On a straight stretch of interstate highway 25 near Fountain, Colorado, in June 2018, Amy Kirch’s life took a frightening turn. First there was the terrible auto accident that left her, her husband and her two children severely injured. Then there was the stroke caused by a blood clot in her brain. Her luck could hardly have been worse but for one saving grace: she was in the right hospital.
It’s often said that when strokes occur, time is brain. By some estimates, two million neurons die each minute of an ischemic stroke – one in which a clot blocks blood flow to the brain. The quicker the medical response, the better the chance of minimizing the physical and cognitive damage of the stroke, said Dr. Daniel Huddle, a neuro-interventional radiologist at UCHealth Memorial Hospital Central in Colorado Springs, where Kirch and her family were transported after the accident.
Because she was already in the hospital’s intensive care unit, Amy was on an operating table in just under an hour – a very efficient response in the world of stroke, with Huddle ready to work on clearing the clot with arterial stents and giving her a chance for a productive life, one that she continues to pursue.
“Where is the best place to have a stroke? In the hospital,” Huddle said, recognizing, of course, that nobody wants one. But not just any hospital. Memorial Hospital Central is a Comprehensive Stroke Center, a designation from the Joint Commission that it earned in January 2018, just five months before the Kirch family’s mishap. The hospital maintains 24/7 coverage by a neuro-endovascular team, capable of clearing clots minimally invasively, as Huddle did; a neurosurgical team; and neurologists, nurses and rehabilitation specialists specifically trained in stroke care. All of that skill helped save Amy Kirch.
Lifesaving response to a stroke
It started in the ICU, where providers recognized the facial drooping and speech difficulties that are signs of stroke, summarized by the American Stroke Association as “F.A.S.T.” With that, the hospital called a stroke alert, mobilizing a response team that rushed Amy to the hospital’s imaging suite, where a CT scan revealed a clot in her brain. Huddle was on-site and arrived at a prepared OR with a team ready to go to work to clear the clot from her brain. The prompt alert improved the chances for a good outcome, Huddle said.
“With the quick recognition and astute care in the ICU, we had a relatively quick response and there was still salvageable tissue in Amy’s brain,” he said. He pointed out that had she had the stroke in a different setting, providers would have had to spend precious time getting her prepared for transport and then sent to another hospital. The single hour that elapsed before getting treatment could easily have been four to six, he said.
Despite the hospital team’s efforts, the stroke took a toll on Kirch, now 49. She is lucid and expresses herself clearly and continues to further her recovery. But the stroke affected the language center in the left side of her brain, so she has some difficulty forming words. The stroke weakened the right side of her body, which for now prevents her from running the streets and trails of Tucson, Arizona, where she lives. Her career as a social worker is on hold, at least for now. But she refuses to let these limitations define her. Amy Kirch’s story is as much about determination as it is about expert medical care.
“There are no stop signs on recovery,” she said. “I believe that if you work hard, you might not be able to recover entirely, but you can achieve things that nobody thought possible.”
Life-threatening chain reaction that led to a stroke
To understand Kirch’s determination, we have to revisit the scene of the accident and the events that followed. She and Jay, her husband of 27 years and a computer scientist with IBM, and their son Zachary and daughter Jordan were headed to Denver to celebrate the 100th birthday of Jay’s grandmother. As they reached Fountain, about 80 miles south of Denver, traffic suddenly stopped, the result, she later learned, of an accident up ahead. Jay, who was driving, hit the brakes, but the car behind him recognized the slowdown too late and violently rear-ended him. The Kirchs’ car then careened into another vehicle on the passenger side, where Amy was sitting.
The force drove the seat-adjusting bar into Jay’s heels and sliced them open. Amy remembers Jordan screaming in pain, the result of a displaced hip. Zachary had sustained a broken femur and traumatic brain injury. Amy, who remembers the incident only in small flashes, was critically injured: four broken ribs, a fractured scapula, a collapsed left lung and a dissected (torn) left carotid artery that would later lead to the stroke.
An ambulance rushed the family to Memorial, about 15 miles away, where Amy, Jay and Zachary went to surgery and intensive care; Jordan went to the Orthopedics floor after surgery. Providers tried to stabilize Amy’s torn carotid artery with blood thinners. Huddle explained that the carotid artery has three layers. A tear of one of the layers doesn’t cause bleeding into the rest of the body, but rather within the artery. Blood builds up within the artery, pushing its walls inward. That is a problem in and of itself that the body compounds by rushing coagulating platelets to the injury, increasing the risk of a clot breaking off and causing a stroke.
Stroke strikes in the ICU
Amy got heparin, an anticoagulant, which Huddle said frequently succeeds in preventing clots from forming while the artery heals. But Amy wasn’t so lucky. A clot dislodged and cut off the flow of blood from her carotid artery to the brain. That’s when her ICU providers recognized the signs of stroke and triggered the alert. As we’ve seen, Huddle was ready to go after the clot an hour later.
