Tuesday, April 01, 2003

The War of Rehabilitation

Striking Back at Stroke: A Doctor-Patient Journal

By: Cleo Hutton and Louis R. Caplan M.D.

A woman in her early forties awakens in a hospital unable to get out of bed, scarcely able to speak, and terrified that her children may visit her and witness her vulnerability. This was stroke, and for Cleo Hutton, only the first of several. Through it all, she maintained an intimate journal of her experiences and her emotional roller coaster ride from panic, to determination, to pride. Striking Back at Stroke: A Doctor-Patient Journal juxtaposes Cleo’s virtually unedited journal entries with incisive commentary by stroke specialist Louis R. Caplan. This excerpt follows her struggle for rehabilitation.

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On June 9, 1992, Cleo Hutton, a 43-year-old pediatric nurse, had a stroke, followed nine days later by a second one. Like more than three-fourths of the 750,000 people in the United States affected each year by strokes, Cleo Hutton’s was an “ischemic” stroke, involving inadequate blood flow to some part of the brain. As she underwent treatment, including surgery for a congenital heart defect, and then faced the challenge of rehabilitation and adapting to a new way of living, Hutton was plagued with questions. Why, as a nurse, hadn’t she seen this coming? How could someone so young have a stroke? What part of her brain was affected? What would “recovery” actually mean?

Through it all, she kept a daily journal that documented her experience. “As a nurse,” she said, “I felt compelled to document the medical aspect of my recovery. As an adult who had lost control of communicating and understanding the written and spoken word, I needed to express the terror and frustration associated with stroke.” During her rehabilitation, as she sought to interpret her experience, and answer her nagging questions, Hutton reached out for medical expertise. She found Stroke: A Clinical Approach, by Louis R. Caplan, M.D.

What would it be like to read a frank, intensely personal account of one individual’s struggle with stroke—and then to discuss each chapter with a professor of neurology at Harvard Medical School who is one of the country’s top clinical researchers on stroke and chief of the stroke service at a major teaching hospital? That is what became possible when Dr. Caplan responded to Hutton’s letter and they decided to collaborate to create Striking Back at Stroke: A Doctor-Patient Journal.

We present an excerpt from chapter 3. Dated journal entries are the original text as written by Hutton, with very little change for publication. Commentary is by Dr. Caplan. 

Excerpted from Striking Back at Stroke: A Doctor-Patient Journal by Cleo Hutton and Louis R. Caplan, M.D. © 2003 by Cleo Hutton and Louis R. Caplan, M.D. Published by Dana Press. 

CLEO HUTTON’S JOURNAL ENTRIES

June 16, 1992

Doctors and nurses continue to stream in and out of my room. I cannot communicate with them. I cannot make my mouth form the words. The words are there in my brain but I cannot get them out. When the nurse talks to me I want to scream, “I’m here!” I am frustrated, but more than that, I am scared.

By evening, I begin to form some small words. I walk to the bathroom with the help of a walker and a nurse. I’m back! My left side is still paralyzed, my left eye and ear are not assimilating sights and sounds correctly. However, I can communicate to some extent. I am happy about the few words I can get from mind to mouth, with a small amount of the language I have taken for granted all my life.

But I feel as if I’m on an emotional roller coaster. I am not only afraid for myself but what this vulnerability will do to the children. I panic and cry whenever the hospital personnel mention their names. No! No! Keep them away from me! The doctor will fix me up good as new and I’ll be okay. Imagine what this will do to their psyches, seeing their mother unable to communicate, unable to say, “Everything will be all right. Mom is fine, don’t worry.” I don’t want to see anyone, especially the children.

June 17, 1992

I am uneasy, yet excited. Today I am leaving our community hospital to enter a rehabilitation center at a larger facility. The therapists refer to it as “boot camp.” I can’t wash my hands or position myself in bed without help. The world exists only through my right eye.

