Cryptogenic Stroke | Ken Kurdziel had never heard the term “cryptogenic stroke” when he had one. But his experience illuminates the strange and frightening phenomenon of an unexplained attack on the brain that strikes without warning.
In simple terms, a cryptogenic stroke is one for which there is no clear explanation. Kurdziel, who had his in 2006 at the age of 48, still doesn’t know why. But he has a congenital condition called a patent foramen ovale (PFO), the result of a small opening between the upper chambers (atria) of the heart failing to close during infancy. The theory is that a PFO in some cases allows blood clots to pass between the atria and find their way to the brain. After Kurdziel’s attack, he decided to enroll at University of Colorado Hospital in the RESPECT clinical trial, which tested the safety and efficacy of a PFO-closure device called the Amplatzer PFO Occluder as a treatment to prevent a second stroke (see accompanying story).
The randomized trial divided patients into two groups. One received the closure device; the other received anticoagulant medication therapy. Chosen for the first group, Kurdziel underwent a minimally invasive procedure to close his PFO with the Occluder. Seven years later, he said he is in good health and has noticed only minor aftereffects of the stroke – a short-term memory issue associated with a migraine headache that quickly vanished and occasional problems with speech that have been happening less and less.
Those are annoyances he cheerfully accepts after his brush with potential disability or even death. Kurdziel was working an office job for a company in the aerospace industry the day he suffered his stroke. He described himself in excellent health. He had no history of heart problems. His blood pressure was normal, as was his weight.
“My life was uneventful,” he said. “I had no warning.”
Sudden danger. But as he stood outside his office that day talking to a coworker, Kurdziel said he suddenly felt very fatigued. Then his head slumped and he felt the right side of his face sag. He began mumbling. When he walked back to his office, he hit the doorjamb. He tried to type, but he had trouble raising his right hand, which flopped back down on the desk.
“That’s when I realized I was having a stroke,” Kurdziel said.
He called to a coworker to contact his wife, Susan, who worked down the hall. She drove him to Saint Joseph Hospital in Denver, where he spent the next 10 hours in the emergency department. The sagging and other symptoms had passed, but he went through a battery of imaging tests that confirmed he’d had a stroke.
He stayed another three days at Saint Joe’s, wondering why the providers there looked at his heart rather than his brain. He later understood they had been running tests to identify a PFO, the possible result of a bout in infancy with scarlet fever, a strep infection that can lead to heart problems.
“The scarlet fever could have set me up for failure,” Kurdziel said.
Trial run. He learned of the RESPECT trial from his providers at Kaiser, who referred him to Alan Anderson, MD, a neurologist with the CU School of Medicine and principal investigator for the trial at UCH. Another round of testing followed, including a trans¬esophogeal echocardiogram, or TEE. The TEE, which produces images of the heart, requires inserting a sound wave-emitting transducer into the esophagus, an experience he compared to “having a golf club shoved down your throat.”
He also went through sonograms of his carotid arteries and aortas and tests for hypertension and hypercoagulability – a tendency to clotting that would have excluded him from the trial.
“I was impressed by the thoroughness,” Kurdziel said. “I realized how well thought through it was. They were trying to eliminate all other possible causes for my stroke.”
For his part, Kurdziel said he had a simple motivation for voluntarily submitting to the pokes and prods. “I’ve worked as a scientist,” he said. “I wanted to help expand the knowledge of man.”
After he qualified for the trial, he reached into a jar and drew a slip of paper that put him in the device group. Shortly thereafter, he met with John Carroll, MD, director of interventional and vascular cardiology at UCH. Carroll was first author on the recently published New England Journal of Medicine article that detailed the results of the RESPECT trial.
Kurdziel perfectly fit the profile of the RESPECT trial patient, Carroll said, in that he seemed an unlikely candidate for a stroke.
“We targeted people who were active, working and raising families – people who were free of a long list of medical conditions that would lead you to expect that they were at risk of a stroke. Ken was very fortunate that he had resolution of the most severe manifestations of stroke that occur in some people.”
But the risk of a second one lingered. So Kurdziel entered the Cath Lab at UCH for the procedure.
Carroll threaded a catheter carrying the Occluder through the femoral vein while a fully conscious Kurdziel watched the fluoroscopic image and occasionally conversed with the procedural team. After Carroll implanted the device and removed the catheter, a resident applied pressure on the vein to prevent bleeding. Kurdziel spent a couple of hours in post-op, took a wheelchair to his car and got a ride home. Three or four days later he was back at work with no residual issues.
“I’ve done just fine ever since,” he said.
Grateful to have survived the attack that he knows could have had grim consequences, Kurdziel said he encourages others to contribute to the body of medical and scientific knowledge necessary to battle stroke and other conditions.
“Don’t be afraid to volunteer for clinical trials,” he said. “Clinicians go through great lengths to reduce the risk and make the studies meaningful. My hat is off to UCH and the School of Medicine for the way they conducted this trial.”