Stroke

[HammerHead05]

My long time dive buddy recently had a stroke (Jul 5) which impacted his cerebellum and a portion of his brain stem. He is going thru some intense PT which has resulted in a significant improvement on his balance. He has no paralysis but has lost surface feeling in his left hand and it’s not expected much of that will return.

We had a dive trip set up for Oct to Cozumel but his neurologist said that would be too soon. We also have another trip to Cozumel set up for March and the neurologist said maybe. The neurologist isn’t a diver but apparently understands the stress on the circulatory system due to the atmospheric pressure changes.

Any legit opinions from other divers who may have had a stroke?.

 

[Duke Dive Medicine]

HammerHead,

What kind of stroke was it?

In general, there are a few things to keep in mind. First, residual stroke symptoms can mimic decompression sickness, which may make it hard to differentiate between the two. Along those lines, if your buddy suffers another stroke while diving, differential diagnosis could be even more difficult, which could significantly delay treatment.

Having had a stroke, he already has an area of his brain that's been damaged, possibly irretrievably. If he has an incident of DCI that affects the same area, he could suffer more damage and possibly incur more disability.

Another thing to think about is the comorbidities that he may have. For example, stroke is often accompanied by peripheral vascular disease and heart disease, so he may be at increased risk of cardiac problems while diving as well.

If he has residual balance issues, he'll be at increased risk of falling, which would be exacerbated by wearing heavy diving equipment and/or moving around on a dive boat that's pitching and rolling.

His best bet is to listen to his neurologist, and also consult with a board-certified hyperbaric physician or diving medical examiner.

Best regards,
DDM

 

[drbill]

I am NOT a medical doctor and speak with no authority on the issue of strokes other than personal experience. I had mine 25 years ago while working with Jean-Michel Cousteau on Alcyone. I did experience paralysis of the right arm along with facial paralysis. Some symptoms were still present 4 months afterward and I don't think I started diving again for at least 8 months.

 

[TSandM]

I'd be looking at a lot of factors.

For one thing, moving around on a dive boat requires a good bit of strength and balance. In some places, it's fairly possible to don your gear in the water, but with Cozumel's currents, I doubt that's an option. Falling on dive boats in gear can result in nasty injuries -- a friend did that on a boat in Moorea, shattered her shoulder, and ended her diving career.

For another thing, I'd want to know as much as possible about what was learned about the etiology of the stroke. Does your buddy have abnormal heart rhythms? Does he have bad vascular disease? Was anything done to reduce the likelihood of recurrence? And, as DDM has already said, strokes on the basis of arteriosclerosis are associated with vascular disease elsewhere, like the heart; before resuming diving, if I were this patient and the stroke was ischemic, I would want at least a treadmill to evaluate my cardiac status. Heart attacks are a sadly common cause of death in divers.

A lot depends on how much he is able to rehabilitate, and diving is likely not all lost, no matter what; but it may be a good idea, if deficits persist, to hook up with the Handicapped Scuba Association and find out what modifications are necessary for him to dive safely. And it may be that other destinations will be preferable.

 

[knotical]

... stress on the circulatory system due to the atmospheric pressure changes...

Curious whether there really is much of this. Pressure changes would seen to add some stress to the respiratory system because of the increased density of gas at depth, but circulatory?

 

[Bubbletrubble]

Curious whether there really is much of this. Pressure changes would seen to add some stress to the respiratory system because of the increased density of gas at depth, but circulatory?

Several studies have demonstrated hemodynamic changes in humans while scuba diving...

Immersion in water induces a shift of venous blood from peripheral to central locations (Lin, 1984; Gabrielsen et al., 1993).
This increases secretion of atrial natriuretic peptide, leading to augmented diuresis (Epstein et al., 1989).
During a dive, the elevated ambient pressure increases PO2, which results in diminished cardiac output related to simultaneous decreases in heart rate and stroke volume (Molenat et al., 2004).

Another thing worth mentioning is that the circulatory and respiratory systems are intimately associated with one another. Perturbations of one system will likely affect the other.

Sources:

• Epstein, M, Norsk, P, Loutzenhiser, R Effects of water immersion on atrial natriuretic peptide release in humans. Am J Nephrol 1989;9,1-24.
• Gabrielsen, A, Johansen, LB, Norsk, P Central cardiovascular pressures during graded water immersion in humans. J Appl Physiol 1993;75,581-585.
• Lin, YC (1984) Circulatory functions during immersion and breath-hold dives in humans. Undersea Biomed Res 11,123-138.
• Molenat, F, Boussuges, A, Grandfond, A, et al Hemodynamic effects of hyperbaric hyperoxia in healthy volunteers: an echocardiographic and Doppler study. Clin Sci 2004;106,389-395.

 

[Cruisin Home]

My Chief Medical Officer, Stroke NeuroLogist, former Harvard Medical Professor of the Year pioneered a study about 10 years ago studying outcome in cerebellar stroke. The study showed that in time patients (statistically) can have "excellent" recovery from stroke to this particular brain region. But that is statistically speaking. Your friend is a singular data point ( not an average of a cohort of people) and it matters very much as to what type of stroke (A. Ischemic: embolism, thrombus, lacunar or B. Hemmoraghic) and what therapy was given A. surgery such as decompressive craniectomy?, or Pharmaceutical: such as tPa, blood thinners, etc.

It is even possible that your friend had this type of stroke via Trauma to the vertebro-basilar artery system (such as dissection of his vertebral artery from something as simple as whiplash) . they dont call this injury the dental chair stroke for nothing. If he had this type of stroke you really wouldnt want to stress the head and neck through lifting, bending etc. for a very prolonged time. So right now there is nobody on this board that can advise your friend better than his neurologist re his recovery because we simply do not have the information.

But once your friend has recovered from the stroke (normally we say that the patient is as good as he will be at one year post stroke) and his deficits do not interfere with his ability to safely dive, and he doesnt have a serious co-morbid medical problem, then it is my opinion that shallow water, non stressful diving can be safely practiced. E.G. stay below 30feet (hell, thats where the best stuff is anyway). Charter dive in calm seas (you have a lot of people to assist with donning gear, easy entry/exit, etc.). Cozumel has many such dives. As opposed to deep, cold ocean water dives with long swims, decompression, tough surf entries etc which would not be recommended.

I personally know of many ex-stroke victims of all etiological types that swim, snorkel, and scuba. A lot of them that have motor and/or balance deficits on land find it much better in the water.

Whats the alternative? To never do any form of exercise or cardiovascular activity post recovery? That's very rarely a prescribed regimen.

You are a good buddy, he will find that the most valuable resource in his recovery. Go slow and be supportive.

 

[Cruisin Home]

For got to add that their are some excellent stroke an TBI advocacy groups nationwide as well as regional and local. Unfortunately being the #3 cause of deathe and #1 cause of disability leaves many in the same baot as your friend. I am sure there are people in these groups that can share advice on recovery and post-recovery athletic activities.

if your friend cannot find any, just PM me and I will provide a list.

 

[HammerHead05]

Thanks

 

[HammerHead05]

Further testing (MRA and TEE) indicate no issues which may cause another. Additionally, he had a stress test and got it up to 13 METS without any adverse reaction. Will continue to focus on the PT and pray!!