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The Lazarus Effect

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Monday, January 8, 2018 - 18:15

By Athos Patsalides, MD
Associate Professor of Radiology in Neurological Surgery

Vascular specialists, who work with patients experiencing conditions and disorders of the blood vessels, often talk of the “Lazarus effect,” a phenomenon in which a patient revives after coming to the brink of death, as happens in stroke or heart failure. Until recently I’d never witnessed it personally. Then, a few months ago, I treated a patient whose blood flow in the left half of the brain was completely blocked and who was in some sense of the word dead (or at least perilously close to it) when I saw him suddenly come back – at my hands. It was a profoundly moving experience for both of us.

Mr. Lichtenstein had already had a stroke – and a major stroke of luck – earlier that evening, when he’d experienced the dizziness, confusion, and deterioration of speech that signaled a brain attack. The stroke, caused by a blood clot in the brain, easily could have claimed his life, but a 911 dispatcher called for the new Mobile Stroke Treatment Unit (MSTU) from NewYork-Presbyterian. This specially equipped ambulance is designed to get stroke victims the immediate help they need to prevent damage to the brain, and Lichtenstein was given tissue plasminogen activator (tPA, the “clot-buster”) while he was still en route to the hospital. His life had been saved. But the night wasn’t over yet.

Like all stroke patients, Mr. Lichtenstein was evaluated upon arrival in the ER to see what steps to take next. If a clot had still been present, the neurology stroke team would have called in the interventional neuroradiology (INR) team to determine if he needed emergency surgery to remove the clot. That night, it was determined that the clot-busting drug had done its job and surgery was not needed.

Several hours later, however, Mr. Lichtenstein suffered a second, and much worse, stroke. He was unable to speak or move his right arm. The neurology stroke   team ordered an immediate CT scan, which revealed a new clot. It was larger than the earlier one, affecting a much larger area of his brain. With every minute that passed, his brain was being deprived of oxygen, risking irreversible damage.

Pre- and post-procedure scans of blood flow The scan at left shows the location of the blood clot (red arrow) and the resulting lack of blood flow in the circled area. At right, the scan shows restored blood flow after Dr. Patsalides removed a very large blood clot using a special clot retriever.

Mr. Lichtenstein got his second lucky break of the night when the emergency room team sent those CT scans to my smart phone. As it happened, I was with several other members of the INR team at a nearby restaurant celebrating the graduation of our latest class of residents and fellows. No sooner had we all settled into our seats than I got the call – and the scans — and could see that this patient needed surgery to remove the clot, immediately. Those of us who were on call that night — Felix De Russo, Elissa Besabe, RN, and Thomas Link, MD — jumped from our seats and headed over to the hospital.

Our patient was in very serious condition. Not only could he not speak or move his right arm, we knew his brain was dying, right in front of us. The part of the brain that suffers from lack of blood flow dies soon after being cut off from oxygen, and when oxygenated blood is blocked by a clot there is simply no time to spare. The clot had to come out immediately. The INR team had to act fast.

INR specialists are used to performing delicate image-guided procedures in the brain – we can insert a microcatheter in the large artery in the thigh and thread tiny tools up into the blood vessels in the brain. We do this for a number of reasons – to repair an aneurysm, to insert a stent into a narrowed vessel, even to deliver chemotherapy directly to a brain tumor – and it’s a slow and careful process. On this night, our task was to go into Mr. Lichtenstein’s brain immediately and get that clot out – a procedure called embolectomy — before his brain died. We wasted no time in getting this patient ready for the procedure.

Watching on the procedure room monitors as I snaked a special clot retriever tool up into Mr. Lichtenstein’s brain, the team held its collective breath. He was conscious, not under anesthesia, as this is a painless procedure, but he was unable to speak and was partially paralyzed. I knew that every minute counted as I maneuvered the retriever into place.

Blood clot removed from patient having a strokeThe ruler tells the story: This very large blood clot was threatening Mr. Lichtenstein's brain until interventional neuroradiologist Dr. Patsalides removed it using a special clot retriever.

The retriever tool did its job, and within minutes the blood clot was removed and blood flow to the brain restored. As soon as the images on screen confirmed this, I turned to Mr. Lichtenstein and asked, “How are you?”

“Doing well,” responded the man who moments earlier had been unable to speak. We had a short conversation, then I asked him to raise his right arm – the arm that had previously been paralyzed. He raised it easily. He recovered fully within minutes and was able to talk to his wife soon. 

I would not have been more amazed had Lazarus himself sat up on the table. Mr. Lichtenstein was alive, and neurologically intact, with no significant damage from his close brush with brain death.

It’s not easy to just return to dinner after an experience like that. But we did, celebrating the end of the academic year with a case that was one for the history books. I had already been proud to send these young residents and fellows out into the world, to bring their skills to patients across the country. This one last procedure was the icing on the cake – any patients out there who see one of these young neurosurgeons in the ER one day should thank their lucky stars to be treated by such talented doctors.

Best of all, Mr. Lichtenstein continues to do well. My team and I had returned him to his family with more life for them to live together. All in all, as a day at work goes, this was a pretty good one.

Read more about Mr. Lichtenstein’s experience in this New York Daily News article about it.

More about Dr. Patsalides