Youth is served in stroke save

Collaboration the key in successful procedure at UCH on 14-year-old patient
March 20th, 2016

It was late afternoon on Feb. 26, and 14-year-old Iram Quezada was doing something unremarkable for a kid his age: playing baseball on an unseasonably warm day. Then something most uncommon happened to the Fort Lupton teenager.

He had a stroke.

Sharon Poisson, MD, co-medical director of the Stroke Program at UCH, and neurosurgeon Joshua Seinfeld, MD, played key roles in the rescue of 14-year-old Iram Quezada.
No one knew it at the time, but it was obvious something was wrong. Iram had finished up a batting drill and was walking over to talk to his manager when he suddenly had trouble speaking. He turned to walk away, then stumbled and fell.

“I got up and fell down again,” Iram said in a phone interview. His left side was also weak.

One of his coaches set Iram against a fence and called 911. His mother, Maria Arellenes, got a call that something was wrong. She thought initially Iram had suffered one of his periodic asthma attacks, but when she raced to the field and saw him, she knew that wasn’t the case.

“The paramedics were there, and I noticed he couldn’t move his left side,” Maria said. “I knew this was not good or right.” The ambulance transported Iram to Platte Valley Hospital in Brighton, where providers in the emergency room examined him.

The quick action set the tone for a rescue that draws a bright line under the oft-repeated line that in cases of stroke, time is brain.

Quick catch

A coordinated effort between emergency medical service providers, Platte Valley Hospital, University of Colorado Hospital, and Children’s Hospital Colorado got Iram from the baseball field to a table in the Interventional Radiology suite at UCH in less than three hours. By the end of the evening, a few seemingly insignificant red splotches – blood clots in the brain that caused the stroke – lay on a piece of sterile gauze. Three days later, Iram was home recovering and working toward resuming his pre-stroke life.

The life-threatening blood clots Seinfeld removed from Iram’s right middle cerebral artery.
The story could have had a much different ending if anyone involved had been slower to recognize the seriousness of the situation, said Meredith Snyder, RN, CCRN, SCRN, manager of the Stroke Program at UCH.

“A stroke destroys 2 million neurons per minute,” she said. “If even small pieces of our response go a little bit off, the results can be devastating.”

In Iram’s case, the response was quick and decisive. Providers in the emergency department at Platte Valley quickly recognized Iram’s left-side problems and other symptoms as signs of stroke and ordered a CT scan and angiogram, said neurologist Sharon Poisson, MD, co-medical director of UCH’s Stroke Program. The tests revealed a blockage in the right middle cerebral artery of Iram’s brain.

Poisson called Platte Valley’s work crucial. “Strokes are much less common in children than they are in adults,” she said. Because of that, they are frequently mistaken for migraines and other problems that mimic the signs of stroke, Poisson added.

“Recognizing stroke in a patient 14 years old is a big deal,” she said.

Timothy Bernard, MD, director of the Pediatric Stroke Program at Children’s Colorado, put the prompt recognition in perspective, noting that the stroke rate in children is 2 per 100,000. Only half of those occur in previously healthy kids like Iram. The average time to diagnosis nationally for a child who suffers a stroke is 24 hours, Bernard added.

Wheels in motion

Platte Valley’s catch set multiple wheels in motion. After reviewing the brain images, their providers contacted the patient transfer center at Children’s Hospital Colorado. As the neurologist on-call, Poisson consulted with emergency physicians at both hospitals and accepted Iram for transfer and a possible procedure to remove the blood clot.

Iram Quezada and mom Maria Arellanes speak Stroke specialists at Children’s Colorado and UCH have worked together closely to establish guidelines for deciding which hospital will accept young stroke patients, Poisson said. Children with blockages of a large blood vessel in their heads who are at least 12 years old and weigh more than 40 kilograms are considered for transfer to UCH for intervention, while other children with stroke transfer directly to Children’s Colorado.

Iram exceeded all of these requirements, so the decision was made jointly to transfer him to UCH. The hospital’s DocLine pre-admitted him, creating a medical record in Epic and setting a flurry of activity in motion.