[My oldest daughter,] Paige is here to drive me the twenty miles or so to the rehabilitation hospital. It is a gorgeous day in June, and I do not want to be in any hospital. It feels wonderful to be dressed again, to be in the fresh air and sunshine. I smile at Paige and feel a bond between us that I have never known before. I convince her to go through a fast food place for a soda. She understands my pointing, grunts, and moans. I believe I am speaking clearly, but I recognize from her keen look that she has to listen diligently for every word I say.

We travel within blocks of our home and I feel that the nightmare is over. I want her to take me home and to forget all of this as if it were a bad dream. I try to be strong. I beg to stop in for a minute to see Mark and Betty Rae. I haven’t seen them for several days and my mind jumps quickly from one thought to another, never capturing an entire thought and bringing it to conclusion. I feel hypersensitive to the car ride as snapshots of still-frame pictures barrage my sight. If I close my eyes, my body seems to be moving at warp speed and I feel dizzy. When Paige makes a left-hand turn I grab the dashboard with my right hand even though I’m buckled in. I’m frightened to see Mark and Betty Rae when I seem so out of control. I want to be whole again.

“Mom, now you know we have to register by a certain time,” Paige says.

My world no longer revolves around the family. In fact, it is just the opposite. I have become self-absorbed. I am only aware of what is happening in the present moment and space of time. The past does not exist except for familiar faces that enter my world.

The first day at the rehabilitation hospital is devastating. As we arrive at the hospital registration area, I have to use the bathroom. I tell a nurse. Paige is busy at the registration desk, and a male nurse whisks me up to my floor, wheels me to the bathroom, and proceeds to pull my pants down to my ankles. By assisting me, he strips me of my dignity. I feel so ashamed. A male nurse had never helped me before, and it is a shock when done so abruptly. Paige returns to the two-bed ward and sits in the chair next to my bed. I try to be brave and repeat to myself, “Don’t you cry, Cleo. Cleo! Don’t you dare cry!” Paige tries to smile as she asks if there is anything else I need. I shake my head and gather a cassette recorder, pen, and paper to make it appear as if I’ve got things under control. Paige kisses me on the cheek and leaves. My world no longer revolves around the family. In fact, it is just the opposite. I have become self-absorbed. I am only aware of what is happening in the present moment and space of time. The past does not exist except for familiar faces that enter my world. I am in the bed closest to the door and if I turn my entire body to the left I can see the lady in the other bed. I begin to tape a journal entry and I hear her sob.

The room has blue-green walls and a wide plaid curtain marking each person’s bed and desk area. I’m on the sixth floor of the older section of the hospital, which has been converted into a rehabilitation floor.

I am introduced to some friendly people. A therapist gives me written information and rules of the unit. They are not going to do me any good. I can’t read or remember worth a darn! I am told my schedule. I cannot assimilate it all.

At suppertime, the patients eat communally in a large dining hall. Five elderly men sit in wheelchairs around an oblong Formica table, awaiting their meal. Two of the men wear white cotton bibs. A towel is draped over the chest of another. One man’s face constantly winces. A gray-haired man is slumped to one side of his wheelchair and drooling. I try to eat but, in my mind, I refuse to belong to this group. Bending my head, I weep uncontrollably.

When I return to my room, a doctor informs me that I have had several strokes. Not one or two, but several. Am I going to have another one? Will I die?

I am given a suppository. The nurses seem to be preoccupied with the frequency of my bowel movements. I’m afraid I’ll soil my-self. By early that evening I am lying in feces.

June 18, 1992

I have been wheeled down to the physical therapy department twice today. The sweat beads up on my forehead as I strain to control my left leg. It’s too heavy to lift. Why do I have to relearn to walk? Why can’t I just do it?

In speech therapy I learn to make a new sound and to say a new word—“um” and “bad.” I used these words frequently to describe my condition.

“How are you today, Cleo?” “Um, bad.” I respond.

My hair is pulled back in a low ponytail at the nape of my neck and fastened with a barrette that I can clasp with my right hand. I try to apply makeup but apply it to only half of my face. I don’t notice that my lipstick is smeared above the lip line.

