A lot of luck, plus new brain surgery techniques make quick work of a stroke
Published 4:00 am, Sunday, June 11, 2006
Chris Palamountain has no family history of strokes so it seemed strange when out of the blue her sister Kara sent her an e-mail titled "Recognizing a Stroke," in three easy steps.
It seemed less strange 10 days later when she awoke at her usual 5:30 a.m. "with the worst headache of my life," says Palamountain, 38, a marathon runner and Stanford law school graduate. She put on her workout gear and headed toward the door and "started bumping into things on my left side." When she failed to negotiate her way around a car parked in front of her driveway, she came back in and that is when she remembered the test.
Smile in front of a mirror, to make sure both sides of the face work.
Raise both arms overhead, palms up, like holding a platter.
Speak a simple sentence. "It is a sunny day."
She passed the test, even as she was probably having the beginning of a hemorrhagic stroke, or bleeding on the brain. It was a slow leak, like the tremor before a major earthquake.
Because she was 18 weeks pregnant and lives alone, Palamountain happened to have the on-call obstetrics number at UCSF Medical Center. The doctor who answered gave her the choice of phoning a friend who could be there within 10 minutes or calling 911 for an ambulance.
It was still early on a cold January morning so she had no problem finding a friend who was ready to go to work. On the 15-minute drive over the hills to Parnassus Heights, Palamountain began vomiting, and reached the UCSF emergency room just as the slow leak busted open. "I remember being helped onto the gurney and seeing the white acoustic tiles as I was being wheeled in," she says from her office at Chavez & Gertler LLP, a consumer class action firm in Mill Valley.
Dr. Michael Lawton, chief of cerebrovascular Surgery at UCSF, had just finished one surgery and his second was being brought to the operating room when Palamountain came to his attention.
The family of the scheduled patient was in the hallway waiting to give her moral support. "I literally stopped the bed from going in," he says. "Everybody waited for a minute while I looked things over with Ms. Palamountain and said, "She's gotta go in." The other patient was sent back to her room while Lawton went to apologize to her family for the delay.
What he had seen on Palamountain's CT scan was a blood spot the size of a softball. Dye injected into the veins revealed a ruptured arteriovenous malformation (AVM) within the clot.
"As soon as I looked at the CT scan I knew exactly what she had," says Lawton, 41. "If she hadn't had her surgery right then and there she'd be dead or significantly impaired."
AVMs are masses of abnormal blood vessels that tangle the arteries and veins "like a basket full of snakes," Lawton says. Normally, arteries that feed the brain connect to capillaries that slow down the blood and route the flow into the veins that drain the organ. With an AVM the capillary connection is missing. Arteries feed directly into veins, applying too much pressure. As the vein weakens the AVM eventually bursts, causing the clot.
AVMs happen in about 1/2 of 1 percent of the population. It is rare enough that it isn't listed in Stedman's Medical Dictionary. If you Google AVM, as Palamountain later had the chance to do, "you only get bad news," she says. It's also true that you only get bad news on AVMs if you watch the HBO mortuary drama "Six Feet Under." Lead character Nate Fisher has an AVM, which is played out over a few seasons before he has surgery, ultimately dies and the series ends.
Neither Lawton or Palamountain watched the show, but her sister Shea, a Houston pediatrician, did. "When she heard it was an AVM," Palamountain says, "she thought she was coming to my funeral."
"When there's a big clot and there is pressure pushing on the brain, it will kill people quickly, because the brain has only a limited amount of space," Lawton says. "If you have a ruptured blood vessel the size of a softball, it means that the rest of the brain gets smooshed. It doesn't like that."
Once the blood clot was removed, which took an hour, the AVM beneath it was about average, a twisted knot the size of a golf ball. It took another two hours to excise the AVM by cutting and cauterizing.
"The best analogy is like pulling wires on a time bomb," Lawton says. "You have to figure out what goes to the bomb and then what goes to the normal machinery, and then only pull the wires that are dangerous. If you're not careful in preserving all this normal stuff then you end up with a stroke."
As Lawton moved onto his delayed surgery, his third of the day, Palamountain went to the ICU. Eight of her friends gathered at the hospital were told there was no way of knowing if or when she would wake up and whether there would be neurological damage. So it was a surprise when she came out of anesthesia an hour after surgery.
"She immediately woke right up," Lawton says. "It was pretty amazing because going down to surgery there was so much pressure on the brain that it had gotten down to her deep brain stem regions. She was down to her basic reflexes."
By her six-week follow-up she was perfectly normal except for a loss of peripheral vision in her left eye, a deficit caused by the blood clot.
Looking back, Palamountain sees all the pieces of good fortune that added up on that day. The timing of her sister sending that stroke test is just one of them. AVM is a birth defect, but the rupture may have been exacerbated by her pregnancy. The theory is that increased circulation puts more stress on an AVM, but it hasn't been proven. Then again, "If I hadn't been pregnant I wouldn't have had a number to call," she says. "That was one of the things that really made a difference because that's what connected me to UCSF."
If she'd gone to her neighborhood emergency room at St. Luke's Hospital, she likely would have been sent over to UCSF for surgery anyway, and the time lag would have cost her some neurological function.
If she'd arrived a few minutes later, and Lawton had started that second surgery, she would have lost time she didn't have, especially if another operating room wasn't available. If her AVM had burst five years earlier, CT angiography wouldn't have existed, Lawton says, and she would have lost time on a formal catheter angiogram. As it was, a catheter angiogram was done the following day to make sure Lawton had gotten all of the AVM. If he hadn't, he would have opened her skull back up and gone after it. But he had.
In April, Palamountain went back to work full time. The baby is due July 2, a girl to be named Caroline Marie. Lawton Palamountain was not in consideration, though it is a thought.
"How do you thank the man who saved your life?" she says.
When Palamountain met Lawton for the first time, the morning after surgery, she told him "it would be a lot easier to recognize you if you just wore the red cape and the blue shirt with the 'S' on it."