On the eve of her 21st birthday last February, probably the furthest thing in Kaitlin Holton's mind was someone her age ever having a stroke.
She was getting ready for a dinner date with her new boyfriend and noticed that her entire left arm felt numb. As she applied her makeup the sensation was if a "stranger was touching my face – maybe a pinched nerve." The odd symptoms melted away for a time until she got into her car and gazed into the rearview mirror.
"The left side of my mouth drooped and wouldn’t move," says Kaitlin, a senior at the University of Indianapolis. "My boyfriend said some of my speech was slurred, but I was still in denial, but after thinking about it, I thought – maybe I just had a stroke." That seemed to add up when she remembered that several of her symptoms mirrored those of family members who had gone through that ordeal.
The next day, while getting ready for a birthday dinner with her family, Kaitlin told her mother, Kimberly Holton, a resident of Franklin Township, what she had experienced the evening before. The former Franciscan Health nurse stared at her daughter intently and matter-of-factly and said, "We have to go to the ER. Now."
After arriving at the Franciscan Health Indianapolis’ emergency department, a team of doctors, nurses and other clinicians immediately went into action. Several hours of MRI and CT tests revealed two tiny spots on the front of the young patient’s brain. The on-call neurologist, Sara Schrader, MD, confirmed Kaitlin’s grim suspicions.
The Birth Of A Stroke
During fetal development, the hole between the heart chambers functions to provide oxygen from the mother to the baby. This hold should close immediately with a flap after birth. However, in certain people this hole can persist.
When the flap doesn't close it’s called a patent foramen ovale (PFO) – a veritable "hole in the heart" that can be as miniscule as one centimeter in diameter.
"It is not that uncommon of a condition and can affect up to 25 percent of the overall population," says Abdelkader Almanfi, MD, an interventional cardiologist and member of Franciscan Physician Network Indiana Heart Physicians (IHP) in Indianapolis. "Luckily the majority of patients don't need treatment. Only those at higher risk of stroke or who've had a stroke with no explanation might deserve an evaluation by a cardiologist and neurologist for potential therapy with a closure device."
Dr. Almanfi and a multidisciplinary team of experts at Franciscan Health Heart Center Indianapolis, neurologists and other clinicians mapped out a plan of action. A so-called "bubble test," a noninvasive approach allowed doctors to assess blood flow through the heart. The flap was not fully closed in Kaitlin's heart.
While PFOs do not cause strokes, per se, having the condition slightly increases the risk for some patients such as Kaitlin. Blood clots developing in the heart may move through the open flap, spiral to the brain and cause a stroke.
Fixing The Flap
There are three ways to ways to treat PFO depending on the severity in individual patients. medications, open surgery or a noninvasive procedure. Dr. Almanfi and his team chose to treat Kaitlin with the latter option a few days after her stroke.
"The diagnosis and treatment of PFO has changed significantly in recent years," says Dr. Almanfi. "In times past, medicine or open heart surgery were the only alternatives."
The relatively new transcatheter approach has been used with great success by Dr. Almanfi and fellow IHP interventional cardiologist Saeed Shaikh, MD, more than 30 times since the beginning of 2018.
The transcatheter PFO closure device underwent rigorous clinical trials before being approved by the FDA in mid-2016.
The procedure typically is performed as an elective procedure in the cath lab under conscious sedation. A catheter is inserted into a groin vein and is carefully threaded through to the PFO. Inside the tube is a small mesh device (imagine a pair of closely connected pinwheels) and it is carefully secured to close the hole in the PFO under X-ray and echocardiogram guidance. The catheter is then removed and the insertion site is closed with a bandage.
The procedure takes 30 minutes to one hour to complete, Dr. Almanfi says. With no complications, the patient goes home the next day. The benefits are obvious: faster healing because the minimally-invasive approach is less prone to infections, and a shorter hospital stay. Within six months, heart tissue regenerates and gradually takes the place of the mesh stent - just the way nature intended.
"Kaitlin was the youngest patient we have treated [with a transcatheter PFO closure] so far and was most suited with the approach we took," Dr. Almanfi adds.
Because of the stroke, Kaitlin remained at Franciscan Health Indianapolis for six days so that Dr. Almanfi, neurologists and nursing staff could closely monitor her progress. She kept them on their toes, too.
"Well, I am an active person and couldn't lay still all the time," admits the history and secondary education college student. "At nights, I would get up and walk around on my own and sometimes dance around and they were continually checking on me because the activity was affecting the telemetry readings of my heart rate."
The eldest of six siblings, she says her family rarely left her side during her hospitalization.
Looking back, Kaitlin says the entire experience was emotionally draining, but considers herself fortunate. She didn't require physical therapy and had no permanent facial droop or other difficult effects as is common with some stroke patients.
"Dr. Almanfi and all of the doctors, nurses and staff were fantastic," she says. "I felt loved and taken care of. They genuinely cared about me."
To be certain, it was the strong collaboration between Franciscan Health's ER team, Dr. Schrader's assessment and battery of tests and Dr. Almanfi's interventional work that paved the way for her complete recovery.
And Kaitlin Holton has another takeaway from her experience. It's possible for a 21-year-old to have a stroke.
Photo caption: Kaitlin Holton, right, and her mother Kimberly Holton.
By Joe Stuteville Media Relations Manager, Franciscan Health