I learn to walk between the linen carts and wheelchairs that line the wide halls. The nurses are distributing medications. I begin to learn my own scheduled curative regime in preparation for the outside world.

June 18, 1992

EVENING OR NIGHT. I hear voices but I can’t respond or understand what they are saying. My body is stiff, heavy, and uncontrollable. Lights, people, someone is yelling, quiet voices talking all around me, asleep, fighting to stay conscious, warm blankets... I remember the warm blankets! That night I have a second major stroke.

June 18, 1992

[Transcribed from memory days later.] I awake alone in a room. I can’t stay awake for more than a few seconds and then I drift off again. I hear something beeping and there are bright lights above me. There is a window at the end of the room and I seem to remember seeing Larry [Cleo’s husband] intently watching me through it with his hand against the glass. I can’t fight sleep. The large room is empty except for my bed. The side rails are up but I can’t move my heavy body.

On or about June 19, 1992

I am in Cardiac Intensive Care. Doctor Kendel, my cardiologist, explains that my heart is not working normally. A hole in my heart allows blood clots to travel from the right atrium to the left atrium and pump to the brain.

Larry is by the door during the doctor’s explanation. His face appears pale and expressionless, and he stands as if at parade rest in his business suit. The doctor leaves a model of the heart on my bedside table, and as I try to assimilate this new information, Larry leaves without a word. The snapshot is imprinted on my brain: the heart, and Larry leaving. How can he leave me now? Doesn’t he understand the way I feel? I don’t understand—is he grieving too? It cannot be my heart. I had a coronary angiogram less than six months ago and the cardiologist said I was fine. Apparently, without one particular test it was impossible to see the defect. Not again! I had open-heart surgery when I was a child for a valve that didn’t open correctly. It was called pulmonary stenosis. I was referred to as a “blue baby.” It was repaired in 1955. I didn’t have to take medication. My children’s births were normal deliveries. I had had several surgeries without complications. A hole in my heart! Am I hearing right? Is there another way this could have happened? At this point, I am not sure I want to hear it.

On or about June 20–24, 1992

I am transferred out of the Intensive Care Unit to the neurological floor. I cannot speak except for the word “bad.” I use it often to describe my condition and some of the procedures. I must have been there three or four days. My mind runs thoughts together and I have no idea what date, month, or time it is. Larry is here, in and out as his work schedule permits. I sleep most of the time. I try to listen, try to comprehend, but my eyelids are so heavy that everything shuts away and, for a while, I am lost.

The doctors and speech therapists believe I am showing signs of aphasia, which means that I have difficulty with the ability to use and understand language in various forms, such as reading, speaking, or writing. Aphasia is an unconscious foe that will strike at the most unusual time and hold me captive.

Thank God I can write a little with my right hand and read a few basic words in large print, so not all communication and comprehension is lost. When I listen to what people are saying, it sounds strange and disjointed. I need to just hold their hands and hope this frightening experience will pass. I must take my time to write, and I can read using my far right field of vision. My glasses are no good now. The doctors and speech therapists believe I am showing signs of aphasia, which means that I have difficulty with the ability to use and understand language in various forms, such as reading, speaking, or writing. Aphasia is an unconscious foe that will strike at the most unusual time and hold me captive. [I was unaware, at this point, that memory difficulties or some type of aphasia would be my nemesis for years to come.] I find myself mixing words or letters. Words do not come out the way I intend. It is as if my vocabulary just disintegrates and I am reduced to a game of charades. Things that should come automatically are now a slow ticker-tape process from mind to mouth. Many times I think of myself as a life-size robot that needs batteries for thinking and processing and when my batteries wear down I must rest. Aphasia is my adversary and I don’t like people treating me as if I am a child. Some medical personnel speak to me in a very loud staccato voice and it frightens me. Give me time, work with me, and help me recover.

Exact dates not recorded in journal

I am scheduled for another MRI brain scan.

