letang
The Pittsburgh Penguins broke their silence Friday and announced that the mysterious injury that has kept Kris Letang out since January 27th is a stroke. Not the flu, not mono, not any of the other usual garbage that young healthy people get, but a stroke. Strokes are uncommon in young people (but not impossible), and the team has said that they believe a congenital heart abnormality may have been the cause. How can this happen? And how can only six weeks possibly be how long he’ll be out?

 

Kris Letang’s last game was January 27th against Buffalo. An episode of nausea and dizziness on the 29th kept him out of the LA game on 30th, but he continued to travel with the team. When his symptoms still hadn’t cleared by the time the team hit Phoenix a couple of days later, he underwent some tests. Those tests were suspicious for a stroke, and Letang was sent back to Pittsburgh for yet more testing. In the course of all the diagnostics, doctors discovered “a very small hole in the wall of his heart since birth”, which could have precipitated the stroke. That’s a lot of information to take in all at once, and none of it seems to make sense in the context of a young, healthy athlete.

 

Nausea and Dizziness? That’s a stroke?

 

While there are two kinds of strokes – ischemic and hemorrhagic – the outcomes can run the gamut from death to major (or minor) disability to almost no side effects at all. Ischemic stroke is caused by an interruption in blood supply to a certain part of the brain – like from a clot. Hemorrhagic strokes are caused by bleeding into the brain. Letang’s stroke was ischemic, and his symptoms were mild enough that he obviously had no idea there was anything wrong with him until several days later.

Okay, so how do you know you’ve had a stroke?

 

Strokes often present with obvious symptoms like slurred speech, weakness on one side of the body, or facial droop. Sometimes it can be as subtle as numbness in a hand, a vision problem, or balance issues. The workup for an obvious stroke or more subtle neurologic problems often starts out the same, which is how Letang’s issue was diagnosed. You start with a CT scan to look for bleeding in the brain, and a crapload of bloodwork to rule out other causes (thyroid, infection, anemia, being drunk as hell). Sometimes strokes show up on a CT scan, and sometimes they don’t. MRI is next, and can detect old and new strokes. It’s actually not unusual to find an old stroke a patient never knew they’d had on a scan.

 

Strokes. CT on the left (with an arrow in case you missed THE HUGE STROKE) and MRI on the right (you don't need an arrow for that).

Giant strokes. CT scan on the left (with an arrow in case you missed THE HUGE STROKE) and MRI on the right (you don’t need an arrow for that).

 

I had a stroke. Now what?

 

Once a stroke is diagnosed, the hunt for the cause begins. If there’s a huge brain bleed, your job is pretty much done other than figuring out which blood vessel is at fault. If there’s no bleeding, then you start looking elsewhere for a source:
  • Carotid dopplers (ultrasound) to look for plaques in the carotid arteries that can break off and end up in the brain. Plaques are the crap that builds up after too many years of bad lifestyle decisions.
  • EKG and cardiac echo (ultrasound) to look for irregular heart rhythms or structural problems that could cause a clot. Irregular heart rhythms allow blood to swish around in the heart instead of rocketing through, and when blood holds still, it’s more likely to clot. Some structural heart problems can provide clots with ways to get to the brain (causing a stroke).
  • More blood tests to figure out if you’ve got some kind of genetic predisposition to clotting.

In about a third of strokes, no cause is ever identified. Letang falls into that category – sort of.

 

A hole in the heart? What?

 

This is a PFO, and one in four of you have it.

This is a PFO, and one in four of you have it.

 

The hole in Letang’s heart is most likely a PFO (patent foramen ovale), which is actually present in about 25% of people, most of whom will never know it’s there. Before you’re born, your blood doesn’t circulate through your lungs. Fetal circulation is weird, and not worth getting into other than to say that blood skips the lungs by way of a hole between the two upper chambers of the heart – the foramen ovale. When you’re born, that hole closes up about 75% of the time. When a PFO and no other possible cause is found as part of a stroke workup, then you’ll probably assume it’s the culprit. The blood that sneaks through the PFO hasn’t been through the lungs. In addition to loading your blood up with oxygen, the lungs serve to filter out various garbage like little clots. A little clot you’d never even know was there, up until it skips the lungs and gets sent out of the heart up to the brain, where it blocks circulation. Then you have nausea and dizziness, and you’re Kris Letang.

