Grace Under Pressure: Riley Surgeon Saves Teen From a Near-Fatal Brain Bleed

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“There’s a two to four percent risk of hemorrhage per year with the likelihood of that happening with increasing age. In other words, the younger the patient is at the time of diagnosis, the more likely it is they will experience a hemorrhage at some point during their lifetime,” explains neurosurgeon Jodi Smith, M.D.

Being a teen girl has its challenges, but for most newly minted teenagers a brush with death usually isn’t one of them. That wasn’t the case for Ella Reis, of Liberty, Indiana. In February, 2016, what appeared at first to be a garden-variety headache turned out to be a symptom of a life-threatening brain condition.

“It was around 8:50 at night and Ella told me her head was hurting. I gave her ibuprofen and sent her to bed,” recalls her mother, Amy Spivey. “Something told me to check on her later. I found her unresponsive.”

Mercer, an internal medicine physician who practices in Oxford, Ohio, knew something was very wrong, so she and her husband (Ella’s stepfather) rushed Ella to the emergency room at Reid Hospital in Richmond, Indiana. “I thought Ella may have had a seizure,” says Spivey, “but a CAT scan showed Ella’s brain was herniating.” From Reid, Ella was rushed by ambulance to Riley Hospital for Children at Indiana University Health.

The bleeding in Ella’s brain was so bad, “I thought we were going to be pronouncing a thirteen-year-old at Riley,” Spivey says. “But because Ella was moving her arms and legs, the doctors did a repeat CAT scan. It showed some improvement, so they put a drain in place to remove the excess fluid.”

The cause of the bleeding was an arterial venous malformation, or AVM. “A tangle of blood vessels in Ella’s brain bypassed normal tissue and directly diverted blood from high-pressure arteries to low-pressure veins,” explains neurosurgeon Jodi Smith, M.D., at Riley Hospital for Children. “This diversion of blood from arteries to veins leads to life-threatening bleeding in AVMs like Ella's. That’s because arteries typically deliver blood to veins through arterioles, then capillaries, and finally tiny veins called venules, so by the time the arterial blood reaches the veins, it isn’t as forceful. When high-pressure arterial blood flow goes directly into veins, there’s an increased risk of bleeding.”

According to the American Stroke Association, AVMs are rare, occurring in fewer than one percent of the general population. They’re usually congenital. Ella was probably born with hers, says Dr. Smith. “There’s a two to four percent risk of hemorrhage per year with the likelihood of that happening with increasing age. In other words, the younger the patient is at the time of diagnosis, the more likely it is they will experience a hemorrhage at some point during their lifetime,” she explains.  

Ella was in the hospital for several weeks while doctors figured out how best to treat her. Dr. Smith, who had taken over Ella’s case from the physician on call when Ella arrived at Riley, consulted with Aaron Cohen-Gadol, M.D. Dr. Cohen-Gadol, director of Neurosurgical Oncology/Brain Tumor Surgery at Indiana University Health, is internationally recognized for tackling brain tumors and aneurysms often considered inoperable.  “Ella presented with significant intraventricular hemorrhage from her AVM, and she almost died,” says Dr. Smith. “Dr. Cohen-Gadol agreed to come over to Riley for Ella’s surgery.”

The procedure lasted 13 hours —a long time. “As a doctor myself, I’m aware surgeons aren’t perfect,” says Spivey, “but knowing Dr. Smith was on the case I was as calm as I possibly could have been. I understood she and Dr. Cohen-Gadol were taking their time.”

The surgery was highly successful. Ella spent a week in rehab at Riley before going home, and now has physical therapy twice a week to deal with some minor weakness on her right side. Otherwise, Ella’s “a normal kid with no restrictions,” says Dr. Smith. “We’ll likely do an angiogram in the future to make sure there’s no residual AVM, but otherwise she has no restrictions and she isn’t on medication. As long as the AVM doesn’t come back, she should live a normal life.”

Mercer says Ella's doing great. She’s getting all As and Bs in school, and she remembers only bits and pieces of what happened. “We’re all amazed,” adds Spivey. “We do talk about it, but she’s not worried. It was scary, but it brought a lot into our lives. Today, we consider Dr. Smith to be a part of our family.” 

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