This procedure mandates that I go out of the hospital to another building via a stretcher and ambulance service. As I reach the door of the hospital, I feel the breeze, cool and wonderful. I smell the fresh air and feel the warmth of the sunshine against my skin. This feeling is replaced by a Velcro chin fastener and the whirring of the coffin-like MRI machine.

Later that day, I hear the cardiologist talking to Larry about heart surgery. The doctors want to prevent further strokes by surgery or blood thinners. What if I am too weak and debilitated to survive it all?

Occupational therapists, physical therapists, and speech therapists come every day, but I am not out of bed yet. I need to get up and start moving around.

Our neighbors for the last four years are Claire and Don. Their son is [Cleo’s son] Mark’s age and the boys spend a lot of time together. Claire and Don visited me this evening and brought music tapes of Phantom of the Opera and Les Misérables. I seem to remember Larry and me attending one of these Andrew Lloyd Weber productions with them at the theater, box seats if I recall correctly. I remember Don likes the song about the Red and Black ... must have been Les Misérables. Don and Claire always look so put together and their hair appears carefully groomed with look-alike silver highlights. We have had great times together and usually get together at least once a week.

I find the music peaceful even though I can’t understand all the words. I feel the need to have something soothing to listen to and the calming effect of the soft music brings me back to a place of serenity and pleasant times.

I have lost my appetite, and with it about thirty-five pounds. Most things taste like metal. However, cold things like watermelon, iced tea, Popsicles, and water taste moist. The food is always mashed up. At times, the nurses smash my pills and put them in peach baby food. It is humiliating. I can swallow. It only takes time.

The medical costs are many, many thousands of dollars. I can’t do anything about it now. I know I have fine doctors.

Larry is talking about selling the house and buying a much smaller rambler-style. He sits on the bed next to me and stares out the window as if in a daze. We had purchased the house with my child care income in mind, although we qualified for the mortgage under his income alone. I hand him a signed blank check from my business account. It was the last check I would sign from that account as it only held about eight hundred dollars. We were like everyone else, living on credit from paycheck to paycheck, never realizing our house of cards could topple over. Larry may have worried about our financial future before but had rarely voiced his concern. Now, with his voice cracking and his eyes empty of comfort, I know he is serious.

I write d-i-v-o-r ... on a piece of paper. I think that financially speaking it would be better for the kids and Larry. I can’t go back to child care, and nursing doesn’t seem like a probable option either. For me, employment of any type looks far away.

“Don’t,” he replies. I was hoping for a better response, maybe one from the ending of an old movie. But this isn’t high drama, this is real.

I am full of trepidation about going home. Will it be the same? Will I be able to move and do everything as I did before the stroke? Will I be a good wife to him? Will we be able to love each other as we once did? Will I be pretty in his eyes? Will I walk without a limp and move my arm comfortably. Will I feel his kiss?

Last night I slept very soundly but awoke disoriented. I’m afraid to sleep at night, afraid of having another stroke. I can’t shake off the fear.

It is late one evening, after visiting hours, when our family physician arrives. I try to say his name but all I can do is sob. Tears flow so easily now. He has been our family physician for many years.

“Well, how are you doing? I thought I’d stop in to see my favorite patient.”

I begin to scribble notes to him. “Yes, yes, now you calm down and let me talk. You need to rest. Your speech will come back. What is this I hear about you not wanting your children to visit you? They need to see you. They love you. It will be all right. Now, don’t worry.”

No, no! Don’t you see? My babies will be scared. Not yet! I’m not ready for them yet! I’m supposed to be the strong one. I’m supposed to be their mother. I have to care for them and I can’t right now, my thoughts raced without the use of words.

At five o’clock Larry is bringing the children to see me. I have not seen them since I came to the rehabilitation hospital. I’m anxious about it. I do not want to frighten the children. Larry insisted that I see them today. I cannot speak, hear them completely, or see them to the left. I’m terrified at what that might do to my sweethearts. 

