Venous Strokes: Rare but Real
Survivor Sharon Wilson
At age 56, Sharon Wilson just wanted to look good and feel better about herself. The mother of four daughters and the grandmother of four decided to have liposuction — “I wanted my body to look a little bit more perfect,” she said.
She works as a medical assistant, so she investigated and did the proper tests before she flew from her home in New York to the clinic in Florida. After the procedure, she had problems with her vision. After mentioning it to the physician, she went to spend the night with a girlfriend. By the next day, her vision hadn’t improved. “My eyes were maybe a little worse, and I was very, very dizzy,” she said. The clinic suggested it was the pain meds she had been given, so, on her own, she stopped taking them.
“Then I started feeling leg pains, so right there I should have known there was a problem,” she said. She stayed in Miami another week, and neither the leg pain nor dizziness went away. She returned to the clinic, where they wrote her a letter saying she was okay to fly.
“That plane ride was the worst experience I’ve ever had because the leg pain was so intense,” she said. “When I came off the plane everything was dark, like at night, so I knew something was wrong.” She went home and went to bed.
Despite those problems, she went to work the next day because she had been gone longer than anticipated. Her coworkers said she didn’t look so good and suggested a visit to the hospital. The next morning, she stopped at the hospital on her way to work. “I wanted them to run some tests,” she said. “When I told them about my vision, they ran a head scan. After that three doctors came over, and I knew ‘this is a serious thing.’”
After some questions about what she had been doing — the liposuction, the flight, having a headache, being dizzy — the doctors told Sharon she’d had a stroke and ordered a full-body scan. “That’s when they found the two blood clots,” she said. “One in my lung and one in my head.”
Dr. Joe F. Lau
A CT scan of her head “showed left occipital and right frontal infarct,” says the doctor’s report. “Sharon’s blood clot was in one of the main veins within her brain,” said Joe F. Lau, her cardiologist and director of Vascular Medicine at Northwell Health in New Hyde Park, New York. “Having a clot there can lead to symptoms such as headaches and visual disturbances — symptoms that Sharon had before she was diagnosed with stroke. The headaches can come on suddenly, and may be the only symptom that a patient with this condition has.”
Her physicians initially suspected that her stroke might have been directly related to deep vein thrombosis (DVT), possibly from her leg. “Sometimes a blood clot in the leg can cause both a pulmonary embolism and a stroke,” Lau said. “This is called ‘paradoxical embolism,’ but the patient would usually need to have a hole in the heart to allow the blood clot to travel from the legs to the brain. In order for a blood clot from the legs to cause a stroke, the clot has to somehow go from the right side to the left side of the heart, and a hole in the wall that separates the heart chambers can be that gateway. But we performed a special ultrasound, and Sharon did not have a hole between the chambers.” Furthermore, a special type of head scan subsequently identified that Sharon’s strokes were unusual in that they were caused by blood clots within the veins of her brain, and not the arteries.
Lau’s best explanation of how this happened is that Sharon probably formed clots in both her lung and brain at the same time, as a result of the timing of her surgery and air travel. “We call this a ‘hypercoagulable’ condition, caused by a perfect storm — the surgery, air travel, and perhaps even an underlying autoimmune or genetic condition that we sometimes can identify after comprehensive blood testing,” Lau said, “But our medical knowledge today is only capable of answering questions for some patients, and much about how our other patients develop blood clots remains unknown.”
Sharon was treated with intravenous heparin in the hospital and switched to warfarin when she was released and which she still takes.
She returned to work part-time, four hours a week at first. “My internist didn’t want me to come back to work and told me I needed to stay home,” Sharon said. “She said, ‘You can hardly see.’ So, she told me I could work part-time, which I did for four or five months.” Those hours were not enough to cover her bills, and eventually, she returned to regular hours.
Being on warfarin has required some lifestyle changes. “I try not to eat too many green, leafy vegetables, or food items that contain high levels of vitamin K,” she said. “I can’t drink as much wine as I used to. I liked to have two glasses of wine after work. I really don’t go out as much as I used to.”
She anticipates getting off warfarin and out from under the restrictions it imposes, but for now her doctors advise her to stay on it until they tell her otherwise, in part because she is doing quite a bit of traveling.
Her advice to other stroke survivors is to get up and get active as soon as possible: “At first, I was lying down, but it’s best you get up because if you lie down, you’re going to just lie down forever,” she said. “In the beginning, I was very tired, but you have to get up and keep moving because if you don’t, the stroke is going to slow you up a lot.
“After I had gone back to work, a patient came in and said, ‘I have the same thing you had,’” Sharon said. “She’d had surgery on her leg and then noticed she was getting a pain in her other leg. After she started throwing up, she went back to the hospital, and they found a clot in her chest. This was a young girl, not a woman of my age. My advice to anyone having surgery is be very, very, very careful.”
Immobility and VTE
Immobility of the legs for long periods as can happen after surgery, long distance air travel or paralysis following a stroke is a major risk factor for venous thromboembolism (VTE). When the legs don’t move for long periods, blood flow slows, and clots can form as a result. In fact, with stroke survivors this risk of VTE can be as high as 15 percent in the first few weeks after a stroke.
“When part of your body is paralyzed after a stroke, blood flow becomes more stagnant locally, and the nerves around the blood vessels don’t work well either,” said MingMing Ning, a neurologist specializing in ischemic stroke and co-director of the Cardio-Neurology Division at Massachusetts General Hospital.
“Normally, the nerves around the blood vessels keep blood flowing so clots do not form. When there is paralysis, that doesn’t happen,” Ning said. “Right after a stroke, in addition to being immobilized, your blood is more pro-inflammatory and pro-coagulable, that is, your blood actually turns thicker within the first couple of weeks. So, during that time window, not only are you not moving, but you’re more likely to form clots — it’s a perfect storm for clot formation.”
Source: Stroke Connection Fall 2016
For more about VTE and its risk factors, see the Heart Insight Special Topic Supplement: Venous Thromboembolism.