Stroke patient walks difficult path to recovery

June 14, 2016
Road to recovery
“No one saves us but ourselves. No one can and no one may. We ourselves must walk that path.” Buddha
The perspective noted above is particularly true for patients trying to recover from a major healthcare event. When the doctors and nurses and therapists have completed their work, the patient must take on the responsibility for the rest of his or her recovery. It’s often an uphill climb. And it can tap inner strength, resilience, and creativity that the patients themselves didn’t know they had. This is a story about one such journey…
 

On February 2, 2014, 43-year-old Richard Vierling was in North Dakota, working for an oil field maintenance company. He woke up that morning and couldn’t move the right side of his body. He was taken to a hospital for treatment…and then to another hospital. The first couldn’t help him; the second knew what was wrong and recognized the complexity of the problem. They sent Vierling to the University of Minnesota Medical Center where he became a patient of cerebrovascular neurosurgeon Ramu Tummala, MD.

“Richard had a rare congenital arteriovenous malformation [AVM] in his brain that ruptured,” said Tummala. “In an AVM, you have arteries directly connected to veins, so the high-pressure artery blood dumps directly into veins designed to handle low pressure. The most serious consequence is bleeding, which is what happened in Richard’s case.”

Rupture destroyed brain tissue
When an AVM ruptures, the blood goes into the surrounding brain tissue. “The blood became a big mass, basically destroying the brain tissue,” said Tummala. “It’s a type of stroke because the net effect is the same.” Rather than a blood vessel blockage, which causes the more common ischemic stroke, Vierling had what’s known as a hemorrhagic stroke.

Ramachandra Tummala, MD“In Richard’s case, our main priority was to keep the AVM from bleeding a second time, potentially killing him or causing more harm and interfering with his recovery. Because it had already ruptured once, we decided that removing the AVM was the best treatment rather than leaving it alone or radiating it; however, Richard’s AVM was large and in an area of the brain where  language function lies. We knew that several procedures would be necessary to remove this thing safely,” noted Tummala (pictured at left).

Vierling’s U of M care team took him through three embolization procedures during which a tiny catheter was threaded up to his brain through an artery in his leg. Through the catheter, Tummala injected glue into blood vessels to help slow the AVM’s blood flow in preparation for removing it.

No sugarcoating
Weeks later, the final major surgery “was the trickiest,” according to Vierling. It involved opening his skull and exposing the area of the brain in which the AVM was located. As they worked together throughout the treatment, Vierling noted that, “Dr. Tummala was awesome. He never sugarcoated anything, never gave me false hopes. Everything he told me pretty much came true.”

During the surgery, “we disconnected the AVM from the rest of the blood vessels,” explained Tummala. “We cauterized or clipped the vessels and ultimately, removed in one piece the ‘tangle of spaghetti’ that the AVM had become.” Vierling’s family told him later that the procedure took about 11 hours. “I didn’t care,” he laughed. “I was sleeping.”

Vierling was in the neuro ICU for a few days after the surgery where his blood pressure was kept under strict control. He was then moved to the neurosurgical ward where he had several preliminary therapy sessions with physical, occupational, and speech therapists. “Our nurses also worked very hard to make sure he didn’t have any setbacks,” said Tummala. After going to acute rehab and completing more intense therapy, Vierling was finally ready to transition to living on his own.

Lifelong impact
“Our treatments, if you add all the time associated with the various surgeries, maybe totaled about 20 hours,” noted Tummala. “Weigh that against the 24-hour continuous process for which Richard would now be responsible. This will have a lifelong impact on him.”

A soft-spoken man, Vierling sometimes hesitates as he articulates his thoughts. His AVM affected his ability to speak, write and read. It was in what Tummala described as the “eloquent” portion of the brain that controls such abilities. “My physical self came back a lot quicker,” said Vierling. “I still have problems in that area, but I can move everything pretty well on my right side. Writing is hard because I don’t have my fine motor skills back yet.”