At five o’clock Larry is bringing the children to see me. I have not seen them since I came to the rehabilitation hospital. I’m anxious about it. I do not want to frighten the children. Larry insisted that I see them today. I cannot speak, hear them completely, or see them to the left. I’m terrified at what that might do to my sweethearts.

They come despite my fears. I hug Betty Rae, as best I can with one arm, and we cry. Paige uses an electric curler on my hair. We begin to laugh as I write notes to them. However, I can tell that Betty Rae is upset. She lies with me in bed and I can smell the fresh grass in her hair. Mark is aloof, quiet like his dad. They try so hard to be strong like their father, but I can tell it is ripping them apart. I am glad they came, though. Not seeing me is far more dangerous to their imaginations. They will be back, to see me improve. They will survive this and so will I.

June 22, 1992

Finally, I am up walking with the assistance of a walker. The speech therapist, occupational therapist, and physical therapist are here this morning and afternoon. The neurologist says that my comprehension is improving. I am hearing better on the right side. I will practice by naming things in the room.

My spirits are low because Larry is working out of town. I am very lonely. I am taken to the physical therapy department this afternoon. As long as I keep my eyes and my mind on the therapist, I can concentrate.

I can see the other patients. I appear to be the youngest, except for a girl maybe in her twenties; she is trying desperately to stack cones on top of each other. After therapy the patients are wheeled into a line. There we await an attendant for the return trip to our respective rooms. While in line, many patients fall asleep from exhaustion. No one speaks. Many patients have intravenous tubing and urine collection bags hanging from their wheelchairs.

Larry and the children came this evening. I smother the children with kisses. I miss them so much that my heart aches.

Flowers and plants decorate my room. I have to write thank-you notes. It will give me something to do.

Cora is my roommate. She is a petite, white-haired woman, probably in her seventies. She can speak, eat, and walk much better than I. The doctors say she must go to a nursing home because she is not a good candidate for their rehabilitation program. Both of us cry.

DR. CAPLAN’S COMMENTARY

Rehabilitation and Setbacks

When Cleo transfers to the rehabilitation facility a week after her stroke, she enters a new and different phase of her treatment. She has begun to realize how much difficulty she has performing common tasks of daily life. Contact with other patients at the rehabilitation hospital, especially during communal meals, shows her that many stroke victims are severely handicapped and helpless. Perhaps this provokes her to strike back and not become like them...

For a patient to overcome a deficit, it is very helpful if the person recognizes exactly what is wrong. That is his or her first step toward recovery. Thoroughly explaining the nature of the potential handicap is essential. For example, many individuals whose illness has resulted in a visual field abnormality do not recognize or understand that the problem is not in the eye and do not realize what they are not seeing. Consider a left visual field defect, one of Cleo’s problems. Showing Cleo that she isn’t noticing objects or words on her left and that she doesn’t look toward the left is the start of retraining. A patient like Cleo is then trained to always look left and to make sure that she has looked to the farthest left edges of reading material, pictures, food, and scenes, lest she miss items on her left side. Missing things to the left presents an important problem when the patient tires and may forget to use this skill when crossing the street or just walking in a congested area.

A physical therapist may work on limb strength, exercises, and walking stability or may help train patients with paralysis in transferring from bed to chair to toilet and so on. Occupational therapists might work with a patient in a makeshift kitchen to help him or her to be able to cook again. Speech therapists might work with speaking, reading, and writing skills and may also evaluate and treat swallowing problems.

Rehabilitation hospitals also usually have specialists who can make and fit various devices such as braces, slings, and supports that can help patients move and use their limbs better. The strategies are to correct everything that can be corrected and to find alternate ways of doing things that can’t be corrected. For example, a right-handed person who develops paralysis of the right hand is taught to do things more with the left hand. 

Much of the recovery is spontaneous and related to healing of the injured brain area and development of other brain regions that take over lost functions. Because many functions are represented in more than just one place in the brain, if one brain area is injured other regions can sometimes take over with time and training.

