I am Jolly

The personal website for Robert Jolly

Stroke recovery and long-term outlook

It’s now just over two years since my stroke. It’s time for an update. Too much time has passed since I’ve posted an update on this blog. Fortunately, the comments on my “Recovery progress after stroke…” thread have been active enough to keep me happy. That activity shows that sharing my story is likely helping others in some small way.

How I’m doing now

I feel very well, physically. My physicians have long-since removed all activity restrictions and have even encouraged me to return to pushing my limits. My stroke recovery is about as complete as it can be at this point. I still shy away from things like roller coasters and anything with potential impacts to the head or neck.  And I will never, ever consider a chiropractic adjustment after learning about the risks of artery dissection and stroke from those “therapies.”

I still have some maintenance meds to take, but the Warfarin (blood thinner) therapy is now a distant memory. Aspirin and the lowest dose of blood pressure medicine is all I routinely take. I don’t ever feel any physical symptoms of the dissection and stroke, but occasionally I feel worried it will happen again. I can’t imagine that not being normal for those who have experienced what I have.

Looking forward

I can truly say I’m lucky. The stroke didn’t do any serious or permanent damage. Perhaps it was a warning sign or wake-up call to care for my health in other ways, which I’ve tried my best to do. Hopefully, I’ll be around for many years to enjoy the love of my family, to provide for them, give them joy, and do some good for others in this world.

There is life after stroke.

Little Swami at Swami's Beach

 

 

Recovery progress after stroke and vertebral artery dissection

I have been meaning to provide an update on my recovery progress after suffering the vertebral artery dissection and stroke. I had another MRA (magnetic resonance angiogram) scan of my head and neck vasculature on January 30th, about eight weeks after the stroke and six weeks after beginning the anticoagulant therapy.

MRA results

The report I received from the radiologist who read/interpreted the MRA images stated that my vertebral artery had an “essentially normal appearing lumen” with no signs of the dissection from before. This is simply amazing to me that the dissected vertebral artery has healed completely.

While I’m overjoyed, I do need to await the consult with my neurologist to discuss the MRA report and determine what happens next in my treatment plan. That appointment is in about 10 days from today. My expectation is that I’ll still need one or more follow-up MRAs to watch for any potential issues with my vertebral arteries or cranial vasculature—just in case—and hopefully I can scale back or discontinue the anticoagulation therapy immediately.

Vertebral artery images: then and now

Below are images of my vertebral artery showing the dissection and narrowing of the lumen (left) as compared to the same after six weeks of anticoagulant therapy (right) showing a return to normal size and function.

Comparison MRAs showing vertebral artery dissection (left) and recovery (right)

 

And, below is the larger image of the latest MRA of the carotid and vertebral arteries with the right side showing signs of recovery.

My follow-up MRA showing recovery of right vertebral artery 8 weeks after dissection.

What now?

My primary doctor has cleared me for any activity I want to do including running, cycling, and other sports with the exception of anything at high altitudes (> 10,000 ft.) or at extreme pressure (scuba diving). I’m slowly getting back into my fitness/training regimen with an eye toward some ultra running goals later this year. With the recurrence possibility of this type of artery dissection and stroke slim to none, I intend to live life fully and demonstrate that exercise truly is the best medicine.

Stroke photos

I wanted to follow-up my last post that detailed my stroke with a few images from the MRI and MRA studies. I intend to build catalogue of these images for comparing these initial images with future ones as my recovery progresses. There are nearly 700 photos of my brain and neck region from just the initial MRI and MRA studies alone!

MRI showing ischemic insult, 09 DEC 2011

MRI showing a stroke

The bright yellow area shows the damaged area that was caused by a loss of blood flow.

MRA showing right vertebral artery dissection, 16 DEC 2011

MRA - right vertebral artery dissection

This MRA image shows the severity of the reduction in blood flow through the right vertebral artery. The larger blood vessels on the right and left are the carotid arteries. There are no signs of trouble anywhere else other than the right vertebral artery.