Vierling has orchestrated his recovery since the AVM in numerous ways. “Every day I have to go through my exercises…I work on them over and over,” he said. “When I was relearning how to read and speak, I would put a movie in the video player, turn the sound off, and read the subtitles out loud.” That was his own therapeutic invention. His speech therapist, Cindy Lannis, gave him “a lot of other things to do,” noted Vierling. “I can’t say enough about her.”

Big setback
Three months into recovery, Vierling returned to work. It would turn out to be too soon as it led to his first seizure. “From a psychological standpoint, the seizure was a big setback for Richard,” said Tummala. “It meant he wouldn’t be able to drive for three months.” As a single man, driving was a symbol of his independence, added Tummala. “Not being able to represented a substantial loss of freedom and identity.”

As with many patients who have long roads to recovery, Tummala saw that Vierling started to get depressed after his seizure. “He had looked at all the rehab and work he’d put in as a way to get back to driving,” said Tummala. “You could just see it on his face that we took something precious away from him.”

Vierling essentially began his recovery process all over again. “I had faith that everything would come back,” he said. “I knew it wouldn’t happen overnight, I had to keep working at it. There were so many days when I didn’t want to deal with it, when I wanted to curl up into a ball, but you can’t. The more you do, the easier it gets to do it.

Although he lives alone in St. Paul, MN, Vierling has a support network of family and friends that helped him through his recovery in numerous ways, from bringing over food, to watching “his crappy TV” with him, to including him in gatherings. He is especially grateful for his sister, Mary Smith. “She worked with the doctors and the insurance company,” he said. “And she took me to my doctors’ appointments.” His sister wasn't the only one there for him. “I always knew I had really great family and friends, but the way they stepped up, they’ve inspired me, they really have.”

New normal
Vierling’s reaction to his “new normal” is pretty typical. “I used to read all the time,” he said. “I used to love to go outside and go fishing or canoeing. I want to be that guy, not the guy I am now.” Perhaps that had some influence over a more recent speed bump on his road to recovery.

He had another seizure. “I was an idiot,” Vierling said, honestly appraising what happened. “There were a bunch of things I’m supposed to do and things I’m not supposed to do and I pretty much reversed them all. So that morning, I was flopping around like a fish. It’s my own fault; I have to be smart about this stuff.”

As a result, he’s back on his medication and is making sure he gets plenty to eat and plenty of sleep. “I’m monitoring my health and if something doesn’t feel right, I have to call Dr. Tummala.” And yes, he was back to not being able to drive for three months.

Hold on to the good times
Based on his own experience, Vierling advises other patients who have similar journeys ahead of them to be aware that “time stands still in a hospital. You find yourself awake at 3 a.m. and your mind will wander. The next day, there will be doctors and nurses and people who come to visit so your mind won’t go to bad places. Hold on to how you felt during that time and remember it at night. You have to remember that people are rooting for you.

“There will be jumps in your progress,” he continued. “But then they stop. Nobody really knows how the brain works. It won’t feel like you’re progressing for weeks or months; then all of a sudden, words you couldn’t say, you can say. You might think you’ve hit a dead end, but you need to keep on going. Who knows? Maybe this is as good as I’ll get, but I’m not going to stop trying. If I don’t try, it will be. I want to know I did everything I could.”

There is a “but”
“Richard is an example of how people can recover really well and live good lives, but there is a ‘but,” said Tummala. “We need to make sure that patients know there is a lot of work ahead after these procedures. The surgery is just one piece; the surgeon, nurses and therapists are team members in this endeavor, but the patient is the most important team member.”

Now, Vierling gets together with friends and family to watch sports and to grill outside or go fishing. “Spending time with people, especially now that we can actually have a conversation without it being too much of a headache for them, is great,” he said.

Even though Vierling has the support of his family and friends and his care team at the university, his ability to “actually have a conversation” has been his responsibility. He is truly walking that difficult path alone.