It was a seemingly uneventful evening in March of 2022. Gretchen Dejter, a 60-year-old woman, was in her barn at her home with her husband when she suddenly grabbed her head and collapsed after yelling out that her head was hurting. Her husband lowered her down to the ground and called 911, as she was now experiencing nausea and vomiting and he needed help. When she was transported to the closest hospital she was still awake and able to talk, but as she was being taken to the computed tomography (CT) scanner she once again developed nausea and started vomiting. Because there was concern she may not be able to protect her airway, a breathing tube was placed out of caution. The emergency department team then noticed that she was starting to develop lip-smacking movements that were very concerning for seizure activity, so she was immediately given levetiracetam, an anti-seizure medication.

Gretchen’s head CT (Figure 1) demonstrated diffuse subarachnoid hemorrhage (SAH), a hemorrhage that occurs on the surface of the brain, as opposed to inside it, and is commonly caused by a ruptured aneurysm. She was urgently transported by helicopter to ChristianaCare’s Neurocritical Care Unit (NCCU) in Newark, Delaware. Upon arrival her exam was concerning, as she was unresponsive and not following any commands. Some of her most basic reflexes were intact, but she was extending her upper extremities and triple flexing her lower extremities, worrisome signs that indicated that her brain was under extreme conditions.

Figure 1. Selected axial images from the initial non-contrast CT head

After her initial evaluation she underwent a repeat CT, and this time vessel imaging was performed as well (Figure 2). Not much time had passed, but the new CT showed hydrocephalus, representing an accumulation of spinal fluid in the brain blocking normal flow and causing a build-up of pressure. In addition, there were new areas of blood in the brain and in the ventricles that were responsible for the obstruction. Ultimately, an aneurysm of the anterior communicating (AComm) artery was identified as the culprit.

Figure 2. Images from a repeat non-contrast CT head as well as a reconstructed view of the CTA demonstrating the aneurysm.

The team suspected that Gretchen’s aneurysm had re-ruptured prior to her transfer – an ominous sign to any neurocritical care provider. When an aneurysm ruptures a second time it does not bode well for the patient and there is usually a poor outcome. Based on her exam findings and imaging, she was graded on two severity scales as the highest level of severity – Hunt Hess 5 and modified Fisher 4. This means her neurologic status was poor on arrival and that her imaging showed a significant amount of blood within the brain, both factors that increase the likelihood of poor outcomes.

Now that the team knew what the problem was, they had to start working on alleviating the increasing pressures within the brain. An emergent external ventricular drain (EVD) was placed, which allows a tube to drain fluid and blood from the brain, thereby relieving the build-up of pressure. She also needed special lines to be placed so that her blood pressure could be monitored closely and to allow access for medications to be given safely.

The next step was to secure the aneurysm so it couldn’t bleed again and cause more damage. Depending on the location and shape of the aneurysm, it is usually clipped off or coils are placed inside to occlude the abnormal part of the vessel. Gretchen’s aneurysm was tricky, however, and the neuroendovascular team decided to place a Woven Endo Bridge (WEB) device to secure the aneurysm (Figure 3). A catheter was navigated all the way up into the vessels in her brain and the WEB device was deployed into the aneurysm, securing it in the process. But while this was a step in the right direction, Gretchen still had a long road ahead in the NCCU.

Figure 3. Angiogram images pre- (left) and post- (right) deployment of the WEB device.

Now that the aneurysm was treated, the team could safely make adjustments to the EVD to more aggressively drain the spinal fluid that had built up in Gretchen’s brain. There was a host of medical treatments that would follow: daily transcranial dopplers (TCD) to monitor her blood vessels; regular doses of a medication called nimodipine, which is one of the few treatments that can improve outcomes after aneurysmal SAH; and continuous electro-encephalogram (EEG) monitoring to assess for any underlying seizure activity (which she fortunately did not have). Despite all of these measures, Gretchen remained comatose for the initial portion of her hospitalization. Then, in the midst of monitoring for neurologic complications, she developed a pneumonia and was treated with antibiotics.

Despite her initial rocky stay in the ICU, she started to make some progress by hospital day 8, when she started to follow commands and her breathing tube was able to be removed. She was awake and able to follow commands, though with some delay, and she had weakness in her right arm and both legs. But a day later she suffered a setback with worsening symptoms, and there was concern she was developing vasospasm. This is one of the most feared complications of a ruptured aneurysm, where the blood in the brain causes irritation and can lead to strokes. Her blood pressure was increased to allow for more blood flow to the brain, and she was closely monitored for almost another week. Eventually an MRI was completed on hospital day 14, and while it did show some areas of stroke, it was felt to be related to the initial injury and not due to vasospasm (Figure 4).

While the “time window” for vasospasm was coming to an end, she still had the EVD in place to drain excess spinal fluid from her brain. After several more days of close neurologic monitoring, the EVD was able to be removed and she was stable enough to transfer to the floor after spending almost 3 weeks in the NCCU. In another week, she was well enough to be discharged to an acute inpatient rehabilitation facility.

Gretchen’s husband Rob recalls this time in the hospital with despair, and said that what was most unsettling was not knowing what would come next. He remembers feeling powerless not knowing what to do, so he relied on the Neurocritical Care team – what had started as a group of strangers but had now somehow started to feel like family after Gretchen’s prolonged stay in the ICU. While Rob remembers this challenging time, Gretchen still has no memory of her hospitalization to this day. The first thing she actually remembers is her ambulance ride on her way to the acute rehabilitation center. She remembers counting randomly… 134, 135, 136, 137… which she apparently continued to do during her first week at rehab.

