May 10, 2019
On a sunny Monday morning in December 2018, Rachael Ferguson kissed her husband as she left their home in Cameron, Missouri. She dropped their 3-year-old son at daycare and drove to St. Joseph, Missouri, where she worked full-time at her parents' business.
In the office, Rachael placed her 3-month-old daughter, Sadie, in a nearby baby seat. She was about to start the day's paperwork when her mom, Jennifer Yarnell, walked in the door.
"She wasn't supposed to come to work that day," recalls Rachael.
After chatting with her mom, Rachael stood up to grab a file. That's when something went terribly wrong. She slumped into her chair, and her left arm dropped lifelessly into her lap.
"Mom asked if I was OK," Rachael explains. "I tried to tell her my left hand was numb, but she couldn't understand me."
Jennifer remembers thinking, "This can't be happening to my 27-year-old daughter. She can't be having a stroke."
Knowing the signs
It was lucky Jennifer was there. By recognizing the symptoms of a stroke, she may have saved her daughter's life. Anyone with new arm or leg weakness, slurred speech or facial drooping needs immediate care. Jennifer ran to tell Rachael's father, Todd Yarnell, to get the truck. He rushed Rachael to the nearest emergency department at their local community hospital.
When Rachael's husband, Blake, arrived at the hospital, he was in shock. The emergency care staff asked his permission to administer clot-busting IV tPA medication. They also recommended transfer to The University of Kansas Health System's Advanced Comprehensive Stroke Center.
Blake agreed. Then he watched as Rachael – his young wife, the mother of his children and his best friend – was life-flighted to Kansas City, Kansas.
Removing one clot
The University of Kansas Health System stroke team prepared for Rachael's arrival. Neurologist Lee Rosterman, DO, reviewed the CT scan and RAPID perfusion imaging tests – which evaluate for healthy brain tissue that can be saved – sent ahead by Rachael's community hospital team.
"We could see she had already suffered a very small stroke," explains Dr. Rosterman. "Without immediate and expert intervention, that small stroke would turn into a large one."
Rachael's blood clot was in the right hemisphere of her brain. The brain's right side controls the body's left side. When a clot stops blood flow, brain cells die. The longer the brain goes without blood and oxygen, the greater the chance for long-term disabilities or death.
As soon as the helicopter landed, the stroke team whisked Rachel to the interventional radiology (IR) suite, where high-tech imaging equipment, banks of monitors and large observation windows set the scene for world-class stroke care.
"I remember the anesthesiologist telling me I was going to be OK. I could see the blood clot in my brain on a monitor. Then I went to sleep," says Rachael.
Interventional neuroradiologist John Madarang, MD, performed Rachael's endovascular thrombectomy. In this minimally invasive, image-guided procedure, Dr. Madarang threaded a catheter through an artery in the groin to the blood clot in the brain. He directed a tiny tool called a stent retriever to the blockage. He grabbed the clot and removed it, restoring blood flow to the right side of Rachael's brain.
"After she woke, Rachael was able to lift her leg slightly. And the X-ray images showed the right middle cerebal artery was completely open. The intervention was successful," describes Dr. Madarang.
Dissolving another clot
While Rachael was recovering in the neuro ICU, Dr. Madarang stopped by to check on her.
"One of our expert stroke nurses, Courtney Austin, told me Rachael seemed a little weaker than she had been in the operating room," he says. "I wondered if the same vessel had become blocked again. We rushed her back to the IR suite."
An angiogram of Rachael's brain revealed a new blood clot in a more remote location of the brain's right hemisphere.
"We could not extract this clot. The tools required are too large to reach that area," explains Dr. Madarang.
Instead, he administered tPA blood thinner through a catheter in Rachael's artery. He bathed the clot with with the medicine and watched for progress using X-ray imaging. After 35 minutes, the clot finally dissolved.
"Rachael had 3 strokes in a single day. A small one took place before she came to us. The next 2 could have left her paralyzed for life, but we were able to fix them both," shares Dr. Madarang.
Dr. Rosterman praises the stroke team, the community hospital and Rachael's family.
"Immediate stroke recognition was key to her success. The quicker you get to a hospital, the better we can help you," he says.
Facing her fears
Rachael spent 5 days in the ICU. She was closely monitored for new blood clots or complications.
"My mom was there comforting me. My husband was terrified. And I was angry with God," she remembers.
For Rachael, it didn't matter that her brain scans looked good or that the procedures had been successful. She had regained her speech, but she still couldn't move her left arm or leg.
