She Felt Fine, but Her M.R.I. Showed Several Strokes. What Was Wrong?



The 67-year-old woman had just flown back to her old hometown, Eugene, Ore., to pick up one more load of boxes to move them to her new hometown, Homer, Alaska. As usual, the shuttle to long-term parking was nowhere in sight, so she pulled out the handles of her bags and wheeled them down the now-familiar airport road. It was a long walk — maybe half a mile — but it was a beautiful afternoon for it.

A lone woman walking down this rarely used road in the airport caught the attention of Diana Chappell, an off-duty emergency medical technician, on her way to catch her own flight. She watched as the woman approached a building where some airport E.M.T.s were stationed. Suddenly the woman stopped. She rose to her toes and turned gracefully, then toppled over like a felled tree and just lay there.

Chappell jumped out of the car and ran to the woman. She was awake but couldn’t sit up. Chappell helped her move to the side of the road and took a quick visual survey. The woman had a scrape over her left eye where her glasses had smashed into her face. Her left knee was bleeding, and her left wrist was swelling.

She’d dropped the handle of one of her rolling bags, the woman explained. When she tried to pick it up, she fell. But she felt fine now. As she spoke, Chappell noticed that her speech was slightly slurred and that the left side of her mouth wasn’t moving normally.

“I don’t know you, but your speech sounds a little slurred,” she said. “Have you been drinking?” Not at all, the woman answered — surprised by the question. Chappell introduced herself, then asked the woman if she could do a few quick tests to make sure she was O.K. Chappell asked her to smile, but the left side of the patient’s mouth did not cooperate; she asked her to shrug her shoulders, and the left side wouldn’t stay up. You need to go to the hospital, she told the woman. The woman protested; she felt fine.

At least let me call my E.M.T. pals to check your blood pressure, Chappell insisted. After a fall like that, it could be high. The woman reluctantly agreed, and Chappell called her colleagues. The woman on the ground was embarrassed by the flashing lights of the emergency vehicle but allowed her blood pressure to be taken. It was sky-high. She really did need to go to the hospital.

It was getting dark by the time she was rolled into the PeaceHealth Sacred Heart Medical Center at RiverBend. The doctors and nurses were ready for her. They knew her speech had been slurred but said it no longer was. When they asked her to smile, as the E.M.T. had, they noted that the left and right sides now matched. Despite her improvement, the emergency-room doctor was concerned that she’d had a stroke. An IV was placed, monitors were attached and she was zipped to the CT scanner. The CT scan of her brain was normal, but the E.R. doctor consulted with a neurologist, who thought she should get an M.R.I.; she still might have had a stroke. The M.R.I. showed that indeed she had. She shouldn’t go home, the E.R. doctor told her.

It was early the following morning when the neurologist, Dr. Margareth Saldanha, introduced herself to the woman she had already heard about. Saldanha explained to the woman that, even though she no longer had evidence of a stroke on examination, she had had a few small strokes that were clearly visible on the M.R.I. She shouldn’t leave the hospital until they figured out why she had these strokes, so they could try to stop her from having more of them.

The woman was bewildered by what felt like unnecessary concern; she wanted to go home. Saldanha pulled the computer over to the patient’s bed and showed her M.R.I. images of an array of tiny white dots indicating damage to her brain amid the normal gray swirls. Shocked by the sight, the woman agreed to stay.

Saldanha talked the woman through her thought process. She didn’t have any of the usual risk factors for stroke. She quit smoking decades ago. She didn’t have high blood pressure or diabetes or any of the other disorders that make strokes more likely. Moreover, the pattern of the injury — a spray of dots rather than a single larger area — suggested that her brain had been spattered with tiny blood clots.

This kind of stroke is usually seen in patients with an abnormal heart rhythm called atrial fibrillation. In AFib, as it’s often called, the heart beats in an uncoordinated way, allowing blood to pool within the heart and form little clots. When these clots escape, they block off tiny vessels in the brain and cause multiple small strokes. But the patient didn’t have AFib — her heart’s rhythm had been monitored continuously since she was first seen by the E.M.T.s, and it was normal.

Saldanha suspected that the patient might have a different problem causing the clots seen on the M.R.I. Some people have a hole between the right and left sides of the heart. That kind of opening allowed blood and potentially clots to travel straight from the body into the brain, without passing through the filter of the lungs. Clots can form in the legs during periods of immobility, and Saldanha wondered whether the woman developed clots during the long flight. If she had a hole in her heart, when she started walking, those clots could have broken free, zipped through the hole and ended up in her brain.

The patient had undergone an ultrasound of the heart, which hadn’t shown a hole. But there was a better test, and Saldanha wanted the woman to stay in the hospital until it could be done. This test, a transesophageal echocardiogram, involved putting a camera into her esophagus — which runs right behind the heart — to get a closer look. The patient was willing. Though she still felt fine, those bright white spots on the M.R.I. scared her.

The test was done the following day. The probe — an ultrasound-based camera, placed at the end of a long, flexible tube — was inserted into her mouth and throat, then lowered to a position next to the heart, about halfway to the stomach. From there, doctors can see many of the structures of the heart that can’t be seen from the front, where the usual echocardiogram is done. As the cardiologist moved the camera to look for the suspected hole, something unexpected swung in and out of view: a tumor in her heart.

Cardiac tumors are rare. In a series of 12,500 autopsies performed over 20 years, cardiac tumors were found in just 161 individuals. Most were metastatic growths from an underlying cancer. The tumor was the most likely source of her strokes; by interrupting the flow of blood, it was creating an opportunity for clots to form. It had to be removed both to stop the strokes and to allow the pathologist to determine if it was caused by a cancer hidden somewhere in her body or if it was an isolated tumor of the heart, which is usually benign. But to get it out, they would have to do open-heart surgery.

Three days later, a surgeon removed an irregularly shaped blob about the size of a brussels sprout. As the patient recovered, she worried that she had some type of cancer. When she got word from pathology, it was good news. She had something known as a papillary fibroelastoma — an extremely rare but benign mass that usually grows at the edge of the valves in the heart. The cause is still unknown. But once removed, it rarely comes back.

Strangely, perhaps, the patient feels that she was very lucky. Lucky she had her stroke before she got to her car. Lucky to be found by an experienced E.M.T. Lucky her neurologist was sure she needed to find out why she had the strokes. And really lucky to be able to go back to a life in Alaska that she is still very much enjoying.

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