MRI showing no problems at all, just a wild pattern in my nasal area. 09 DEC 2011

MRI showing a weird/cool pattern

It's funny how these interesting patterns show up in scans. Looks trippy, eh?

I had a stroke

At around 5:00am on the morning of December 6th, I woke up with a massive headache with an epicenter in the middle, right interior of my head. I’ve had headaches before, but they were never migraines nor anything near this painful. In the past, I have suffered a few broken bones and have had injuries and illnesses, but this headache was much more intense—most definitely a 10 on a 1-to-10 pain scale.

Initially, I thought this could be a migraine caused by the current level of stress in my life. It was finals week and, that, along with other ongoing problems I deal with day-to-day seemed to be culminating in my first migraine.

Tipping point

I got up to go to the bathroom and take some ibuprofen. When I walked, I couldn’t maintain a straight line, veering into the wall. I didn’t lose my balance, but I felt it odd that my mind wanted to walk straight, but my body couldn’t. I started to feel nauseous, but I took the ibuprofen and was able to keep it down.

I hobbled back to the bed, again in a right-diagonal route. My wife noticed the difficulty I was having and asked if I was alright. She offered to take me to see a doctor. At the time, I thought I would be fine, but I was really hurting. I still thought it was a migraine and said she should go on in to work at the usual time.

The pain persisted no matter how I shifted positions while laying in bed. I started worrying about how I didn’t walk straight earlier, and silently gave myself a mini neurological test to see if I could detect any loss of strength or movement with any of my extremities. I passed my own exam but was still concerned, so I told my wife about it. She agreed insisted I should go to the hospital, I reluctantly agreed, and she drove me there.

Tests, tests, tests

The hospital’s emergency department wasn’t too busy, but I had to wait about an hour to receive some pain medication and an initial assessment by the staff. Apparently, there were a couple of other more pressing emergencies that the physicians and nurses had to deal with. The physicians ordered a CT scan to rule out a tumor or brain hemorrhage. The scan came back negative, so they wanted to perform a lumbar puncture to verify with even more accuracy that there was no bleeding within the brain, as CT scans are not 100% accurate. The spinal fluid tests came back negative for both blood and signs of infection.

With the medicines they gave me, my initial massive headache had subsided, so they released me after about seven hours at the hospital. I was instructed to see my family doctor that week and told that he would likely order an MRI. I did that, and he agreed that an MRI would be good to do. I was fortunate to have the MRI performed the same day (a Friday), and my results would be available to my doctor by Monday.

When Monday arrived, my doctor called and told me that they found a problem in my cerebellum, and that he wanted to refer me to a neurologist. He didn’t know if it was a stroke or some other issue, but further testing would likely determine what I was dealing with. I got an appointment with a neurologist who had a cancellation for the next day, and looked forward to getting to the bottom of this issue.

My neurologist talked to me at length about the MRI report, and said that there was a possibility that I had a stroke or was suffering from some other vascular problem located in my head. He ordered an MRA, which is an MR scan of the blood vessels, and he wanted to have that done as soon as possible at one of the facilities he routinely uses. Again, I was fortunate to get my appointment during the same week, although I was going into my second week after the trip to the hospital.

Diagnosis: stroke.

With the MRA results in, my doctor phoned me with my diagnosis and further instructions. I was told that I have a right vertebral artery dissection with significant occlusion (but not total) of the lumen (blood vessel interior opening) which caused decreased blood flow to my cerebellum and subsequent infarct (stroke).

Basically, the inner wall of my artery has a tear in it which separated from the outer wall. This separation allowed blood to pool in the new space (false lumen) between the vessel walls, creating a bulge. This bulge restricts the artery’s internal opening and also raises the possibility for clots to break apart and travel upstream and block blood flow to my brain (thrombosis) which causes a stroke. That’s the most likely explanation of what happened on December 6th (VAD resulting in ischemic insult/stroke), and I’m not totally out of the woods yet.