"I wouldn't be able to hold my baby or play with my son. I didn't have any hope," she says.
"It's hard for us to predict when someone will get their strength back after a stroke," explains Dr. Rosterman. "It's the most common question patients and families ask – and it's the hardest question to answer. But we strongly encourage patients to go to rehab because it's their best chance for a return to normal."
Rachael moved into a private room at The University of Kansas Health System's inpatient acute rehabilitation unit. Physiatrist Alexandra Nielsen Arickx, MD, developed a personalized recovery program for her.
The first physical therapist to visit Rachael lifted her into a wheelchair and said, "We're going to get you walking!" Rachael responded, "No, you're not." But the rehab team was persistent. Therapists moved Rachael's left foot for her while she walked with her right. They helped her remember the sensation of moving.
Dr. Arickx also prescribed medication to relax Rachael's muscles so she could control them better. "The first time I bent my arm by myself, I was so excited. That's when I started to feel hopeful," she shares.
After several days of diligent effort, Rachael was able to open up her left hand, which had been frozen in a fist. She was able to get on all fours and bear weight without assistance. She learned to roll from her back to her side.
"My husband took video of me lying in my hospital bed and lifting my left leg a few inches in the air. He was elated," she remembers. By Christmas morning, just 8 days after her stroke, Rachael took her first few steps.
That day, Blake brought son Nolan and baby Sadie to the hospital along with a small Christmas tree and presents.
"I hadn't seen my kids in a week. I was so happy I cried," Rachael says. Being reunited with her children inspired her to work even harder. She walked everywhere she could.
On January 4, Rachael decided to leave the hospital. Her rehabilitation was not complete, but it was her 28th birthday, and she wanted to be with her family. She made arrangements to continue therapy at a rehab center near her parents' home. By the end of February, she had regained the use of her left arm.
"Rachael is a testament to the benefits of rehab therapy. If you stick with it, the results can be dramatic," says Dr. Rosterman.
Searching for answers
When a young, healthy person like Rachael has a stroke, everyone wants to know why.
"Our neurology team starts asking questions as soon as the patient recovers from an acute stroke," says cardiologist Peter Tadros, MD. "If the heart is involved, they consult with me or another member of our cardiology team."
Dr. Tadros performed an echocardiogram called a "bubble test." It revealed an abnormality in Rachael's heart. She had a congenital condition called a patent foramen ovale (PFO), an opening between the 2 upper chambers of the heart.
"It's one of the more common causes of strokes in young people," Dr. Tadros explains. "Before birth, the opening is natural. At birth, the hole seals up for about 75% of the population. For the 25% that it remains open, it usually causes no problems."
But Rachael's PFO was large, and her condition was complicated by extra tissue known as an atrial septal aneurysm. Together, these defects may have allowed blood clots to travel to her brain instead of being filtered by her lungs.
According to Dr. Tadros, PFOs can be managed with medicine, but closing the hole is a superior solution.
"In the early 2000s, the only way to fix a PFO was open heart surgery," says Dr. Tadros. "Today, we can repair most PFOs with a minimally invasive procedure called transcatheter intervention. We go in through the femoral vein and implant a small round device to seal the opening in the heart. Patients can go home the next day. It's pretty amazing."
Rachael and her mom met with Dr. Tadros to learn about her options. "We were both on board with the repair. If it could reduce the risk of another stroke, we wanted to do it right away," Rachael recalls.
On March 11, Rachael received transcatheter intervention. "When it was over, Dr. Tadros said the device fit perfectly," remembers Rachael.
"The procedure went very well, and the opening sealed immediately. The PFO repair should markedly reduce the risk of blood clotting and stroke down the road," explains Dr. Tadros.
Returning to normal
Just 4 months after her strokes, Rachael is feeling great. She no longer has to think about making her left arm and leg move. It again happens naturally. She feels she has regained about 98% of her previous abilities.
"I'm able to watch the kids now, and my husband is back at work. I can't wait to get back to work too," she says.
Rachael knows she couldn't have come this far without her family's support. Blake encouraged her with exercises and massages. Her dad always wanted to be by her side. Her mom drove her to every appointment.
"My mom is my rock," says Rachael. "She's always checking on me."
When it comes to The University of Kansas Health System, Rachael speaks fondly of the care she received.
"I would absolutely recommend them. They know what they're doing. The stroke and rehab teams are amazing," she says. She and her family are doubly grateful for the expertise of Dr. Madarang. As Rachael puts it, "He's the one who saved my life twice."