Good Medicine - May 2010

Photography by Rebecca Baxter By Su Byron May 1, 2010


A Bomb in the Brain

This is a story of beating the odds. It’s not so much a story of luck as it is a story of teamwork, expertise and clockwork precision. It’s the story of Ashley White and the cadre of medical professionals, family and friends who changed her life when an aneurysm ruptured in her brain—the kind that most people don’t survive. She did.

At 35, Ashley is a petite, delicate-boned woman with a soft voice and gentle manners. Originally from North Carolina, she still carries traces of that state’s gracious intonation when she speaks. Her husband, Mike, 37, is a hard-working national account manager and sales associate for the Robson Corporation, a national sign manufacturer based in Sarasota. They have two sons, Joey, who’s eight, and four-year-old Michael. Their lives are filled with family, work and church.

One Saturday morning in August 2009, Ashley experienced a skull-splitting migraine. The Whites didn’t wait to see if the migraine would go away. They’d been through this scenario four years earlier, when Ashley, pregnant at the time with Michael, experienced the worst headache she had ever had. When the pain became too much for her to bear, they had taken her to the emergency room, where she was diagnosed and treated for a ruptured aneurysm on the left side of her brain.

It was a miracle she survived—and another miracle she survived without serious neurological damage. But they always knew there was a chance that the aneurysm could re-rupture where it had been treated, or worse, that she could develop another one. Aneurysms often run in families; both Ashley’s grandmother and great-aunt had died of ruptured aneurysms.

Ashley and Mike were well aware of the grim statistics: The National Institute of Neurological Disorders and Stroke estimates that 40 percent of people with a ruptured aneurysm die within 24 hours. Another 25 percent die within six months. Of those who survive, many are left with severe paralysis and worse. They knew they had to get Ashley to Sarasota Memorial Hospital’s emergency room.

But let’s pause the movie for a moment. What is an aneurysm?

Our expert and a key player in this story is Dr. Robert Knego, Ashley’s neurosurgeon. “Imagine a blood-engorged blister or bulge on an artery,” he says. “In the case of a cerebral aneurysm, it usually occurs on an artery at the base of the brain.” Knego explains that as long as the aneurysm doesn’t rupture, it’s not a problem. “But,” he says, “if the size of the aneurysm increases and it eventually ruptures, it causes a cascade of complications and even death.” When an aneurysm bursts, the bleeding is referred to as a subarachnoid hemorrhage (SAH).

According to Knego, the worst effect of a burst aneurysm in the brain is pressure—like a sudden break in a high-pressure fire hose. The rush of blood can damage or kill surrounding brain cells. The flow of blood can cut off oxygen to the brain and result in significant neurological damage and death.

Back to the story. When Ashley arrived at Sarasota Memorial Hospital (SMH), Dr. Michael Schremmer, a board-certified emergency room physician and 19-year veteran of SMH’s ER department, was waiting. Aware of Ashley’s medical history, he knew exactly what to do. He ordered a CT scan of Ashley’s brain, which indicated that there was mild cranial bleeding. When he saw the bleeding, Schremmer called Knego, who was enjoying a Saturday off with his wife and five children (they now have six).

Knego jumped in his car and sped to the hospital. He knew the clock was ticking.

At the hospital, Knego reviewed Ashley’s CT scan and suspected that it was another aneurysm, this time on the right side of Ashley’s brain. The scan showed that mild bleeding had occurred. Knego was relieved to see that the bleeding was mild, which meant that there was a window of a few hours to work with. A cerebral angiogram, which would more accurately pinpoint the location of the aneurysm, was the next step.

Again—let’s hit that pause button.

There are basically two ways to repair a ruptured cerebral aneurysm. Surgical clipping is one procedure. The surgeon opens the skull and exposes and clips the aneurysm. Neuroendovascular surgery is the less invasive approach. In this, a specialist called a neurointerventionalist first locates the aneurysm using advanced 3D angiogram imaging technology. This minimally invasive surgical technique consists of passing a microcatheter through a small, keyhole incision in the femoral artery and up through the body into the brain. Because this procedure grants access to the brain, it’s a simple second step to find the aneurysm and fill it with a bonding material or a small coil that obstructs the flow of blood into it.

Knego felt that endovascular surgery was the way to go with Ashley’s case. There was only one problem. The area’s best neurointerventionalist, Dr. Nasser Razack, was in Orlando on a family vacation.

Knego dialed his number and quickly filled him in. Razack didn’t hesitate. “I’ll be there immediately,” he said.

Knego felt the chances were good he would arrive in time. Ashley seemed OK—a little sleepy but still lucid.

Everything seemed to be on course, until Knego heard his name being paged to the ER. Ashley’s condition had suddenly deteriorated.

