"SUPERGLUE" AND TINY PLATINUM COILS SEAL A DANGEROUS BRAIN VASCULAR MALFORMATION IN 7-YEAR-OLD GIRL

Jeff and Holly Lucas tried not to panic.

Their 7-year-old daughter, Olivia, had suddenly climbed out of a motel swimming pool,
complaining of a severe headache. When Olivia began vomiting as well, the family drove to the emergency room at Mercy Medical Center in Des Moines. There, C.T. and M.R.I. exams showed that a tangled mass of blood vessels called an arterial venous malformation (A.V.M.) had formed deep in Olivia’s brain. Worse, an aneurysm had formed above the A.V.M., creating a high risk of hemorrhage and possible death.

“It was the worst possible news,” Holly says. “The word ‘aneurysm’ is every parent’s nightmare.”

Mercy’s neurosurgeons, John Piper, M.D., and Mary Louise Hlavin, M.D., knew that conventional brain surgery was too risky. Instead, they referred her to University of Iowa Children's Hospital at University of Iowa Hospitals and Clinics, where Olivia was evaluated by an interdisciplinary team of experts in pediatric and neurovascular diseases. This included two neurosurgeons, Arnold Menezes, M.D., and Vincent Traynelis, M.D., as well as a neuro-endovascular surgeon, John C. Chaloupka, M.D., who ultimately managed the case.

Although the group agreed that an open operation would be too risky, Olivia was deemed a good candidate for a new treatment using minimally invasive endovascular surgical techniques. The treatment involved accessing the A.V.M. through blood vessels within the brain and then permanently blocking
the blood flow to it using soft platinum coils and a liquid surgical sealant, similar to the common household “super glue.”

Chaloupka is an internationally known expert in neuroendovascular surgery, and one of only a few physicians in the U.S. trained and skilled to perform curative embolization of a brain A.V.M. “The use of glue for therapeutic embolization of brain A.V.M.s has evolved considerably so that the technique can now be used in some cases as a primary or curative treatment,” he says.

In Olivia’s case, the A.V.M. was actually an unusual and more dangerous variant called a pial arteriovenous fistula (A.V.F.), which tends to form very large, direct connections between one or two brain arteries and the adjacent draining veins. Such fistulous connections result in extremely high blood flow
through the malformation, usually leading to formation of aneurysms on the affected blood vessels. As these aneurysms enlarge, their thinning walls are at risk of rupturing, causing high pressure bleeding into the brain that is often life-threatening and associated with severe neurologic deficits. These features also make the lesion more difficult and dangerous to treat with embolization.

Under x-ray fluoroscopic guidance, Chaloupka maneuvered a tiny microcatheter through an artery in the leg up to the brain. The microcatheter then had to be positioned exactly at the site of the A.V.M. and associated aneurysms.

In Olivia’s case, the shunt flow through the A.V.M. was so great that he first had to place soft embolic platinum coils into the fistula to gradually slow the torrent of blood flow. Chaloupka then carefully injected the super “glue,” called N.B.C.A., into the A.V.M., resulting in complete occlusion of the malformation.

“A follow-up angiogram indicates Olivia’s brain A.V.M. has been permanently obliterated so there will be no need for additional treatment,” he says.

Olivia’s recovery has been nothing short of amazing.

“She’s nine years old now and doing great,” says Holly. “She loves to barrel race on her horse and play softball and go swimming.”

“How do you thank a doctor who did so much for us? It’s hard to find the words.
—Holly Lucas

INSARTERIAL VENOUS MALFORMATIONS (A.V.M.) Developmentally abnormal collection of blood vessels within the brain under high flow and pressure that is prone to catastrophic bleeding Less common cause of hemorrhagic stroke (compared to aneurysms) A.V.M. hemorrhages can be fatal in 10-25 percent of cases Various neurologic problems can also develop including: paralysis and/or numbness on one side of the body, difficulty speaking and understanding speech, imbalance and incoordination, loss of vision, and seizures A sudden, severe headache often heralds the onset of an A.V.M. hemorrhage INSIDE THE BRAIN Angiograms reveal a tangled mass of blood vessels deep in Olivia's brain (top) and the repaired occlusion with super glue (bottom). 'SUPER GLUE' AT-A-GLANCE N.B.C.A. is a medical grade liquid adhesive that is chemically similar to the common household formulations "Super Glue" or "Crazy Glue" N.B.C.A. glue was specifi cally developed and F.D.A.-approved by Cordis Neurovascular for therapeutic embolization of brain A.V.M.s The embolic glue is injected in liquid form through a tiny catheter placed into the A.V.M., where upon contact with the blood, it solidifies, and completely fills the lumen of the abnormal blood vessels If the A.V.M. blood vessels are completely embolized with N.B.C.A., they will remain permanently blocked Other variations of medical grade "super glue" are being used to close skin wounds and to produce connections for vascular grafts instead of using sutures

FIELD OF DREAMS
Olivia Lucas finds contentment on the back of her pet pony, Smokey.