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Hole may be clue with Bruschi

When Tedy Bruschi suffered a mild stroke last month, the cause was a mystery -- at least publicly. But a teammate's assertion that the Patriots linebacker is now being treated for a hole in his heart yielded an important clue into how a pro athlete in the prime of life could have been felled by a stroke, doctors said yesterday.

Fellow linebacker Willie McGinest, speaking Tuesday night on "Total Access" on the NFL Network, said Bruschi had a hole in his heart. Tucson television station KOLD also reported Tuesday that Bruschi has the defect and that he was expected to undergo surgery.

Neither Bruschi's family nor the Patriots would provide details yesterday of his medical condition. A spokeswoman for Massachusetts General Hospital, where Bruschi was treated for the stroke, referred inquiries about the Pro Bowl linebacker to the team.

But specialists in cardiology and neurology not involved with Bruschi's treatment said that when young, fit patients suffer a stroke, one of the first suspicions is that the patient has what's known as a patent foramen ovale -- a tiny, oval-shaped hole between the two upper chambers of the heart. The condition can be treated with minor surgery or blood-thinning drugs.

The specialists said the hole can allow small blood clots that would otherwise be absorbed in the lungs to pass from one chamber of the heart to another and then travel to the brain. There, clots that would be innocuous elsewhere in the body can become wedged in narrow vessels, blocking blood flow to a portion of the brain and causing a stroke.

"It's a very common explanation for why young people have strokes," said Dr. David Thaler, director of the Tufts Comprehensive Stroke Center at Tufts-New England Medical Center.

All developing fetuses have the hole, which allows blood to bypass the still-forming lungs. Once the child is born, though, there's no longer any need for the tiny tunnel and in most infants it closes by itself within a few months.

But medical studies have estimated that the hole -- measuring about a tenth of an inch -- persists in up to one of every four adults, but typically with no or few consequences. It does not prevent strenuous activity or even a career as an athlete, and doctors said it's not practical to screen the general population for the defect.

"On a physical exam, you'll never find it," said Dr. Carey Kimmelstiel, director of interventional cardiology and clinical cardiology at Tufts-New England Medical Center. "And why would you? It's not going to lead to a murmur, it's not anything you're going to hear."

In fact, as far as specialists know, it only becomes a problem when a blood clot succeeds in squeezing through the opening.

Those clots could develop in the leg or in the heart or in other parts of the body. They might form, for instance, during a lengthy plane flight, when blood pools in the extremities.

Shortly before Bruschi developed classic symptoms of a stroke -- persistent headaches, blurred vision, and numbness on his right side -- he had returned from playing in the Pro Bowl in Honolulu.

"If you're sitting in an airplane from Hawaii to Boston, the blood is just sitting there," Thaler said. "We make these little blood clots all the time, and usually they're of no consequence."

Even though clots may travel from the leg into the right chambers of the heart, those clots in most people are filtered out by the lungs before they can reach the left half of the heart, which pumps blood back out into the body -- including the brain.

So, Kimmelstiel said, when a younger patient with no traditional risk factors -- high blood pressure, diabetes, history of head trauma -- suffers a stroke, doctors begin looking for a hole in the heart that would allow a clot to skip the lung-filtering step.

They find the opening in about half of stroke patients who otherwise have no underlying condition predisposing them to the potentially lethal attack.

There's no definitive medical research showing how doctors should respond when they find a hole in the heart of a stroke patient. Studies have offered varying assessments of the likelihood of a second stroke: from less than 1 percent to as high as 15 percent in the year after the first stroke.

The hole can be surgically closed, either by implanting a device to plug it or by sewing it shut. Or doctors can prescribe blood-thinning drugs to discourage the formation of clots. Right now, two studies are under way to assess the merits of both approaches.

But this much is sure: Doctors almost certainly would opt to close the gap in the heart of a professional athlete or any other patients whose professions place them in substantial peril of regularly bleeding. Once the hole is closed, there's no reason that the heart condition, doctors said, should preclude a professional football player from returning to the field.

Instead, a return to play would depend on the extent of neurological damage resulting from the stroke.

"If [Bruschi's] nervous system is functioning normally and the cause of his event was thought to be patent foramen ovale and if that gets closed," Thaler said, "then he should be able to return to a normal life, vigorous and violent as he likes."

It is the sort of active life cherished by Stran Smith -- both before and after his stroke. He was 32 and a professional rodeo cowboy when he suddenly lost the ability to speak.

Diagnosis: a stroke.

"The first specialist said to me, `There's other things that you can do with your life,' " Smith recalled yesterday during a telephone interview from Houston, where he was preparing for a rodeo. "He said, `You'll live to an old and happy age, but you can't do what you do.' And I live to do what I do, which is the rodeo."

Later tests revealed the true culprit in Smith's stroke: a patent foramen ovale.

"Before all of this, nothing at all was wrong with me," Smith said. "It was hard to understand. It was pretty amazing to me."

Ultimately, he wound up at Tufts-New England Medical Center to have the hole fixed. That was two Mays ago, and these days, he's back roping calves.

Stephen Smith can be reached at stsmith@globe.com.

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