At first, 13-year-old Christina Blumstein thought she had an ordinary headache. She and her parents were returning from a visit to Long Island in July 2014 when the pain struck. Was it a bout of carsickness? Too much screen time on her iPad?
But a few hours later, back home in Old Bridge, New Jersey, her mother MaryAnn says, "Christina started screaming that somebody was stabbing her in the head with a knife." Soon afterward Christina was comatose and in an ambulance - and her life was in grave danger.
Until that night, nobody knew that Christina had been born with a rare clump of small, abnormal blood vessels in her brain called an arteriovenous malformation, or AVM - which occurs in just 18 people per 100,000 according to the American Association of Neurological Surgeons. Most AVMs cause no harm, but a few - like Christina's - rupture and cause bleeding inside the brain. Christina had suffered a stroke.
"It's a shock for parents whose child was normal and healthy just a few hours earlier," says Sudipta Roychowdhury, director of interventional neuroradiology at Robert Wood Johnson University Hospital, who had to explain to Marc and MaryAnn Blumstein what had just happened to Christina and how he and his colleagues would work to save her life.
The first step was sealing the blood vessel shut with what Roychowdhury calls "brain glue." He and neurosurgeon Gaurav Gupta, an assistant professor of surgery at Rutgers Robert Wood Johnson Medical School, inserted a catheter through an artery in Christina's leg, guided it past her heart and through the carotid artery in her neck, and positioned it at the site of the bleed. "It's almost the same as Krazy Glue," Roychowdhury says. "If you pour it on your fingers, you will make them stick together. With a microcatheter we injected the glue, and we were able to shut the bleeding down."
Pediatric neurosurgeon Rachana Tyagi then led a team that removed part of Christina's skull, to prevent further damage as her brain tried to heal. "The pressure from the swelling can cause secondary damage to additional areas of the brain," says Tyagi, also an assistant professor of surgery at the school. "We gave her brain space."
With a life saved, a recovery begins
Christina emerged from surgery still in a coma, which would last for nine days. When she woke up in the pediatric intensive care unit, her mother MaryAnn says, "It was 'oh my God - she recognizes me and she can speak.' One of the first things she asked for was her phone, so I knew things were happening in that brain, that this is my child and I'm getting her back."
Christina remembers none of this - in fact, everything is a blank from the headache in the car until she was in rehab hoping to recover use of the left side of her body. But she remembers very well what she now considers the turning point in her recovery - just a month after her stroke, when she began to walk.
"I really pushed myself because I wanted to get out of there," Christina says of the strenuous rehab sessions that began just days after she awakened. "I wanted to get out by my birthday, August 31, and I made it, one day before."
Soon she resumed her 9th grade school work at home, wearing a helmet to protect the area where the portion of her skull was still missing. She stayed mostly indoors for a few months, because "I didn't want to be seen that way." She also set another deadline - this time for the medical team. "We had to have her major treatment items done before Christmas," Tyagi recalls. "It was very important to her."
That meant reattaching the piece of skull, and also performing a delicate procedure designed to eliminate all remnants of the AVM - so it could never rupture and bleed again.
For that, Tyagi enlisted Atif Khan, an associate professor of radiation oncology at the medical school, whose specialty is using a Gamma Knife, a device that destroys malignant cells with radiation. It was Khan's job to demolish Christina's abnormal blood vessels. Guided by imaging technology, Tyagi showed Khan which delicate structures of the brain he needed to avoid, and Khan did the rest.
Advanced technology protects the healing brain
"We used headgear that resembles the ladies who used to sit under the drying machines with curlers in their hair," says Tyagi. "Imagine that the curlers can shoot. You choose angles from which brain tissue won't be damaged, and then shoot multiple beams to deliver a high dose to the spot you want with submillimeter accuracy."
As recently as 10 years ago, says Tyagi, trying to eliminate the abnormal vessels would have produced significant complications, because the risk of damaging brain tissue would have been too high. Now, she says, "it's a one-day process and it's much more precise, only possible because we have a great team of subspecialists, and the latest technology."
Christina got her Christmas wish. She was all back together by mid-December, and since then has progressed even more, picking up where she had left off at the dance studio. In June, she gave a stirring jazz dance recital.
The one lingering vestige of her stroke appears to be her memory. Christina feels she needs to work harder to retain what she learns at school. With cognitive therapy, that, too, is getting better. "I'm feeling great," Christina says. "I think I've recovered really well."
That, in turn, means everything to her physician. "It makes staying up at night, phone calls at 3 in the morning, all worth it," says Rachana Tyagi. "It's the best reward you could ever ask for."
Young adults face rising risk of large vessel occlusion strokes