The Road to Recovery

Transitioning to acute rehab was not easy for Gretchen. She remembers having a roommate with many visitors and was overwhelmed with the stimulation, so she was moved to a private room to help her get more rest, which would prove important to her road to recovery. Her initial two weeks were grueling, as she was not able to sit up in bed or even roll over on her own. Gretchen remembers feeling relief when her family was there and she would ask the same questions over and over to help her understand what had happened. She may not have had memories for her time in the hospital, but she does remember the small steps that therapists would encourage – whether it was taking her out of her room for little breaks, or indulging her love of art by getting her to color a picture of a baby dinosaur that she nicknamed Eggebert Humperdink!

There was also a speech therapist who encouraged her to write things down to allow them to stick in her memory, and a physical therapist who would play music on her phone to encourage her to walk around the gym while they laughed together at how she looked like a character from Star Wars with her walking lift (Figure 5). She also holds dear all the tender moments with all the loving staff members who would help her curl her hair before her husband’s arrival on their anniversary day and advocate on her behalf for her to get two more weeks of therapy before leaving rehab. Most of all, Gretchen is thankful for her “wall of hope,” a rolling divider with pictures and cards and a printed reminder in the center that her husband had made for her. It said: “You are at a hospital. You are SAFE. Your family knows you are here. You are LOVED.” This simple arrangement helped her to reorient herself whenever she woke up feeling confused, and if she has one piece of advice for any nurse, therapist, or family member, it is to have a sign like this for all patients! It can help take away some of the fear, disorientation, and worry that they are alone. Even now, she remembers leaving rehab in a confused state, and is just now piecing the story together after hearing from the perspectives of others. Even reading this piece as it was being prepared gave her some pause as she realized what had happened during her hospitalization.

Figure 5. Gretchen in her walking lift (left) and having her anniversary dinner (right) while at rehab

Coming Back Home

Once she was able to walk by herself Gretchen was able to leave rehab, and she had a chance to “ring the bell” before leaving. She remembers having different visions of home in her head, but as they approached, things seemed to click and she was able to piece everything together. Upon returning home Gretchen initially relied on a walker, raised toilet seat, and shower seat. Her thinking was slow and she required time before she was able to organize her thoughts and speak, and time to move from place to place. Gretchen was so grateful for her husband Rob, who had been by her bedside all this time and continued to help her, but with his focus on her safety he would not let her shower by herself. But she was determined and stubborn – so one day, while her husband was in the yard, she decided she was going to go shower by herself and told her daughter to keep her ears open. Difficult as it was, she was able to manage it. Her persistent determination was certainly something that was difficult to balance for the whole family – but it was also what allowed her to take the chances necessary to recover and move forward.

Rob remembers feeling trepidation on returning home and compared the feeling to bringing your first baby back home: up until that moment they had professionals helping to care of Gretchen, but now it was all up to him. Within two weeks, Gretchen was able to move away from all support equipment except for her walker. She still had balance issues and did have a couple of stumbles, but she always made sure to have someone by her side, or else her phone in her pocket. She also required much more planning for any outings, as any activity would drain her of energy very quickly, and loud noises were also bothersome. Due to her ongoing difficulties with communicating, her family had to pick up on cues before she became emotional. But there continued to be great progress, and by the time the six month anniversary of her initial injury came around Gretchen was able to go back to the beach (Figure 6).

Figure 6. Gretchen and Rob at the beach 6 months after her initial injury

Over the next several months, Gretchen realized the importance of surrounding herself with loved ones. She was able to drive with her husband to a wedding in Ohio, travel to South Carolina to see her son and other relatives (Figure 7), through North Carolina to see a college friend, and then on to Ohio again to be with her brother at an event celebrating his wife, who passed while Gretchen was in the hospital. She worked hard to get her driver’s license back, and was even able to return to work as an Early Childhood Specialist! At school year's end, however, Gretchen decided to retire. Maneuvering all the little kids had become a task that was too daunting, yet she still misses the children even now.

Figure 7. Pictures of the Dejter family at get-togethers and outings

A Year Later

A year after her initial admission the Dejter family graciously and generously participated in a ChristianaCare program called the “Thank You Project,” whereby interested patients and their families are able to come back to the hospital to thank their care providers for all their work. This event reunited the multi-disciplinary care teams and the helicopter transfer team with the Dejter family, and everyone got to see firsthand the amazing recovery that Gretchen had undergone. The event was a spectacular hit in the Neuro ICU, where almost every provider had happy tears to share at seeing how wonderfully Gretchen had recovered from her injury (Figure 8). The story was even featured on ChristianaCare’s website and social media platforms and can be found here: Saying 'Thank You' for Lifesaving Stroke Care - ChristianaCare News.

Even 18 months after her initial injury, Gretchen feels like she continues to get better. Rob is ceaselessly amazed at her progress, as she regains the ability to complete new tasks that she had not been able to complete since her injury. Still, Gretchen knows that she will never be like she was before. She still has balance difficulties, as well as arthritis pain that seems to have gotten worse since her event, but there are days that are good and days that are less good. Gretchen graciously takes this in stride and states that her symptoms are manageable. Rob is just incredibly thankful that he gets to continue to have more days with the love of his life and is now thinking of giving back by getting more involved with stroke survivors.

Figure 8. The Dejter family at the Thank You event one year after her injury Credit: Courtesy of ChristianaCare.

The Dejter family visit left a lasting impression in the Neuro ICU, and all her providers were able to hold their heads up higher and feel more validated when thinking about their jobs and responsibilities. All the challenges that the team experiences in the Neuro ICU became insignificant when outcomes such as Gretchen’s are possible with the work that they do.

Thank you to the Dejter family for their kindness and thoughtfulness!