I’ll post some snazzy pictures from the MRI/MRA of my brain and arteries later. Those are too weird looking not to share. :)

Stroke recovery and prognosis

My recovery is going well, so far. I’ve been restricted from strenuous activity, as the doctors don’t want to have any trauma prevent the dissection from healing properly. I’m also on an anticoagulant (commonly called “blood thinner”), which means I need to be careful shaving, avoid falls and bruising, and cannot take certain medications. Hopefully, in three to six months, the MRI/MRA scans will show no signs of the dissection, I can discontinue the medicines, and then return to full, vigorous activity.

The possibility of recurrence is actually quite low, as long as I remain “dissection-free,” according to my doctors and all the literature that I’ve read so far. And, fortunately, all of my neurological exams (real ones, not self-administered) show no signs of lingering problems. The good news is that the neurologist said both my age and overall excellent health played a vital role in regard to my brain’s plasticity. This allowed neighboring neurons to quickly take over the functions of the damaged ones after the stroke.

My quick recovery exemplifies the very real connection between physical and mental fitness. Yes, I was lucky. But, I believe that had I been completely out of shape, sedentary, and unhealthy to begin with, I might not be able to write this post at all. And, for those interested in exploring the connection between exercise and the brain, I highly recommend reading Spark by John Ratey, M.D. It provides a foundation of knowledge about how closely related exercise is to brain function and performance, and it’s quite an accessible read, too.

2012 should be an interesting year, and I look forward to (re)connecting with friends and family, recovering fully to continue my fitness and athletic goals, and sharing good, happy news along the way.

How to set canonical links with WP-Print

A client who runs an industry news site on a WordPress blog requested a print formatting solution that would allow them to serve custom ads for the print-friendly pages.

My starting point, WP-Print

Looking to avoid reinvention of the wheel, I found WP-Print, a plugin that would save development time and money. It was a great starting point for this project because it comes with a number of features and options for non-technical users to control via the WordPress admin interface.

There were, however, two customizations I needed to make. One to preserve SEO integrity via canonical linking (which is the topic of this article) and a second modification to insert the ad code into the print-formatted content. The latter was a requirement from my client and was the reason why I couldn’t just make a print-specific CSS file for the main theme itself.

Canonical links, why should I care?

With the print version, essentially duplicating an article’s content on a separate URL, providing a canonical link to the original content is a good practice to prevent your content from receiving ranking penalties by search engines. For more on that issue, see Matt Cutts talk about it in a video presentation over at Google. Unfortunately, the WP-Print plugin (as of version X) does not provide for a canonical link within the output code. Joost de Valk reviewed WP-Print on his site and also noted this issue and gave the plugin a lower rating on his scale as a result. Fortunately, it’s relatively easy to fix this problem via the insertion of just one line of code in the print template provided with the plugin.

How to add canonical links in WP-Print output to browsers:

  1. Copythe following files from the ../plugins/wp-print/ folder:
    • print-posts.php
    • print-comments.php
    • print-css.css
  2. And paste them into your current theme’s folder. You’ll be working with these new files from now on, leaving clean, original copies of them in the plugin folder.
  3. Add the following line of code within the headsection of the print-posts.php file:
    <link rel="canonical" href="< ?php the_permalink(); ?>"/>
  4. Save it, and test it out!

I placed the canonical link code after the robots meta tag in the print-posts.php file.

The code simply calls the content’s permalink as stored in the WordPress database and will point search engines to the original page so that duplicate content isn’t indexed. That way, Google, Yahoo, Bing, and others will not penalize you for spamming their indexes.

You can make further customizations to the files within your theme’s folder without breaking the plugin and without risk of losing your customizations if the plugin is updated/upgraded. I took some time to clean up the syntax a bit, making changes in the code to have all ID’s and classes in lowercase format as well as other tweaks to make the output more closely match the design of my client’s site.

I’ll be contacting the plugin author, Lester Chan, with this fix. Hopefully, it will be included in a future update. UPDATE! I heard back from Lester, and he’s committed my suggestion for the canonical link code into the plugin, and it will be live with the next release. Check it out here: http://plugins.trac.wordpress.org/changeset/445061.

I hope this post helps make things a little easier for folks who need this type of functionality. If you have any questions about this or need to point out any problems, just leave me a comment here to discuss.

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