With island temperatures hovering in the mid to high 80s on the June 11 Kamehameha Day holiday, Kahului resident Dahna Oviedo ate lunch with her sons and nieces at Fabiani's Bakery & Pizzeria in Kihei.
She had no idea a large blood clot was making its way through her bloodstream, traveling from a small hole in her heart to her brain. There, the mass of blood platelets would lodge in an artery, starving it of life-giving oxygen.
Within minutes, the 37-year-old mother of three sons would be fighting for her life, facing death or paralysis. It would be a shock because she was young and healthy, getting daily exercise and watching her diet.
"I take all the vitamins in the world," she said last week.
After lunch, Oviedo got behind the wheel of her car to drive to the Maui Tropical Plantation in Waikapu. The children wanted to see the plantation's ducks. In the car were two of her three sons, 8 and 4 years old, and her 25-year-old niece, Kim Ignacio.
Suddenly, while nearing Maui Lani on Kuihelani Highway, Oviedo started having "really bad" hiccups and a severe headache, she said. Her left leg wouldn't respond, and she started drifting to the left on the highway.
STROKE WARNING SIGNS
The National Stroke Association urges people to learn the signs of a stroke and call 911 immediately if one is suspected.
The association uses the acronym FAST as a way to help people recognize stroke symptoms. The letters represent:
Face. Ask the person to smile. Does one side of the face droop?
Arms. Ask the person to raise both arms. Does one arm drift downward?
Speech. Ask the person to repeat a simple phrase. Is his or her speech slurred or strange?
Time. If any of these signs is observed, call emergency dispatchers immediately at 911.
It's also important to note the time symptoms first appear. There's a three-hour window for the use of certain blood-clot-busting medication.
Other signs of stroke include sudden:
* Numbness or weakness of face, arm or leg, especially on one side of the body.
* Confusion, trouble speaking or understanding.
* Trouble seeing in one or both eyes.
* Trouble walking, dizziness, loss of balance or coordination.
* Severe headache with no known cause.
Medical professionals say it's vital to get stroke victims to a medical facility as soon as possible because brain tissue deprived of oxygen dies after a short time.
Ignacio asked, "Auntie, you OK?" Oviedo said she had a "weird headache," and as her car veered farther to the left, her niece grabbed the steering wheel and was able to guide the car to a stop on the highway's shoulder.
Oviedo said she couldn't get her left slipper on, and when her niece opened the driver's side door, she fell on top of her.
"I didn't have any pain," she said. "It's a weird thing, not being able to control your body . . . I couldn't walk."
Oviedo's husband, Andy, was at home sleeping after working the graveyard shift as a security guard the night before. When his niece called him, he recalled his emergency response training and knew his wife was having a stroke, he said.
He told his niece to call 911, and he rushed to the scene, arriving there shortly before paramedics. He found his wife sitting in the back seat of their car with her left side paralyzed, he said. The ambulance crew pulled up, quickly assessed Oviedo and rushed her to Maui Memorial Medical Center.
At the hospital's emergency room, doctors ordered a computed tomography scan, better known as a CT scan, using X-rays to try to determine what was happening in Oviedo's head.
Dr. Ronald Boyd reviewed the scan, which showed no evidence of bleeding and didn't provide another explanation of her symptoms. He said he suggested that the scan be repeated but with a technique to show blood vessels in the head.
"These images showed a large blood clot blocking the major artery to the right side of her brain," he said.
Emergency room staff began administering a drug intravenously to try to dissolve and break up the clot, Boyd said, but he knew the medicine was unlikely to remove such a large clot. Another team of doctors and nurses, led by Dr. Turgut Berkmen, an interventional neuroradiologist, was called.
While the clot-busting drug went to work, a magnetic resonance imaging, or MRI, study was done on Oviedo, Boyd said.
"This showed that she had already suffered a small stoke," he said. "This put more urgency on removing the clot to prevent a large stroke, which can result in death, particularly in young patients," such as Oviedo.
She was awake. The experience was "very, very traumatic and emotional, especially for my husband," she said.
