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:

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.

My long overdue 2011 20in24 Ultramarathon recap

The author in the medical tent during the 2011 20in24 Ultramarathon
The author in the medical tent during the 2011 20in24 Ultramarathon
I'm happy to be out of the sun and getting some fluids back in me.

Note: The following is a recap of my race and mistakes at the 20in24 Lone Ranger 24-hour ultramarathon in July, 2011. This contains very little about the event itself (maybe I should post a full race report) although it’s a lovely urban ultra with fantastic support for runners both new and experienced.


That’s how I felt about 18 miles into this year’s 20in24 Lone Ranger Ultramarathon. What I didn’t realize at the time was that I was getting very dehydrated. I wasn’t drinking enough fluids and I was about to reach my breaking point. Although I’m smiling in this post’s accompanying photo, it’s not because I was happy with my performance that day. Rather, my lovely wife and two of my three kids were there to lift my spirits while the friendly and capable medical staff at the 20in24 took care of my physical needs.

What Happened?

On the first two 8.4 mile laps, I felt great. It was hot out, but not as oppressive as last two years’ 20in24 events. So, this day should be a piece of cake, right?!? My pace was purposefully slow with a 5:1 ratio of minutes for running and walking, and I thought I should be able to enjoy a 100+ mile finish for the planned 24 hours. I was sipping my water + electrolyte mixture from my hydration pack at regular intervals. In hindsight, it was entirely too little fluid intake for the effort I was expending. My muscles locked up, I got dizzy and nauseated, and my day was over with only a little more than 20 miles completed. I think I made it 21 or 22 miles in total, but I trashed my body doing it.

Warning Signs

The main things I missed during the event were obvious. But, I was so keyed up on keeping the run/walk momentum that I didn’t listen to and quench my thirst on the first two laps. At the end of the first and second loops each, I only needed to add 500ml of water to the hydration bladder to refill it. I failed to recognize that 500ml (16oz) per 8.4 mile loop in 90+ degree heat wasn’t enough. Proper hydration is just common sense, but I seemed to have very little of that when I was feeling good!

On that third loop, my 15 year old daughter accompanied me as my pacer. I was pouring cold water from the aid stations over my head to cool off instead of drinking it all down. I was still sipping like a miser from the hydration pack as if it were the last potable water on earth. So, after a couple of miles into the loop, I felt the dreaded twinges of cramping in my legs and a pretty rapid onset of dizziness. I slowed to a walk, and we tried to make it back around to the start/finish area about 5 miles away. The cramping and dizziness only worsened, and nausea joined the party to make it clear I was in trouble.

Calling it a Day

I didn’t feel like fighting for a 50 or more mile finish, so we flagged down a couple of race volunteers and they called for someone to pick us up. We returned to the medical tent at the start/finish area, where I was quickly evaluated by the staff. My blood pressure was really low and I had lost 11 pounds during the event. I drank a liter of electrolyte solution and still didn’t feel as if I needed to urinate. I was also still cramping, although less so than when I was on the course. The medical director hinted to me that he may want to start an IV for my dehydration, and we agreed that we’d make that decision together based on what kind of urine output I had. I went to check on that, and there was very little (only about 10ml), and it was dark orange in color, nearly brown, in fact.

I agreed that an IV was a good idea, and I took on 1500ml of fluids while chatting with my family, the medical staff and a few other runners coming in for various ailments. I was relieved to be feeling better, but disappointed about my DNF due to my own inattention to detail. My training quantity and quality was more than adequate leading up to the race, so this added to the frustration I felt. However, I do consider this a valuable lesson that the most basic, common sense details can be overlooked during a race that can later become a major problem. If nothing else, I’m alive to run another day! And, you can bet I’ll be more in tune with my hydration from now on!

After Effects

I had lower back pain for about a week after the event, and I wondered if it was pain from my kidneys or just muscle soreness from dehydration and how I was sitting around in the med tent and back at home. With 20in24 as my major goal race coupled with my earlier decision to drop my entry from the iron-distance triathlon later this year, I’ve just been taking it easy and running and cycling for fun over the past few weeks.

“Only those who will risk going too far can possibly find out how far they can go.” – T.S. Eliot

I’m now contemplating what my endurance goals are for the end of 2011 and into 2012, with ultrarunning being the activity I want to focus on. I feel that I’m more committed than ever to understand exercise physiology, nutrition, and how my own body works to continue to reach for and, hopefully, have more success in future events.

Ultra running is definitely a head game

Deb Bosilevac, an ultra runner from Portland, wrote a really cool guest post on Loving the Run today about what her experience has been with motivation and the mental aspects of running in 24 hour events. It’s refreshing to hear from someone who has similar experiences as I’ve had with thoughts, both negative and positive, during multi-hour/overnight events.

This weekend, I’m running in my first ultra of the season, and I hope to draw from ideas posted by Deb and others about how to stay motivated, entertained, and even awake during a 24-hour ultra run. If anyone has any tricks or techniques to share that either work (or don’t) for you, please leave a comment or send me a reply via Twitter.

Unboxing a Dahon folding bike

I was in Austin, Texas for the South By Southwest Interactive conference, and I had the good fortune to ride and return with a Dahon Speed Uno folding bicycle. It was shipped directly to Austin to Dahon’s art director, Sean Smith, along with some for other SXSW riders, and then delivered to us at our hotels. Thanks Sean!

Besides being fun to ride, the bike is ridiculously simple to fold and travel with. I love it and plan to use it both locally and while traveling.