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A big shout-out to our House, MD fans who recognize the “Three Stories” title. In this case, the homage is appropriate because I am going to use three different real life scenarios to illustrate important aspects of self care, health self-awareness, and just how mysterious the black-boxes that are our brains can be. Also, this will serve as an important lesson of how biology doesn’t always follow the textbook, and things are not always what they seem.
But first, as always, a disclaimer or two. First, some big details were changed to protect the identities of the individuals in these cases. Two, situations like these are rare, so please don’t immediately convince yourself you’re having a stroke every time you get a head rush from standing up too fast. Third, and admittedly contradictory here, if you are having any alarming and unexplainable symptoms, call your personal medical team or 911. Anything I ever say publicly is not medical advice. Your personal health situation is your own, and everything that follows is for educational purposes, not to diagnose or treat any illness.
Patient “Jane” is a woman in her thirties, who was previously healthy without any relevant medical history except an uncle who’d had a heart attack in his 40s. Shortly after giving birth, Jane suffered a bizarre room spinning sensation, nausea, and a condition called nystagmus- a phenomenon of rhythmic eye movements often associated with a handful of different conditions including inner ear, “cranial nerve,” and brainstem disorders. If any of the two or three readers of this blog happen to have medical training, you’re probably leaping out of your chair like a stethoscope-wielding savage screaming “WALLENBERG SYNDROME!!” For everyone else, Wallenberg Syndrome is a commonly tested exam favorite that occurs with strokes to a certain part of the brain stem in the medulla.
Jane and I began working together to try and figure out what the heck caused a 30-something year old to have a stroke, because without a reasonable theory, she was preoccupied with whether or when it may happen again. She’d already had the usual workup before seeing me- cholesterol panel, ultrasound of the heart looking for structural issues, EKG to check for arrhythmias, and testing of blood vessels in the head and neck for abnormalities that may have been a source of a clot.
All of these were normal.
Since she’d had a family history of early vascular disease (Uncle with a stroke), I figured something had to be lurking in her genes. Our testing found one contributory factor, a little protein called Lp(a) that is gaining attention for the trouble it can cause when everything else seems normal. We’ve known about Lp(a) for some time, but our treatments were underwhelming. Now, as our treatments for it and understanding of the risk have improved, more and more clinicians are testing Lp(a) levels when the scenario otherwise doesn’t make sense.
To make a long story short, insurance denied the fancier medication, saying she would be served just as well with a high dose statin. Statins don’t have the same impact on Lp(a), but they lower the “bad” cholesterol (LDL-c), reduce the number of particles carrying LDL-c (known as LDL-p or ApoB), and they’re also anti-inflammatory. Regardless, Jane is now feeling nearly back to baseline, which is great because it's difficult to chase a toddler while experiencing attacks of vertigo.
Thank you for indulging me.
-Childbirth and stroke: Risk of stroke after childbirth is highest in first two weeks, but remains elevated for a few months. Mitigate some of this risk by controlling blood pressure as best as possible. This is still quite rare- some research suggests .03%. However, it is important to understand stroke symptoms so that you may get FAST treatment (more at the end).
-Cholesterol and Lp(a): Jane’s only other risk factor was elevated Lp(a). While not causative, Lp(a) can magnify the risk of other factors.
-Treatment strategies: You cannot drive cholesterol “too low.” We know this both using an ocean of clinical data as well as observational data of individuals who congenitally have profoundly low circulating cholesterol. Statin side effects are likely not the result of cholesterol getting too low- they’re caused by other factors like induced autoimmunity, mitochondrial (“powerhouse of the cell”) effects, and others.
Our next scenario is a 40 year old female, very active, “sleep when you’re dead” type- let’s call her Rihanna. Riri presented to the ER for evaluation of left-sided numbness and weakness that began around 10:30 one morning. She is a group fitness instructor in a gym and shortly after finishing a class, she suddenly felt dizzy, lightheaded, and like she was going to pass out. She also had mild neck, face, and head discomfort and weakness in her left arm and leg.
She got the usual tests like CT (“cat scan”) of the head to make sure there was no bleeding from something like a ruptured aneurysm, MRI to look for signs of a blood clot, and then the usual labs like electrolytes, cholesterol, “troponins” for heart damage, etc. The MRI showed a few small strokes in the cerebellum, which is responsible for coordination and balance. The cerebellum receives blood supply from arteries that go up the spine- not the front of the neck like other parts of the brain- and these sometimes have a tendency to have internal tears. A CT angiogram (CT scan with contrast) showed that this may have been the case; it identified what looked like a small “vertebral artery dissection.” The story was *perfect* ::chef’s kiss::, until they did the ultrasound of the heart (echocardiogram, or echo), which found a clot in the left atrium.
So which was it?
Riri came to me because of this story switch. The clot caused the strokes, but why is this more likely? We talked, and it sounded like there may have been more to this story, after all. Just prior to the stroke, she’d had some chest fluttering or palpitations. These are very often benign, but preceding a stroke this may be relevant. Then, she recalled having a similar sensation with terrible dizziness and just feeling “off” a few months earlier, to the point where she went to the ER and was diagnosed with dehydration.