Berkmen said blood clots in the brain are seen "pretty often" in patients, although they are usually in middle age or older. It's much less common in young people, and then more dangerous because younger people have less room in the skull for a brain to sustain trauma, he said. An older person's skull generally has more room because of some atrophy to the brain.
Oviedo was among the youngest patients he's treated for a stroke, he said.
Berkmen said that when he saw Oviedo, whose left side was paralyzed, he knew the stakes were high.
If he managed to save her life but she was left paralyzed, then "she would have been devastated for the rest of her life," he said. "You're stuck in a wheelchair. You can't feed yourself. You can't take care of yourself. You can't go in the shower . . . She would have to be taken care of the rest of her life."
If the clot in Oviedo's brain were not treated, a large part of her brain would die and start swelling, Berkmen said. If the swelling pushed on vital parts of her brain, including the brain stem, then that would kill her.
Oviedo was lucky. She arrived at the hospital and began receiving treatment well within a three-hour window in which she could receive a strong blood-clot-busting medication called TPA, he said.
The Food and Drug Administration has only approved giving the medicine within three hours of the onset of symptoms because if TPA were administered too late, then it could lead to fatal bleeding in the brain, Berkmen said.
However, giving the medication does not necessarily mean that it dissolves all blood clots, and that is what happened in Oviedo's case, he said.
"It wasn't working fast enough," Oviedo recalled.
So, Maui Memorial's angiography team and Berkmen used X-ray guidance to pass a small catheter (like a tiny plastic tube) from Oviedo's groin, up through an artery and into the location of the blood clot in her head.
The procedure began about 10 years ago and has skyrocketed in use with advances in the last couple of years, Berkmen said.
Tests showed that Oviedo did not have a substantial amount of brain damage, he said.
Berkmen said doctors want a patient awake and not anesthetized in such procedures because they want a patient to be able to communicate how they're doing to see if there's any improvement.
Oviedo stayed awake.
"Everything was on the screen on the monitor," she said.
The procedure took about half an hour, Berkmen said. Just as it appeared that the blood clot had been cleared by the tip of the catheter, Oviedo complained of a headache, which was worrisome because that could mean there was bleeding in the brain.
Berkmen said he asked her if she could move her left arm, which she did.
"It was a miracle," Oviedo said. "It felt like a head rush. All my blood went back to my brain."
Everyone could see the procedure had been a success.
"It was all smiles after that," Berkmen said. "That was the best part . . . It is the most rewarding thing we do."
Oviedo's husband came in, and she hugged him with both arms.
Last week, Oviedo was well on the road to a full recovery. "I'm good. I feel good," she said.
"The nurses and doctors were just fantastic," she said. "I was really lucky to have such a good team all at one time there."
However, her brush with death left her brain bruised, and she has been undergoing six to eight weeks of therapy, doing physical and mental exercises until she's fully healed.
In later trying to discover what caused the blood clot, doctors found a small hole in the back of her heart, Oviedo said. They don't recommend closing it. Instead, she has been told to take a dose of aspirin every day.
"That's it," she said.
About 15 to 25 percent of people have small holes in their hearts and don't know it, Berkmen said. The condition can lead to blood clots, as what happened in Oviedo's case. Blood clots also can form in legs, which sometimes happens with people who sit for a long time on overseas flights, he said.
"It's vital to get to a place where they can be treated as soon as possible," he said.
People sometimes aren't sure if they or a loved one are experiencing a stroke, and they might delay taking action because they don't want to bother other people, especially if it happens in the middle of the night, Berkmen said.
If there's any question of a possible stroke, "people should just get to the hospital as fast as they can," he said. "When it comes to the brain, it's better to be safe than sorry. There's only so much time to play before a stroke can devastate or kill you."
Maui Memorial has a stroke treatment team with the expertise and equipment to treat victims around the clock, every day, Berkmen said.
Oviedo said she plans to return to work later this month at the banquet service department of the Grand Wailea. "I miss everybody," she said.
Through her ordeal, she prayed to God and her deceased maternal grandmother, but she never contemplated death.
"I can't go yet. My babies are still small," she said.
Along with her 8- and 4-year-old sons, she has a 13-year-old stepson.
* Brian Perry can be reached at firstname.lastname@example.org.