Recovery usually takes much longer than the time it took to become ill, and stays in rehabilitation hospitals are usually longer than stays in acute hospitals. Unfortunately, insurers now hurry patients in and out much quicker than in the past, so that patients are often asked to do things that they are not yet ready to do. Much of the recovery is spontaneous and related to healing of the injured brain area and development of other brain regions that take over lost functions. Because many functions are represented in more than just one place in the brain, if one brain area is injured other regions can sometimes take over with time and training. This is especially apt to happen in children.

A very important component of rehabilitation is to fully explain to those in the patient’s home and environment the nature of the new handicaps and how they should be handled when the patient returns home. Wives, husbands, children, other family members, and significant others can help with the therapy and should know the patient’s abilities and limitations. Unfortunately, Cleo’s journal shows a telltale absence of family involvement in her rehabilitation.

She writes in later entries that she has been afraid of encouraging them to visit, that Larry is growing despondent, and that she feels desperate, too—all signs that the hospital may not be giving the family enough counseling, or that it isn’t getting through....

But the aim of rehabilitation is not to return all functions to normal. That is almost always an impossible goal. The aim is to return the patient to as close to normal living as possible. Patients without normal hand function on one side can live quite normally and do almost everything they could do before. The patient should be encouraged to broaden his or her view of recovery toward returning to the interests and routines that made up daily life before the stroke. Overemphasis on formal physical therapy in the clinic sometimes delays return to normal activities and socialization. Much of recovery involves learning to perform daily activities in one’s customary locations—the home, the backyard, the grocery store. The stroke survivor must once again think of himself or herself as a person, not just as a sick care-receiver, a patient...

Aphasia, Language, and the Brain

In addition to Cleo’s dismay at the realities crowding in as she entered rehabilitation, she was there little more than twenty-four hours when she had a serious setback— another stroke. But this frightening development uncovered Cleo’s specific problem —embolism caused by a clot that went through the chambers of her heart into major arteries supplying her brain...

Cleo’s second embolism caused ischemia in the language zone of her left cerebral hemisphere. This was an agonizing turn of events.

Language is extremely important for daily communication. The ability to use written language, to read, write, and spell, separates humans from all other species. I vividly remember the great frustration I felt when trying to obtain directions in Japan; the individuals I asked could not speak any English, and I couldn’t speak, understand, or read Japanese. We simply could not communicate with each other despite earnest effort on both sides. This experience is probably a mere taste of the desperation patients with severe aphasia experience daily.

Speech mostly arises from a region surrounding the large fissure, the sylvian fissure, separating the frontal and temporal lobes on the outer surface of the brain, in the so-called dominant cerebral hemisphere. The left cerebral hemisphere is dominant in right-handed individuals and in 80 percent of left-handers. Left-handed people are more likely to have some speech functions in each hemisphere and may develop aphasia when either hemisphere is injured, but the resulting aphasia is less severe than if speech resided on only one side. Some researchers believe that women more often than men have speech representation on both sides of the brain. The drawing on the next page shows the language areas and also indicates specialization within this region. The right cerebral hemisphere, in the same general areas, is associated with adding emotional meaning to speech. The emphasis and tone of speech, and accompanying facial expressions and gestures, help send messages, and these aspects help others understand the importance to, and feelings of, the person sending the messages...

 

Our ability to use language is controlled by so many parts of the brain, such as Broca’s area (producing speech), Wernicke’s area (understanding speech), and the angular gyrus (related to reading and writing), that a stroke may lead to any combination of language problems—or none at all.

Motor control of the face and limbs on the opposite side of the body is localized in an area called the precentral gyrus. Its lowest part is specialized for control of the muscles of the face, tongue, cheeks, and pharynx. Just below and behind this motor region is the so-called motor speech region, usually referred to as Broca’s area, after Paul Broca, a French physician and anthropologist. Individuals who have damage in and around Broca’s area have difficulty producing normal speech. Patients with Broca’s aphasia talk less than normal, their speech takes considerable effort, and letters and words are poorly pronounced. The speech produced is usually accurate but incorrect grammatically. Writing may also be ungrammatical and telegraphic—that is, small connecting words may be left out, as is often done in a telegram. Most patients with this problem also have some paralysis of their right hand, arm, and face.

