be done expediently and by experienced neurointerventionalists is crucial," explains Dr. Grandhi. "That is exactly what happened in Addison's case. Her scans showed the clot was still present despite the administration of tPA. Given that finding, we knew she could benefit from the thrombectomy procedure because by removing the clot and restoring blood flow, we can prevent a significant amount of brain tissue from dying and get oxygen and nutrients necessary for tissue survival to the affected brain."
As intense moments stretched out for Addison's family, Dr. Grandhi and his team successfully performed her surgery and were able to extract a large clot.
Throughout it all, Alyssa describes the team of doctors and nurses at U of U Health as a grounding force, helping her stay focused and grip onto reality.
"Dr. Grandhi and the other physicians explained the procedure in a way I understood, but also comforted me once it was over," she says. "Everyone was so calm and collected. It gave me such a good feeling that we were in the right place with the right people." Alyssa Wright, Addison's Mother
Thanks to the thrombectomy procedure and the extraordinary care of her team, Addison was miraculously able to walk out of the hospital just seven days after her stroke, and head home. Both the Wright family and U of U Health physicians are quick to acknowledge the outcome could have been heartbreakingly different for Addison without this procedure.
Studies indicate upwards of 35 percent improved rates of recovery in patients with LVOs who undergo a thrombectomy—even up to 24 hours after the initial stroke. This means more patients, including Addison, can move forward in life with minimal disability. In Addison's case, the left side of her brain would have been compromised, with potential for long-term speech/language issues and limiting her ability to walk and use her right arm.
Today, Addison seems like a typical, bubbly third grader. She loves math, macaroni and cheese, the color blue, and traveling with her family. She says she loves to help others, especially when they're lonely, and dreams of getting back on the mat for her favorite sport, gymnastics.
She remembers her stroke, flying to the hospital in a helicopter, and the cool nurse who did her hair while she was in recovery, but she has not let the stroke define who she is.
"Addison is a very positive child," says Alyssa. "She's been so accepting of her situation, but she still feels like she can be herself and do what she wants—she looks at this as a temporary problem, not a permanent condition."
Alyssa is quick to thank Dr. Grandhi, his team, and the life-saving procedure for the reality that Addison can continue to make improvements, despite the severity of her stroke.
Addison's balance, coordination, and energy have been affected most. She attends school on a limited schedule and needs to nap often. She's had to re-learn many tasks such as tying her shoes, brushing her teeth, and even smiling. Her free time is devoted to doctors appointments, physical, occupational, and speech therapy sessions, as well as homework and keeping up at school.
Addison and her parents map out daily time for stretching and muscle memory work at home, as well as cognitive exercises to help with short-term memory loss and vocabulary recognition.
Alyssa mentions that while they would never wish their experience on another family, they are grateful that Addison's case may have added to a growing body of evidence suggesting this technique may be more readily accessible and reliable for other pediatric stroke patients.
"I never felt angry that the stroke happened," continues Alyssa. "We were just so grateful to see the condition she was in, and how much she's continued to improve. Hands down, Addison would not be as well as she is without U of U Health. Dr. Grandhi and the team—everyone involved in Addison's treatment—they were just amazing. They saved her life."