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A telestroke consultation begins with a conversation between the physician at the outreach facility and the neurologist over the phone. If the neurologist believes it is possibly a stroke, the next step is a video consultation with the patient and their family. A nurse from the outreach facility is also in the room to help facilitate the telemedicine visit. Since the neurology specialist isn't able to be in the same room with the patient, the nurse can help with certain parts of the exam. The nurse and the patient's family can also help provide important information specific to a stroke evaluation, such as neurological medical history and key medications. Once the exam is complete, the physicians and medical staff quickly review the assessment and determine next steps.

"We often say that 'time is brain' in stroke care," said Danielle Freeman, director of outreach and telehealth for the neuroscience service line at U of U Health. "Regional hospitals that don't have stroke neurologists working in them need rapid access to stroke experts who can quickly and accurately identify stroke, especially in life-threatening situations, and transfer the patient to a larger stroke center like U of U Health's Comprehensive Stroke Center."

"Time is Brain"

When someone experiences a stroke, time is the biggest enemy. To provide the best care and preserve brain function, a neurologist needs to start certain treatments within a very specific timeframe. Every minute lost is brain cells lost—brain cells that cannot be regenerated.

Because Mark didn't immediately know he was having a stroke, and because his symptoms were coming and going, he waited a little while before going to the hospital. He had already lost some time in his treatment window, and the distance from Moab to Salt Lake City would take too long to drive, even by ambulance. So Dr. Majersik ordered a helicopter to fly Mark to U of U Health's Comprehensive Stroke Center.

Mark remembers the helicopter flight after being diagnosed with a stroke. He thought about all the places he had traveled—first growing up in northern Minnesota, then attending graduate school at Mississippi State. From there he moved to Texas, then California, and even spent a year in New Zealand in his 20s. As a person who was always up for an adventure, it was hard to comprehend how his life might be different after a stroke.

"I was basically resigned to my fate," Mark said. "I thought I was going to be permanently paralyzed or permanently disabled. I wouldn't say I was ever really sad or mad about it, but I didn't really know of any treatments or anything you could really do for a stroke."

He arrived at University of Utah Hospital and felt his symptoms getting worse. His mind was completely lucid, but nothing else was working. His brain knew what he wanted to say and do, but his body wouldn't cooperate.

One of the neurology residents explained that he would probably need a mechanical thrombectomy. Mark was willing to do whatever was required. "When you're in that state of impairment, you really don't care what you've got to do to get out of it," he said. "Imagine the worst dream of your life—the worst nightmare. You'll do whatever you can to wake up."

The Six-Hour Window

The most common FDA-approved stroke treatment, called tissue plasminogen activator (tPA, or alteplase) has to be given within a few hours of the stroke onset. "Very few people get to the hospital within minutes of their stroke," Dr. Majersik said. "So even though you have a few hours total, by the time they get to the emergency room, you might only have 20 to 30 minutes left in the tPA window." In Mark's case, he waited too long to go to the ER, so the intravenous tPA, which is standard treatment for ischemic stroke, was not an option. It must be given within four and a half hours of stroke onset.

Instead, doctors got brain imaging to identify the clot location and saw that it was big enough to remove using a procedure called a mechanical thrombectomy. This procedure is an option for some patients for up to 20 hours after the stroke occurs.

Because the team at University of Utah Hospital knew Mark was on his way from Moab Regional Hospital, everyone and everything was already in place before he got there so they could get started immediately when the helicopter arrived.

A mechanical thrombectomy is a minimally invasive procedure where a neurointerventional surgeon uses a specialized instrument to extract the clot from the blood vessel where it's blocking blood flow. A small catheter is inserted into an artery, then threaded through the patient's body to reach the clot. Along the way, the radiologist uses x-rays to advance the tools to the correct location.

Dr. Matthew Alexander, a neurointerventional surgeon in the radiology and imaging sciences and neurosurgery departments, performed the procedure to remove the clot. Mark remembers being prepared for the procedure while Dr. Alexander told him that he would use a small device to grab the clot and pull it out. It's a low-risk procedure but still involves inserting a device into an artery in the brain. So it comes with some risks.

Mark remained awake for the entire procedure with a local anesthetic, something Dr. Alexander prefers so the patient's brain remains active. He described it like the feeling of going underwater when scuba diving and experiencing some pressure in your nose and ears. He could hear a metal sound as the device deployed to grab the clot. When they pulled the clot out, it felt like a flickering lightbulb that was suddenly screwed in all the way and fixed.

"Instantly I just started crying because I knew that he got it," Mark said.

"Watching Mark's reaction was a moving experience," Dr. Alexander recalled. "He was so calm and quiet throughout the procedure. It was the middle of the night, so I assumed he had gone to sleep. It wasn't until we were finished that he told me he knew exactly what was happening at every step and knew the procedure was successful before I took the pictures to confirm that the vessel was open."

Stroke Prevalence Increasing at All Ages

The case of a seemingly healthy man in his mid-30s having a stroke was a mystery to Mark's doctors. As he recovered from the thrombectomy, they ordered some tests to figure out what happened. Since it was early 2020, they thought he may have contracted COVID-19 and the stroke was a side effect of the virus. But he was negative for COVID.