Back on the Race Track
Neuro team helps stock car enthusiast get behind the wheel again after a stroke
Jim Cox, 67, has owned, built and driven late model stock cars throughout his life. He started working on the racecars at age 14. As a young U.S. Army helicopter test pilot he raced on his base and at nearby race tracks. Later, even after battling cancer and undergoing triple bypass heart surgery, he got back behind the wheel. The corporate engineer from Dyer, Ind., planned to spend more time on his hobby in retirement. But then a stroke three years ago brought on repeated episodes of double vision, slurred speech and balance difficulties.
“Jim’s stroke affected his cerebellum, leaving one artery in the back of his brain completely blocked and another 90 percent narrowed,” said his neurologist James R. Brorson, MD, an expert in cerebrovascular disease at the University of Chicago Medicine. “The effects of the stroke were keeping him from doing his normal activities and he was at high risk for another stroke that could cause permanent damage or be fatal.”
A Conservative Approach
Brorson first treated Cox with blood thinners as well as medications to control his blood pressure and lower his cholesterol. “Starting with medical therapy is the conservative approach for treating intracranial arterial stenosis,” Brorson said. But the narrowed blood vessel was so severely blocked that Cox was still not getting enough blood moving into his brain. It was time to consider other options.
At this point, interventional neuroradiologist Seon-Kyu Lee, MD, PhD, joined Cox’s medical team.
There are two neurointerventional techniques used to treat the narrowing of a brain artery. One is to dilate the artery with a balloon (called balloon angioplasty) and the other is to position a metal mesh stent, or tube, in the artery after balloon inflation.
“Balloon angioplasty by itself has a higher chance of the narrowing recurring but has lower procedure-related risks,” Lee said. “Stent placement after the balloon inflation has a lower chance of the narrowing recurring but has a higher risk of procedure-related complications.” He recommended the lower risk procedure be tried first.
Using meticulous precision, Lee inserted a tiny catheter (thinner than a strand of angel hair pasta), through an artery in Cox’s groin up to the narrowed artery in his brain. Because angioplasty carries a chance of rupturing the delicate walls in the artery, Lee began with the smallest balloon (1.5 mm), gradually increasing the size of the balloon up to 3 mm to dilate the vessel and improve blood flow.
Cox’s condition improved after the February 2012 procedure. At first, the dizzy spells and vision issues stopped. But over time, the episodes returned and his symptoms worsened. “I started blacking out,” he recalled. Cox described his vision as resembling “slivers in a cracked mirror.”
Checking on Cox often, Brorson continued aggressive medical therapy. “But, the fractured vision and other problems were happening too often,” Brorson said. “Medications were clearly not working.”
Opening an Artery, Reducing the Risk
Lee and Brorson then considered the balloon angioplasty with stent placement. Before making a final decision to proceed, the duo presented Cox’s case at neurovascular conference, a weekly meeting that brings together specialists in neurosurgery, neurology, neuroradiology and neuro-critical care.
This interdisciplinary team discussed a recently completed clinical research trial examining intracranial stenting for the prevention of stroke. The study concluded that patients who had aggressive medical management fared better than those who had angioplasty with stent placement. However, the corps of experts in the room recognized that Cox’s condition was an exception and his grave situation left stent placement as the only remaining alternative for treatment. Having completed more than 60 of these procedures with excellent results, Lee is highly experienced in this neurovascular technique.
In April 2013, Lee placed the 1.5 mm balloon first and inflated progressively larger ones to gradually expand the blood vessel wall. After the 4.0 mm balloon was inserted, Cox’s artery opened to 90 percent and Lee positioned the stent in place.
By the time Cox left the hospital, his symptoms were gone. “As a result of the procedure, Jim now has normal blood flow, which is about five to six times more blood to his brain than before the procedure,” Lee said. He puts the risk of the artery narrowing again at only 10 to 15 percent.
‘They Did an Outstanding Job’
Brorson will continue to monitor Cox, carefully adjusting medications to control his blood pressure and cholesterol levels. “Although we don’t have evidence from a larger series of patients, we can expect and hope he will continue to do well,” Brorson said.
The doctors recommended Cox take it easy, but it wasn’t long before he felt well enough to get back to the racetrack. Cox says he is extremely pleased with the care he received from Brorson and Lee. “They did an outstanding job,” he said. “I am so thankful to them for getting this done for me.”