He threaded a catheter about the diameter of a standard Bic pen through her femoral artery and guided it toward the neck and the carotid artery. Once there, however, Huddle encountered a vascular roadblock. The arterial tear wasn’t clean but rather what Huddle called a “spiral dissection” that wound its way through the vessel, leaving debris that prevented him from finding the correct path to the clot. He had to remove that wreckage and rebuild the artery with three stents, in effect clearing the rubble and opening the road so he could drive ahead. Doing so took another hour.
Once he reached the clot, Huddle used a device called a stentriever – a “stent on a stick,” as he put it – to remove the clot. The device, attached to the catheter, uses wire mesh to entangle the clot, which an external machine sucks out. Sometimes just one “pass” with the stentriever clears the clot, Huddle said, but Amy’s clot required three. Once finished, the work completely restored blood flow to Amy’s brain, but some damage had been done.
No guaranteed outcome
Huddle said time is always of the essence in treating stroke, but the results are unpredictable. Every patient has some “vascular reserve” that allows what he calls “collateral blood flow” from sources other than the blocked artery to the brain. He compares it to a driver finding an alternate road when the most direct route is blocked.
“Tissue can sometimes hang on for quite some time,” while an artery is blocked, Huddle said. But he added that everyone is different, and in Amy’s case the collateral blood flow wasn’t sufficient to prevent some brain tissue from dying, despite the relatively short time of the blockage. But he added that her relatively young age and will to recover from the stroke pulled in her favor.
“Determination plays a huge part in recovery,” Huddle said. “You have to have someone who wants to make a recovery and works hard in rehab.”
Strength of will
The nearly two years since Amy’s injuries and stroke provide a real-life example of that point. After receiving rehabilitation at Memorial, Amy transferred with Jay and Zachary to Craig Hospital in Englewood for intensive rehabilitation, including physical, occupational and speech therapy. Jay also had multiple surgeries to successfully repair his badly injured heels.
Four months after the catastrophic car crash, Amy left Craig and returned to Tucson. Jordan had held down the home in Arizona while the others worked their way back from the injuries. Jay made a full recovery, as did Zachary, who will graduate from the University of Arizona this year.
Amy acknowledges the challenges she faces because of the stroke. A committed runner, she finished a half-marathon in San Diego two weeks before the accident. Those days probably won’t return anytime soon. Her right side is still weak, and her slowed speech sometimes makes her anxious, depressed and reluctant to be around others. She tires more quickly and noise distracts her.
“It takes so long to regain strength after a stroke,” she said. “I get so frustrated, but it’s getting better slowly.”
Amy marks her recovery in small steps, literally and figuratively. She said her right arm continues to strengthen. She is able to drive, and she walks unassisted. In fact, on October 28, 2018, just a little more than four months after the crash, she finished the Tucson Lifestyle 5K in 58 minutes, an achievement Huddle called “absolutely remarkable.” The 5K walks continue regularly today on her treadmill.
Amy also relishes being able to talk to her family again, and she put her speech to a tougher test in February 2019, with a short talk at a fundraiser for Friends of Aphasia, an organization that assists people with communication problems caused by stroke and other conditions. She serves as the member liaison on the board of directors.
“People understood me!” she wrote with pride in a recent email.
Limitations, not limits
Today, Amy understands her limitations, but refuses to set limits for herself. She bristles at one particular word: “plateau.” It’s the idea that stroke survivors eventually reach a point in their recovery where they can go no further.
“The idea that you can plateau, I hate it,” she said simply. “It’s up to me what I can achieve.”
That notion drives Amy’s determination, as does her belief in the concept of brain plasticity, or neuroplasticity. In stroke rehabilitation, this is the idea that an injured brain may be able to “rewire” its connections to healthy areas to compensate for the damaged centers. In very simple terms, think of a team that loses a key player but continues to compete because others do more than had been expected of them before. Of course, that requires harder work by them, which is why stroke rehabilitation focuses on repetitive practice to encourage healthy areas to restore, at least in part, what a stroke takes away, like speech or movement.
Huddle emphasized that he is not a neurologist, but said he believes that some patients can plateau. However, he added, every patient is different, which is precisely why it is so important to treat stroke as quickly as possible. Doing so gives patients the best chance to escape severe disabilities and discover for themselves what their limits might be. As for plasticity, he agreed that the brain has it. “Some parts can learn to take over for other parts of the brain that are injured. The brain is one of the most fragile organs, but it is also one of the most forgiving.”
Amy is deeply grateful to Huddle and the entire team at Memorial, as well as Craig Hospital for their care and the opportunity they gave her to reclaim her life. But she also wants other survivors to take their destiny into their own hands, as much as they can.
“Don’t let anyone tell you what you can achieve,” she said. “Don’t get discouraged. Work hard.”