Her team had to untangle a web.
The Root of Her Pain
Imaging by her neurointerventional radiology team revealed that for Terrah, a second, more fatal brain hemorrhage wasn’t a matter of if, but when. She was suffering from a ruptured AVM. Terrah’s condition had likely existed since birth and was finally making its presence known.
It’s like a writhing, abnormal bowl of angry snakes rapidly shunting high-pressure blood into delicate veins.
Recognizing the urgency of Terrah’s condition, Neurological Surgeon Babak S. Jahromi, MD, PhD, sent an email with an unusual request to Cardiac Electrophysiologist Bradley Knight, MD. At February 4, 2019, at 3:02 pm, he messaged that he needed a “heart stopper,” a physician capable of disrupting the heart’s natural rhythm during surgery. Five minutes later, Dr. Knight responded in the affirmative. After Anesthesiologist Ljuba Stojiljkovic, MD, PhD, was also enlisted, Terrah’s care team was complete. What they were about to do was unprecedented.
Performing the unthinkable.
After looking deeper into Terrah’s imaging, her neurointerventional radiology team identified a major complication. Traditionally, to treat an AVM, a neurosurgeon would surgically remove it or enter the blood vessel to embolize it, or seal it, with a special glue-like material. But Terrah’s AVM was located in a part of her brain that would be difficult to access through traditional approaches because her team would need to work against the flow of blood. They would need to stop her heart, stemming blood flow to her brain, in order to travel upstream and reach the abnormality.
Traditionally, we would go into the arteries, get close to the AVM, and inject glue to glue off that connection forever. We couldn’t do that in Terrah. So we figured, what if we come the opposite direction?
Terrah had a posterior circulation AVM in what is called the eloquent cortex — a part of the brain that controls vital functions such as speech, movement and sensation. Removing her AVM through open brain surgery was possible, but presented a substantial surgical challenge: She faced the risk of serious side effects, ranging from paralysis to cranial nerve injury.
Cardiac electrophysiologists like Dr. Knight might be comfortable stopping the heart in 10- to 15-second intervals during surgery. But in order to reach Terrah’s AVM, her heart would need to be stopped for at least 45 seconds, multiple times.
I think my initial reaction was, ‘Are you kidding me?’
This would require a technique known as cardiac pacing, which involves inserting a catheter through a vein in the leg to the heart to electrically stimulate and artificially manipulate the rate of heart muscle contractions. Somewhat counterintuitively, by pacing Terrah’s heart to a rapid 180 beats, Dr. Knight would be able to reduce blood flow to her brain. For the first time in his career, Dr. Knight would intentionally stop and start a heart 12 times. And for the first time in the State of Illinois, Terrah’s team would attack an AVM through a back door.
To protect Terrah’s brain during surgery, Dr. Stojiljkovic carefully placed her under the deepest level of anesthesia possible to safely complete the operation.
You could hear the heartbeats of everyone in the room. The only heartbeat you couldn’t hear was the patient’s, because we silenced it.
With Terrah under anesthesia, the surgical team sped up her heart so fast it slowed to a quiver, temporarily stopping blood flow. Then, Dr. Stojiljkovic kept careful count, “Four…three…two...one — start pacing,” signaling circulation should be started again.
With Terrah’s circulation slowed to a standstill, Dr. Jahromi guided a catheter through Terrah’s artery in the opposite direction of blood flow, essentially the inverse of a conventional procedure. Had there been circulation in the brain, the catheter would have been pushed back by onrushing blood.
Anxiety and stress, to some extent, was heightened. But on the other hand, we work at that level of concern all the time. Just take it up an extra notch.
After 12 stops and starts of Terrah’s heart, Dr. Jahromi was successfully able to embolize the pressurized vein with medical glue and eliminate Terrah’s AVM. After years of living with a ticking time bomb in her brain, Terrah had been healed by her team’s careful measure of minutes and seconds.
Our nurses were crucial members of Terrah’s care team. From start to finish, they provided her with more than care, but true comfort.
What makes us better, makes you better.®
A Heartwarming Reunion
When you’re a mother and a wife, the thought of being separated from your family is devastating. And though her surgery improved her physical health, nothing felt better to Terrah than being back home with her husband, son and daughter.
I believed I was in the best hands. That was the reason that we chose to go to Northwestern Medicine.
The successful operation reinforced a fundamental tenet of the Northwestern Medicine approach to care — better collaboration leads to better patient outcomes. Now back on her feet, it’s almost as though Terrah never missed a beat.
One of the unique features of Northwestern Medicine is that you have leading experts in every field. And if you put them together, you can get amazing results.