“Ashley had come into the ER with a headache that was similar to the one she had during her first aneurysm, so we ordered brain scans and gave her medication for nausea and pain,” says Schremmer. “But in these cases—as in all emergency cases—we’re trained to constantly re-evaluate people under our care and make new decisions as their status changes.”

Schremmer didn’t waste a second. He ordered a second CT scan. This time the news was dire. The scan revealed massive bleeding inside the brain. “It became clear that she was getting worse,” says Schremmer. “She could no longer breathe for herself, and I made a decision to put in a windpipe.”

When Knego saw the second scan, he knew he had less time to act than he’d thought. The window of opportunity was closing.

Knego remembers, “Sure enough, the second scan showed that she was re-bleeding and that the bleeding was huge—enough to cause so much pressure on the brain that she was now in critical condition.” In a matter of moments Ashley’s condition had gone from serious to critical. “We use something called the Hunt and Hess scale to classify the severity of a subarachnoid hemorrhage,” says Knego. “Ashley began as a 1 when she came to the ER; at this point she was a 5. She basically had minutes to hours to live.”

Thinking ahead, Schremmer had already called in Knego’s neurology team; he had also readied ICU to receive Ashley afterwards. Everyone and everything was falling into place. Ashley’s family gathered at the hospital. Before surgery, Knego talked candidly to the family. Sugar-coating the dangers of neurological surgery isn’t his style. He informed them that Ashley’s odds of survival weren’t good. If she did survive, there was a good chance she would have severe neurological damage. Knego distinctly remembers Ashley’s mother Betsy’s response to his news. “She looked me firmly in the eye and told me, ‘No, that’s not going to happen. My daughter is going to walk out of this hospital. You’re going to do a great job and she’s going to be just fine.’”

Ashley’s husband, Mike, was in shock. “They gave me her clothing and wedding band and told me that most likely she wasn’t going to make it.”

While Knego prepared for surgery and waited for his team to arrive, another neurosurgeon who was in the hospital, Dr. John Cassidy, heard the emergency call. He immediately offered his services to Knego.

“You need two surgeons to repair an aneurysm,” Knego explains. “Although my team was on the way, we were running out of time. Dr. Kennedy’s offer is an example of the kind of teamwork that goes on at Sarasota Memorial Hospital every day.”

As it turned out, Cassidy’s services weren’t needed. The rest of Knego’s team arrived. Surgery began. Knego opened up Ashley’s skull to find a mess of blood. Without knowing where the aneurysm was exactly, he was flying blind. “Finding and clipping an aneurysm is like defusing a time bomb,” he explains. “You’re working in a very tight corridor of thick blood; it’s hard to find the artery. One slight wrong move can be devastating. There is no room for error.”

Knego and his team avoided devastating errors during the four hours of intensive surgery. They were able to find the artery, clip it, and vacuum up the pool of blood that covered Ashley’s brain.

Back in the waiting room, Ashley’s family prayed and tried to comfort each other. “You go to God in times like this,” says Mike. “You’re in shock. There’s nothing else you can do.”

The surgeons told them that the operation had been successful—Ashley was still alive. Quality of life was a different question. Would Ashley regain any level of normal functioning? In the weeks following surgery like this, a number of life-threatening conditions can arise. Only time would tell.

Mike says, “They gave me the list of what to expect. None of it was good.”

“Everyone was pulling for Ashley,” says Betsy. “We called family and friends around the country and started a prayer circle. I never in my heart felt she was going to die. I can’t explain it, but something inside of me said I am not going to lose this child.”

And she didn’t. During her nearly three months in the hospital, Ashley went from being comatose and completely paralyzed on her left side to walking and talking. Today, she remembers nothing about the first three weeks of her ordeal. But by the time she was moved to the hospital’s rehab unit, she had gained more lucidity and soon threw herself into an intense regimen of speech, physical and occupational therapy. It was difficult, but Ashley quickly brushes any heroic scenario aside. Her desire to get home to her children overpowered all of her fears and doubts.

“All I wanted to do was go home, see the kids and live again. I felt worse for my family, who were the ones who had to work so hard to keep everything going. All I had to do is get better,” she says.

Some might call her recovery miraculous. Everything went right. Knego still marvels at the outcome. “It was like a made-for-TV movie script about doctors. Everything fell into place. You’d think this kind of thing never happens in the real world, but this time it did.”

Today, Ashley is continuing to recover. She’s taking care of house and family and doing her best to live a normal life. She sees her neurologist, Dr. Dean Sutherland, for regular check-ups. “I had already been through one miracle four years ago,” she says. “It’s too much to expect a second one—but that’s exactly what this is.”

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