New Treatments in Neurosurgery Are Less Invasive and Speed Recovery
MADISON - Diane Norman was walking around with a potential time bomb in her head.
Norman didn't know it, but she had been born with a tangle of malformed blood vessels in her cerebellum, a condition known as arterio venous malformation (AVM). AVM affects about two to five people in 10,000 - or about 250,000 Americans.
Most, like Norman, have no idea there's a problem unless the AVM puts stress on the abnormal blood vessels, causing them to rupture and bleed into the brain. When that happens, 10 percent of patients die and another 30 to 50 percent can suffer permanent neurological damage.
There probably isn't a good time for the time bomb to explode. But there are better and worse times. It could have happened when Norman, 50, was growing up in rural Minnesota, when such conditions were difficult to diagnose and treat successfully.
It could have happened when she was overseas, or running in a marathon. (She has finished several 26-mile events.) Or it might have burst just a few years ago, when the main treatment option would have been opening her skull for surgery, with the risk of damaging nearby portions of the brain.
So Norman considers herself fortunate, in an odd way, that her AVM burst where and when it did.
"You do feel lucky to live in Madison," says the attorney, who was back at work as an assistant administrator in the state Division of Hearings and Appeals two weeks after leaving intensive care.
She woke up from surgery at the University of Wisconsin Hospital and Clinics in Madison with only a Band-Aid on her thigh. And, after rehabilitation, she was able to compete in the annual Crazylegs Run just four months after Dr. David Niemann, a UW Health neurosurgeon, used a relatively new endovascular technique to stop the bleeding in her brain.
Looking back, Norman says she had been experiencing unexplained mild dizziness for months. At an exercise class in McFarland just after Christmas 2007, she felt a pop in her head.
"It was like a terrible muscle spasm," she says. "Suddenly, I was seeing double. I had to sit down. I was clammy and sick to my stomach."
Since these are classic stroke symptoms, Norman now knows she should have called 911 immediately. Instead, thinking "I'll be fine," she called her husband, Mike Flaherty, to drive her home, where she went to bed with the worst headache of her life.
Norman did see a doctor the next day, and was told she probably had the flu. Two days later, when she suffered a seizure, her family called 911. In the emergency room, Flaherty recalls the panic he felt when he was shown the image of his wife's brain filled with blood.
"They said, 'This is serious and we don't have the capacity to treat it here,'" he recalls. "They said they were sending her to UW Hospital where there was a doctor who specialized in this surgery."
That doctor was David Niemann, who trained at Oxford University in England, where he used the Onyx® Liquid Embolic System to stop bleeding from AVMs in the brain. (It was approved for use in Europe before the United States FDA approved it.)
In 2004, Dr. Niemann was the among the first U.S. surgeons to use the technique, when he successfully performed endovascular surgery on a Waupun teenager. Niemann inserted a catheter in the femoral artery in Norman's leg, and watching its progress on an X-ray, guided the tube into the area of her cerebellum where the AVM caused the bleed.
Next, he inserted an even smaller microcatheter into the first tube and guided it to the aneurysm. The smaller tube delivered a shot of a plastic-like substance, with the brand name Onyx®, to the abnormal blood vessel. When the Onyx® reached the site of the bleed, it solidified, blocking the abnormal vessels.
According to Dr. Niemann, Onyx® is easier to control than earlier substances used for endovascular surgery.
"It allows us to treat complicated vascular problems with minimally invasive surgery," Niemann says.
In Norman's case, it meant she woke up with her skull intact and her full head of strawberry blonde hair. A few weeks later, radiation therapy helped shrink what was left of the AVM. Norman was hospitalized for about three weeks while the blood cleared from her brain, then underwent rehabilitation and returned to work in early February.
She still has some minor problems with balance, but she's riding a bike as therapy, and she's returned to running.
"Dr. Niemann basically told me that if it feels OK, do it," says Norman.
While endovascular brain procedures have become more common in the past five years, Niemann says that "the technology is improving all the time." So while there's no good time to have a bleed in the brain, new treatment options mean patients at UW Hospital and Clinics are better off than at any time in the past.
For more information on AVMs, aneurysms and Stroke Care at the University of Wisconsin Hospital and Clinics, call (608) 263-7502. People experiencing symptoms should call 911.