Other language problems come from damage to a region usually called Wernicke’s area, after the German neurologist Carl Wernicke. Wernicke’s area is specialized for the understanding of spoken language and is located toward the back of the head next to the hearing region in the dominant temporal lobe. Individuals with stroke-related damage to Wernicke’s area use wrong and sometimes nonexistent words and have difficulty repeating and understanding what others say to them (Wernicke’s aphasia). They may also fail to understand what they read, and they write wrong words. This is a problem of language, not intelligence. In brain regions near Wernicke’s area, damage can cause difficulty repeating spoken language with preserved understanding of speech. Some individuals with very small lesions in the temporal lobe cannot understand words and spoken language but can hear and identify sounds and speak almost normally (pure word deafness). Others appear as if they are deaf to language and other sound input, although they jump and blink at loud noises (cortical deafness).

Strokes and other causes of damage around a region called the angular gyrus, within the lower part of the parietal lobe in the dominant cerebral hemisphere, bring about functional illiteracy. Individuals with this damage can no longer read, write, or spell correctly. Thankfully, Cleo’s aphasic difficulties would recede. The embolus causing the dysfunction must have passed without leaving severe, permanent damage.

So Many Tests

Probably the most important clues to where a stroke has happened in the brain and what caused it come from the history the doctors take from the patient and their physical and neurological examinations of the patient. Many patients think that these examinations have been replaced by the new technologies, but nothing is further from the truth. Examining a patient is the only way to know what he or she can and cannot do. The doctor should always begin by taking a history of how the stroke came on and developed later, previous events and illnesses, various risk factors, and what symptoms and problems the patient noticed. Examination of the pulse, heart, and blood vessels of the arms, neck, and legs gives the doctor clues to abnormalities in the heart and blood vessels. During the neurological examination, the doctor checks speech, memory, reading, writing, thinking, walking, vision, hearing, strength, coordination and feeling in the limbs, and various reflex functions. The information from the patient’s examination and history helps the doctor plan the appropriate tests.

The tests devised during the last two decades make it possible for doctors today to obtain detailed images of the brain. For stroke, we use two general types of brain imaging tests—CT and MRI. CT uses ordinary X rays and computers to create thin sliced images through various levels of the brain. MRI uses magnetic energy to generate images of the brain. Both tests are safe and do not hurt. Each is done with the patient’s head positioned in a machine; with MRI much of the body is also enclosed. Patients must remain still if the machines are to generate quality diagnostic images. The MRI machine does make rapping noises—Cleo refers to this—and people who are claustrophobic have difficulty staying motionless in it. To gain more detail about the brain image, doctors sometimes order an intravenous injection of some contrast-producing material. With CT, this is usually a dye that contains iodine; with MRI, it is a chemical called gadolinium. Some patients can have an allergic response to these materials, especially to the dye used for CT contrast.

CT and MRI allow doctors to distinguish brain hemorrhages from infarctions... On CT scans, hemorrhages appear white and infarcts gray or black, making it quite easy to distinguish between the two main stroke categories. MRI produces more different brain section images and shows the brain stem and cerebellum better than CT. The brain images show not only whether the lesion is a hemorrhage or infarct but also exactly where the injury is, how large and extensive it is, and whether there is brain swelling and pressure buildup caused by the infarct or hemorrhage. 

In some patients with brain ischemia, CT and MRI scans can be normal, indicating that the brain has not been irreversibly damaged—that is, not yet infarcted. In these patients, doctors find neurological signs when they conduct an examination, but no abnormality appears on the brain images to explain the dysfunction.