Just 35 minutes after she received the initial call, Poisson called UCH neurosurgeon Joshua Seinfeld, MD. He contacted the Interventional Radiology team, which began preparing for a procedure. Orders were put in for an MRI scan. Teams from intensive care, anesthesia, and pediatric neurology were put on alert and got ready for a stroke case.

Iram and Maria arrived by ambulance to UCH’s ED, where he was whisked to Radiology to start an MRI scan in just eight minutes, Snyder said. The scan confirmed the right middle cerebral artery occlusion. While Maria waited, providers explained the treatment they recommended for Iram: a catheter-based procedure to remove the clot and open the blood vessel. Maria consented, and only about 45 minutes after he arrived to the hospital, Iram was on a table in an IR room that had been hurriedly readied.

Seinfeld threaded a catheter through Iram’s femoral artery and aorta to the carotid artery. He then put a smaller catheter bearing a wire mesh device called a stent retriever into the larger catheter. Seinfeld snared the roughly 5-millimeter clot with the stent retriever and pulled it out of Iram’s head, into the larger catheter, and out of his body.

Iram Quezada and mom Maria Arellanes speak with Channel 4 reporter Kathy Walsh in the AIP lobby at UCH March 14.
“We got it in one try,” Seinfeld said. “It was average size, and it came out in pieces.” He estimated the entire procedure was over in about a half an hour.

Bernard said strong ties between Children’s Colorado and UCH, built over time, were a major key to the success.

“Within a couple of minutes, providers at Platte Valley were talking to specialists adept at taking care of kids with stroke,” he said. “Not many places have that kind of access, and without our collaboration, they wouldn’t have that ability.”

On to the next

IIram Basketball ram stayed in the hospital’s Neuro Intensive Care Unit through the weekend and was discharged Feb. 29 with significant improvement in his functioning. He’ll have physical, occupational, and speech therapy and follow-up care with Bernard at a multidisciplinary stroke clinic jointly staffed by specialists from Children’s Colorado and UCH. Poisson and Seinfeld said his prospects for recovery are good, but it’s impossible to make firm predictions.

“He had a stroke,” Poisson said. “It could have been much worse, but he still had damage to his brain.”

Two weeks after the procedure, Iram was back in school. He said he was feeling better, but was weaker and more tired than he was before the stroke.

“I have a hard time focusing sometimes,” he said.

“When we say something to him, it takes him a little bit of time to figure out what we’re saying,” Maria said. “He has to think a little bit. It’s harder for him to understand.”

Fort Lupton teenager Iram Quezada hopes to be back on the basketball court after he recovers from a blood clot in his brain that was removed at UCH. Photo courtesy Maria Arelleanes.
That’s to be expected, Bernard said. The first post-stroke year is typically the hardest for a recovering patient, with physical and cognitive fatigue often presenting especially difficult challenges, he noted.

ram Football“Even as function returns, young stroke patients often feel very fatigued and have trouble focusing,” he said. “That’s very typical.”

As for why such a young, generally healthy kid suffered a stroke, there are no clear answers, Poisson said. “We don’t have an answer for that,” she said, noting that there is no identified cause in about one-third of pediatric stroke cases.

What is known is that the quicker a patient of any age gets treatment for stroke, the better the prospects for a good recovery become. In Iram’s case, everything fell into place. “The stars aligned,” as Seinfeld put it.

The key to success lies in creating a solid system built by committed individuals who quickly recognize the signs of stroke and act on them with a sense of urgency, Snyder said.

“When the process is clear and in place, this kind of outcome is expected. Things go well,” she said. “This was what we want to have happen every time.”

Strokes in previously healthy, active kids like Iram are extremely rare, said Timothy Bernard, director of the Pediatric Stroke Program at Children’s Hospital Colorado. Photo courtesy Maria Arellanes.

About the author

Tyler Smith has been a health care writer, with a focus on hospitals, since 1996. He served as a writer and editor for the Marketing and Communications team at University of Colorado Hospital and UCHealth from 2007 to 2017. More recently, he has reported for and contributed stories to the University of Colorado School of Medicine, the Colorado School of Public Health and the Colorado Bioscience Association.