Teenager Back on Lacrosse Field After Brain Surgery for AVM

Arteriovenous malformation is a tangling of blood vessels in the brain that forms before birth.

The first thing Lauren Adair, age 15, packed for a family trip last spring break to Palm Springs, CA, was her lacrosse stick. Lacrosse is her favorite sport, and Lauren wanted to practice as much as possible to get ready for the high school team the following year. Her plan was to take breaks between checking out colleges for her brother, Carter, so the two could play.

“I play other sports, but I’m most passionate about lacrosse, so learning that I couldn’t play anymore was devastating,” Lauren says.

The night the family arrived, Lauren started having strange symptoms. She had headaches for two days straight and on the third day she started throwing up. The next day, when she tried to say her ABCs and could only make it to C, her parents realized it wasn’t a bug or a concussion from bumping her head, but rather something much more serious. They took her to a local emergency room where a CT scan was performed, revealing a brain bleed. Later that evening she was rushed to a respected brain hospital in Loma Linda. That’s where they diagnosed AVM.

AVM stands for arteriovenous malformation. It is a tangling of blood vessels in the brain that forms before birth. The tangling disrupts blood flow and can lower oxygen levels in the brain. When an AVM ruptures, it can cause hemorrhages (brain bleeds), brain damage, and even death. AVMs can go undetected until a massive brain bleed happens, so Lauren and her family counted the early discovery as lucky.

“It’s a miracle they found it, but it was also shocking and sad. We were told the only definitive cure was brain surgery, and they didn’t think she could be operated on because of the AVM’s size and location,” says Jenni Adair, Lauren’s mother.

For Lauren, one of the worst parts of her diagnosis was that she couldn’t play lacrosse because of the risk of a brain bleed.

Getting a second Neurosurgery opinion at Stanford Children’s

At first the family was relieved that Lauren wouldn’t need brain surgery and instead would receive radiation to shrink – but not eliminate – the AVM. Yet when Lauren ended up at Stanford Medicine Children’s Health’s emergency department a week later after another episode of the same symptoms, they realized that living with the worry of a massive rupture that could occur at any time was worse.

Lauren, along with Jenni and her father, Ed, met with two of the top Neurosurgery experts in the nation for treating AVMs – Cormac Maher, MD, chief of pediatric Neurosurgery at Stanford Children’s, and Gary K. Steinberg, MD, PhD, director of the Stanford Moyamoya Center, the founder and co-director of the Stanford Stroke Center, and the former chair of the department of neurosurgery at Stanford Medicine.

“Lauren’s AVM was sizeable with abnormal movement of blood from the arteries to the veins, so it was challenging to treat. Plus, it was right next to very important parts of her brain, near movement areas for the right side of the body and not far from her language and speech control center,” says Dr. Maher.

The neurosurgeons weighed their options with the family. Lauren’s AVM removal would be difficult with a chance of permanent problems, but leaving it was also dangerous. It could bleed at any moment, and the chance of a brain bleed was 3 to 4% each year. That risk would add up over her lifetime. Plus, surgery was a cure.

“We knew it was high risk, but it was one we felt confident we could mitigate with careful, precise attention and advanced neurosurgery technology. We decided the risk of surgery was lower than the risk of leaving it alone,” Dr. Maher adds.

Complex brain surgery to remove AVM

Lauren received several MRIs, including a functional MRI (fMRI), which measures brain activity by detecting blood flow. The neuroradiology imaging test is a sort of map of the brain. It precisely shows neurosurgeons which areas they can target and which they should avoid. Before surgery, she also received two embolizations to block blood flow to the AVM.

“Thanks to Dr. Maher, the team’s assessment, and Dr. Steinberg’s confidence, they thought they could operate and get to a cure,” Jenni says.

Dr. Maher and Dr. Steinberg teamed up to perform the surgery. Dr. Steinberg has performed 1000+ AVM resections over the course of his career and is known worldwide, and Dr. Maher is a leading expert in AVMs in children. Stanford Children’s is nationally ranked in Neurology and Neurosurgery by U.S. News & World Report.

To ensure good results, the Neurosurgery team at Stanford Children’s has access to highly advanced technology to guide brain surgeries. There’s 3-D surgical theatre technology – which allows surgeons to virtually move around in a patient’s brain and examine an AVM or tumor from every angle. Brain surgeons also have access to Synaptive to create a 3-D dynamic image of a child’s brain.

For Lauren, her neurosurgery team used tractography with a 3-D navigation system. Tractography visualizes and maps the tracts of nerve fibers and their electrical signals in the brain. It allows surgeons to avoid critical neural pathways during AVM removal, lowering the risk of deficits after surgery. It was combined with fMRI to guide Lauren’s surgery, which lasted close to 12 hours.

“It was a highly complex surgery, but we were gratified to have total removal of Lauren’s AVM. Partially removing it doesn’t reduce the risk, so we were pleased to get it all,” Dr. Maher says.

Back to life as a high school freshman

Lauren and her family find great relief in the fact that the AVM is no longer a threat.

“The AVM is gone! She’s cured!” Jenni says. “We are extremely fortunate to have Stanford Children’s and these brilliant doctors available to us right in our backyard.”

While Lauren still has some issues with numbness, speech, and memory, her doctors are hopeful that these symptoms will improve over the coming months. The spunky, sweet teen is getting the most out of life. Most importantly, she’s back to playing lacrosse. She has to catch up a bit to make her high school team, but she’s determined to do so. When she’s not on the field practicing for tryouts in January, Lauren is navigating high school, goofing around with her brother, and hanging with friends.

“Lauren was very brave throughout the process. She’s mature and she asked insightful questions. She had a remarkable understanding of the situation,” Dr. Maher says. “And her parents made great partners in her treatment decisions,” Dr. Maher says.