 

OH CRAP! HOLE IN THE HEART! NOW WHAT???

 

If you haven’t had a stroke and you just happen to be having an ultrasound of your heart, you’ve got a one in four chance that they’ll find a PFO. What do they do about it? Usually nothing. If it’s small and you’re asymptomatic, the risk of fixing it or putting you on medication outweighs the benefit. If it’s huge, it’ll probably get fixed. That’s accomplished either with open heart surgery or with a small device that’s inserted into the hole by way of a catheter threaded through major vessels in the groin up into the heart.  If you’ve had a stroke and they find a PFO, then the first step is antiplatelet therapy, and that’s why six weeks isn’t a ridiculous estimate. Antiplatelet therapy is not anticoagulation. It’s aspirin.

 

So… Aspirin? For a STROKE?

 

Yup. Aspirin isn’t the same as anticoagulants like coumadin/warfarin/the active ingredient in rat poison/the stuff guys like Pittsburgh’s Tomas Vokoun and Winnipeg’s Paul Postma were on. Very, very simply put, anticoagulants (“blood thinners”) like coumadin reduce your ability to clot by messing up your body’s clotting factors (fancy chemicals in your blood). That means you probably shouldn’t be playing hockey, because if you get hit you’re going to bleed easily and it’s going to be a pain in the ass to get you to stop. It’s a good thing if you’ve had a big clot somewhere you don’t want (like your leg) because you really don’t want more clots forming. Antiplatelet agents like aspirin keep platelets from clumping together, which also affects clotting, but doesn’t have nearly the same amount of scary side effects. It also isn’t affected by what you eat (like coumadin), doesn’t require frequent blood tests (like coumadin), and may not keep you from playing hockey (like coumadin). It’s particularly good for arterial clots, and those are the ones that cause strokes. Of course any doctor is going to tell you that you shouldn’t play contact sports if you take aspirin because of the bleeding risk. In reality, good luck telling a guy that takes one regular strength aspirin a day to stay off the ice.

 

So? What now?

 

Now Letang likely gets put on aspirin, and starts rehab to improve his symptoms. In six weeks he’ll be reevaluated, and is supposedly going to start skating after the Olympic break if he’s feeling well enough. While having a stroke at 26 is clearly awful, his outcome could have been far worse, and his attitude is clearly stellar:

I hope that by making my condition public at this time I can help other people by encouraging them to seek medical help if they experience some of the symptoms associated with a stroke, regardless of their age or general health. It obviously was a shock to get the news but I’m optimistic that I can overcome this and get back on the ice.

 

Elsewhere in blood clot news…

 

Tomas Vokoun is off the blood thinners! He had a large clot in an upper leg/pelvic vein in the preseason on which he had a thrombectomy (where the clot is broken up and sucked out), and was then placed on anticoagulants. He’s back on the ice and taking shots, but no word on if he’ll be able to return this season.

Paul Postma is off the blood thinners! Winnipeg’s Postma had some leg pain in October that turned out to be a blood clot. He spent three months on anticoagulants, and was back skating in mid-January. After a short conditioning stint in the AHL, the Jets have called him back up.

MARTY ST LOUIS IS GOING TO THE OLYMPICS. This has nothing to do with blood clots, it’s just great news for St. Louis and his massive majestic legs.

Comments (3)

  1. Hole in the heart always makes me think of Jiri Fischer: http://www.youtube.com/watch?v=kUU4-JKfB_o

  2. Great explanation of stroke in the young, Dr Innes!

    Hopefully, Letang’s coordination wasn’t affected, and he’ll be able to get back to playing soon. And hopefully this discussion *will* bring more attention to stroke symptoms in all ages.

  3. I had a stroke playing senior hockey in Saskatchewan a few years ago. I was 21 at the time and the worst part of it for me was the anxiety that followed. Having another stroke was constantly on my mind. I live with a minor visual impairment now and am glad to hear the Letang seems to have no lasting effects. This kind of thing does happen to younger people, so it’s important to be aware of the warning signs.

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