Stemming Brain Bleeds

Perhaps it’s part of being a doctor, or maybe even a mom, but Wendy Soto, MD, has conditioned herself to press through pain and put others first.

So when a severe headache hit her one Tuesday in early May, she treated it with over-the-counter medications, thinking it was one of her occasional migraines. But her headaches worsened, untouched by Tylenol and Motrin. Even her prescribed Imitrex didn’t make a difference.

The pain woke her at 2 a.m. Friday. “I finally fell back to sleep for a few hours before getting up to go to work,” the 39-year-old internal medicine/pediatric doctor recalls.

While seeing patients, Dr. Soto’s pain grew more severe, and the vision in her left eye became blurry. That’s when she decided to go to an emergency room close to her Hamilton, Ohio, office.

When a CT scan was inconclusive, Dr. Soto insisted on an MRI. That test revealed her left vertebral artery had an injury, called an arterial dissection, which resulted in a traumatic aneurysm (a weakened spot) in her basilar artery. A dissection occurs when one of the inner layers of the artery wall becomes torn, allowing blood to tunnel into the false channel that has been created.

This diagnosis called for the immediate attention of a neurointerventionalist, a specialist who deals with blood vessels in the brain and spinal cord. Fortunately for Dr. Soto, a member of the Premier Health network, a team of doctors with that specialty was available at Miami Valley Hospital. Their sub-specialty is so unique that fewer than 10 of them practice in Ohio. MVH’s group – newly formed NeuroInterventional Specialists of Dayton – includes three of them.

Near Home and in Good Hands

Dr. Soto was taken by CareFlight’s Mobile Intensive Care Unit to MVH and placed in the ICU under the supervision of neurologists John Terry, MD, and Bryan Ludwig, MD. On Friday night, she was in surgery. The doctors repaired the torn blood vessel and reduced the blood supply to the traumatic aneurysm deep inside her brain – all without having to put a scalpel to her head.

The doctors guided a tiny wire and tube (catheter) through her arterial system into the brain arteries. Medical imaging enabled them to follow where the wire and catheter were going. After the doctors deployed three stents to repair the torn vessel, the flow of blood to the aneurysm was immediately reduced. Over the next 24 hours, blood was no longer flowing to the aneurysm, making it unlikely that a rupture would occur.

“A lot of what we do is similar to work done by interventional cardiologists,” says Dr. Ludwig, who is also an assistant clinical professor at Wright State University Boonshoft School of Medicine. “We use some of the same procedures to work on the vessels in the brain. While some new devices have been created, most have been modified from tools used by interventional radiologists and interventional cardiologists.”

The Region’s Only Team

Dr. Soto’s scenario might have been different had she been stricken a couple of months earlier. Before February 2010, MVH had only one neurointerventionalist on staff, William Protzer, MD. Though able to perform the procedures that Dr. Soto required, Dr. Protzer, a radiologist, was not available around the clock.

“Dr. Protzer handled it by himself for a decade,” Dr. Ludwig explains. “When he wasn’t here, patients were sent to hospitals in larger cities. Fortunately for the community, MVH recognized the need for continuous coverage for this emergent patient population.”

So, three years ago, MVH began recruiting other doctors to join Dr. Protzer, hoping to form a team able to provide critical neurological procedures whenever needed. Dr. Ludwig, who at the time was still in neurointerventional radiology fellowship training, had heard of the need through a family friend. A native Daytonian, he had hoped to return to the area but thought his specialty would require him to locate in a bigger city.

Dr. Ludwig then recruited Dr. Terry, who was also completing his neurointerventional radiology fellowship. Dr. Terry, who had been considering a post elsewhere, switched his focus to MVH when he saw the commitment the hospital was making to neuroscience. He was also impressed by the hospital’s partnership with WSU, where he now is an associate clinical professor at the Boonshoft School of Medicine.

Years of recruitment and planning came to fruition when Dr. Terry joined Dr. Protzer in February and Dr. Ludwig came on board in April. As neurointerventionalists, the doctors specialize in minimally invasive image-based procedures to diagnose and treat diseases of the head, neck and spine. Diagnoses include, but aren’t limited to, cerebral aneurysms, brain arteriovenous malformations, and stroke.

Before the team formed at MVH, patients were sent to Cincinnati, Cleveland or Columbus. Now, Dayton patients can have specialized neurological intervention closer to home.

Being treated in Dayton meant one less stress for Dr. Soto, a Huber Heights resident, who already works hard to balance work and life as a mother of four. Two weeks after the procedure, Dr. Soto returned to work.

Recovery, Reflection and Referrals

Dr. Soto was dismissed from the hospital on Monday morning, having spent fewer than three days undergoing treatment for a life-threatening medical condition.

During her recovery, Dr. Soto was able to reflect on her experience and pinpoint how her problem began. While doing an extreme workout program the day before her headaches started, she remembers feeling an excruciating pain in her neck.

It was then, Dr. Ludwig believes, the tear in her blood vessel occurred, creating a new, but unnatural, route for blood to flow between the layers of the artery; this resulted in the creation of a traumatic aneurysm. The headaches and blurry vision were the symptoms that followed.

An artery dissection (i.e., tear) occurs in all ages and can be precipitated by something as simple as a sneeze. Dr. Ludwig says, “Some people are just predisposed to have weaker arteries.”

“My experience makes me a lot more aware of what can go wrong,” Dr. Soto says. “Now when patients come in complaining of headaches, I make sure they have no other worrisome warning signs.”

And if they do, she knows where to send them: NeuroInterventional Specialists of Dayton.

A Better Treatment for Brain AVMs

Miami Valley radiologist Dr. William Protzer, MD, is one of the few doctors in the area trained in a new procedure for treating arteriovenous malformations (AVMs).

An AVM is an abnormal connection between the arteries and veins in the brain that forms before birth. An AVM can cause symptoms ranging from episodic confusion to grand mal seizure.

Treatment involves stopping the blood flow to the area through a minimally invasive procedure called embolization. Dr. Protzer now uses the Onyx Liquid Embolic System to accomplish this.

With this new system, doctors inject a lava-like liquid called Onyx into the abnormal vessels through a micro catheter. The Onyx immediately hardens when it comes in contact with body fluids like blood.

Historically, doctors have performed embolizations with a glue-like substance, which could only be injected in one shot. Onyx can be slowly injected over a period of time allowing doctors to evaluate as they work. Its ability to penetrate the vessels means the blockage of blood is better than it is with glue.

Miami Valley Hospital is the only hospital in the region using the Onyx system to treat AVMs.