My theory, ultimately was this: although geographically the potential artery dissection is closest to the scene of the crime, it was too subtle to likely have caused widespread strokes. The clot in the heart, though, is a common cause of embolic, multi-focal stroke, and it formed because an irregular heart rhythm caused blood to pool in the left atrium longer than normal. The arrhythmia was caused by a mix of dehydration, sleep deprivation, and physical stress.
This theory was even more likely because, on her last day, she had sudden onset of blindness in one eye, a condition called amaurosis fugax. In this case, it was likely caused by a clot blocking one of the arteries to the eye. Fortunately, it resolved quickly, but this shouldn’t happen from the vertebral artery.
Riri is now recovering well, sleeping longer, and drinking more water per doctors orders.
-Vertebral Artery Dissection: I’ve seen these cause strokes in otherwise healthy folks, and the most common story is trauma to the neck- either martial arts or chiropractic manipulation. For the love of all that is sweet and holy don’t crack your neck or, worse, let someone else do it for you. Feel free to crack your knuckles; it won’t cause arthritis.
-Changing diagnoses: In medicine, we are often forced to make diagnoses with limited information. Most are just based on probabilities. In this case, a vertebral dissection was very probable at first- it’s upstream from where the strokes occurred.
-Sleep well, drink water, exercise a little: Do everything you can to lower your risk for bad things happening. Even with this, don’t use good health choices to justify bad ones if you can avoid it. But enjoy your life too; it’s all about balance.
Evan is a 35 year old male with a history of hypermobility syndrome, a family history of strokes at young ages, but no prior history of migraine headaches. We were already working together due to his neck and back pain related to the hypermobility syndrome. One weekend, he suddenly experienced severe headache pain in the back of his head. Having had tension-type headaches in the past, he took Excedrin and went on with his day, not looking to waste a valuable weekend because of a “simple” headache.
After getting a haircut, the headache suddenly became “terrible” and was accompanied by a drunk feeling of the room spinning and a tingling feeling in his arm. At this time, the symptoms were so severe as to warrant a 911 call and trip to the emergency department. Here, the ED staff ordered a clot busting medication for a presumed stroke. Since he received this blood thinner, he was required to be admitted to the ICU for monitoring.
Despite the family history and symptoms quite suspicious for a stroke- WALLENBERG SYN…wait- the MRI was completely absent evidence of a stroke.
Could the MRI have missed it? Sure, they’re imperfect as any other test, especially when the stroke is small. I once watched a neurologist in the ICU on the phone with a radiologist literally planning out what millimeter “slices” were needed of a brainstem MRI for a patient who was almost certainly having a stroke that was missed on multiple previous scans. 35 is very young for a stroke, however, and despite what this blog post may imply, odds are still more likely than not that neurologic symptoms are from a more benign condition than a stroke.
One common mimic are migraine headaches. In individuals with hypermobility, migraine headaches occur more frequently, though, so do blood vessel diseases. I have also seen migraines cause vision changes/loss, weakness/paralysis, and worsening balance- in some cases, this occurs even without a headache (“acephalgic migraine”).
So was it a small stroke that the MRI couldn’t find?
Was it a new migraine, the first of its kind?
Without a diagnosis, we were left in a bind. Because, an “unprovoked” clotting event raises some serious eyebrows and requires some kind of blood thinning medication (aspirin, in this case) to protect the patient from whatever we hadn’t identified that caused the stroke. However, falsely assuming one had a stroke adds an unnecessary cloud of anxiety and influences every future mystery diagnosis. We did the same in depth testing as in the early cases above. The initial LDL-p and Lp(a) were ~normal, but we ultimately identified elevated "homocysteine" as the only marker suggestive of increased stroke risk. Evan's now doing great, continuing his career in healthcare, and making a difference each day in the recovery of patients going through their own health journeys.
- Stroke Mimics: Migraine headaches can easily look like a stroke, especially “acephalgic migraines.” Acephalgic literally means “no head pain,” so you get all the bizarre neurologic phenomena without a headache. Other mimics include seizure and infections, particularly in the brain or if the person had a previous stroke.
- Pain as a clue: Strokes often don’t have any headache, as the brain tissue itself doesn’t feel pain. Any pain in our heads is either the muscles over our skull, or the tissues around the brain or blood vessels. This is why intracranial bleeding may cause severe, fast onset headaches with stroke-like symptoms.
-Sound the alarm? Migraines can occur in individuals without prior migraine history, but if there is accompanying neurologic changes like confusion, weakness or sensory changes in limbs, etc., don’t ignore these symptoms.
Balance changes or loss of coordination
Eyes- sudden blurring, double vision, loss of vision
Face drooping, numbness, or asymmetry
Arm weakness, numbness
Speech that is slurred or unable to make/understand
Time- every minute counts. We say “time is brain,” so call your physician or 911 ASAP.
*A big thank you to my patients who gave me to share their stories. For the sake of keeping this a "short" read I was forced to leave out MANY details, but I hope I did you justice well enough.
In case you were wondering, no I didn't really treat Rihanna.
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