“We had a timeline, we had to reach the clot as soon as possible to prevent more damage from being done to the brain.”
It was six days before Christmas and Richard “Dick” Boshart was trying to connect to the livestream of his granddaughter’s holiday concert while his wife, Annie, prepared breakfast in the kitchen. Suddenly, Dick, who was 84 at the time, rose and began wandering around their home without any apparent intent. When he finally sat back down, Annie noticed the right side of his face was drooping.
The Bosharts live in an independent living community in Lititz, Pennsylvania, about nine miles outside of downtown Lancaster. Annie alerted a nurse, who assessed Dick, then called 911.
He was also experiencing aphasia, a condition that can cause someone to have trouble understanding or speaking. Dick recalled a paramedic asking him questions, but he was unable to respond. The moments that followed were largely a blur.
Paramedics believed Dick was having an ischemic stroke, which occurs when vessels supplying blood to the brain are blocked by a blood clot. They recommended taking him to Penn Medicine Lancaster General Hospital because it’s the only hospital in Lancaster County that performs mechanical thrombectomy, an advanced procedure for physically retrieving a blood clot from a brain vessel. As soon as Annie granted her permission to take him there, one of the paramedics called ahead and activated the hospital’s stroke alert.
This set in motion a protocol that’s meant to expedite a patient’s assessment and treatment upon their arrival at the hospital. The faster a stroke is recognized and treated, the better the chances of preserving brain function and reducing the likelihood of disability.
Nicole Chiota-McCollum, MD, chief of the Division of Neurology for Lancaster General Health, received Dick in the emergency room. She examined him and determined the severity of his stroke using the National Institutes of Health Stroke Scale.
He then underwent a computed tomography (CT) angiogram, a noninvasive test that uses x-rays and a special dye to create images that are pieced together to form three-dimensional reconstructions of an area of concern in the body. Dick’s revealed a blockage of the middle cerebral artery, the most common artery involved in a severe stroke. It consists of four main branches that extend from the internal carotid artery. These vessels supply blood to parts of the frontal, temporal, and parietal lobes of the brain, as well as deeper structures.
With the discovery, Chiota-McCollum administered Tenecteplase via an IV injection. This medicine can restore blood flow by dissolving the blood clot causing the stroke. She then notified Sedeek Elmoursi, MD, a vascular neurologist and neurointerventional surgeon at Lancaster General Hospital, who would remove the remainder of the clot through mechanical thrombectomy.
Racing against the clock
In a nearby suite dedicated exclusively to stroke care, Elmoursi made a tiny incision on the left side of Dick’s groin and inserted a microcatheter, threading it through an intricate network of blood vessels to the blood clot in his brain. His progress was slow because of the clusters of entangled vessels, a result of Dick’s age. He often had to double back and find a new route.
“This was very hard because we had a timeline,” Elmoursi said. “We had to reach the clot as soon as possible to prevent more damage from being done to the brain.”
Once he reached the clot, Elmoursi attempted to suction it out, but the clot didn’t budge. He quickly turned to another technique, inserting a stent retriever—a thin mesh tube—into the catheter and expanding the walls of the middle cerebral artery with it, restoring blood flow to the brain. He was then able to reposition the blood clot further down the artery with the stent retriever, which enabled him to suction it out with an aspiration catheter.
Annie and their daughter, Carolyn Fitzkee, rejoined Dick in the intensive care unit after the procedure. Within a couple hours, Dick was raising his arms and legs, wiggling his toes, and squeezing the nurse’s hand at their request. And by that night, he was drinking water, eating applesauce, and talking in short sentences.
“Every hour he seemed to improve,” Fitzkee said.
Elmoursi checked on Dick and Annie the next day. Dick’s ability to communicate was continuing to improve, and he was gradually returning “to his normal level of neurological function,” Elmoursi said.
Dick was discharged on December 24, five days after his stroke.
Hitting the right notes again
Over the winter, Dick followed up with Romy Styer-Slogik, PA-C, a neurology physician assistant at LG Health Physicians Neurology. He worked with a speech therapist several times to redevelop his thinking and understanding around certain tasks, like using his computer. And he did physical therapy twice a week for balance and strength training.
Although he was able to get around without assistance, in the weeks immediately following his stroke Dick was noticeably weaker, but said he felt generally “OK.”
His stamina returned little by little. When Styer-Slogik granted Dick permission to start driving again at the end of January, Fitzkee said it was a “turning point” in his comeback.
Eight months after the stroke, Dick had made a complete recovery and was exercising regularly. His weekly routine consists of a low-impact aerobic exercise class and a bodyweight strength-training class, both of which are offered at the fitness center in his community. In nice weather, Dick also enjoys riding his bike around the campus. And every two weeks, he tends to the bluebird houses scattered all over his community.
Perhaps most importantly to Dick, he’s returned to singing, a longtime passion. Before retiring, he was a music teacher. In May—National Stoke Awareness Month—he and Fitzkee were invited back to the hospital to share Dick’s story at a large conference. Fitzkee wrote the script and did much of the talking, cutting to her father for the occasional musical interlude.
“It was pretty emotional,” she said.
The day after Dick’s procedure, while he was in the ICU, a nurse observed Dick was in atrial fibrillation (AFib), an irregular and often very rapid heart rhythm. Prior to that moment, Dick said he had never had any heart trouble. For many people, AFib may have no symptoms.
Elmoursi said AFib is one of the leading risk factors for stroke because it can lead to blood clots. A quarter of all strokes after age 40 are caused by AFib, according to one estimate.
Left untreated, Dick would be at high risk of having another stroke. But he’s since started taking a blood thinner that’s specifically formulated to prevent clots and stroke in people with AFib. This medication, Elmoursi said, has significantly reduced the chances of Dick having another stroke, enabling him to continue enjoying retirement on his terms and crooning at every request.