In some patients with brain ischemia, CT and MRI scans can be normal, indicating that the brain has not been irreversibly damaged—that is, not yet infarcted. In these patients, doctors find neurological signs when they conduct an examination, but no abnormality appears on the brain images to explain the dysfunction. Remember Cleo’s CT scan on the day of her first stroke? It was negative, meaning that no abnormalities were found, despite the fact that she had numerous neurological dysfunctions. Many people think that imaging scans are infallible, but they certainly are not. Patients with normal scans will return to normal function if the ischemia is reversible; in many patients, an infarct will develop later, and then CT or MRI scans will show the area of infarction. This is the reason doctors often order scans later, especially if the initial scan was normal. Knowing where the problem is in the brain allows the doctor to know what blood vessels supply the affected region. These vessels can then be examined.

Having identified the brain problem, doctors naturally turn to testing the arteries in which abnormalities could have caused the stroke. Pictures of arteries and veins are referred to as angiograms and the process of taking the images as angiography. CT angiography (CTA), sometimes called spiral CTA, magnetic resonance angiography (MRA), and ultrasound are commonly used now to analyze the nature, location, and severity of any changes in the blood vessels supplying the brain. These tests are all quite safe and can be performed quickly either in the hospital or out. When the infarct is in the thalamus, cerebellum, and temporal and occipital lobes, as it was in Cleo, the doctor knows that the problem must lie along the path to that region, which includes the heart, the aorta, and the subclavian, vertebral, and basilar arteries. Ultimately, material must have blocked the end of her basilar artery and extended into the right terminal branch of that artery, called the right posterior cerebral artery. But if the problem were within the right middle cerebral artery, then the path to be analyzed would be the heart, the aorta, the right carotid artery, and the right middle cerebral artery...

CLEO HUTTON’S JOURNAL ENTRIES

June 25, 1992

I take a shower for the first time at this hospital. It feels wonderful to have warm water, soap, and shampoo all over me. I have to use a shower chair. No one can tell the difference between the tears on my cheeks and the spray of the water. I never want to leave the safe cubicle. Showering, a simple task I always took for granted, is now a marvelous chore.

Last night I began to move my left hand and fingers more purposefully. I am obsessed with the movement and can’t wait to show it off to the neurologist. My elbow leads my arm upward and my fingers can wiggle ever so slightly. I am elated over two distinct movements at the same time. If I am not straining to look directly at my left hand, it moves about in a grotesque bending action, but if I stare at it in thoughtful concentration, I can move my fingers apart and together on the bedsheets. More control, but still numb. In physical therapy I am working so hard that my leg seems to tingle from my knee to my foot. Is it possible that I am getting better already?

Both arms are bruised from daily blood draws. These vampires of the laboratory always arrive before breakfast with a bright disposition because they are not going to be pricked with the damn needle.

This afternoon God smiles on me. My speech is back! It is choppy and monotone. My head twitches when I try to speak and my eyes blink as if I am searching for the word in my mind. I have changed my vocabulary from “bad” to a more persistent and deliberate “um,” as I try to get the specific word from thought to speech.

I receive a single-tipped cane in physical therapy and use it only if I feel myself falling. Sarah, my therapist, is a tall, dark-haired, thin, self-assured woman probably in her later twenties. She insists that I wear the therapy belt whenever we go walking. This wide, white canvas belt is strapped to all the patients during therapy. She says something about it being hospital policy. I am getting better, Sarah, don’t you see that? I try to say.

“One step at a time,” she retorts. “Remember, it takes time.” Time seems to be a four-letter word in this recovery process.  



About Cerebrum

Bill Glovin, editor
Carolyn Asbury, Ph.D., consultant

Scientific Advisory Board
Joseph T. Coyle, M.D., Harvard Medical School
Kay Redfield Jamison, Ph.D., The Johns Hopkins University School of Medicine
Pierre J. Magistretti, M.D., Ph.D., University of Lausanne Medical School and Hospital
Robert Malenka, M.D., Ph.D., Stanford University School of Medicine
Bruce S. McEwen, Ph.D., The Rockefeller University
Donald Price, M.D., The Johns Hopkins University School of Medicine

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