Dr. Justin Mascitelli, MD, Vascular Neurosurgeon at Baptist Health System in San Antonio, Texas talks about how he quickly and safely saved a patient’s life from an arteriovenous malformation, or an AVM.
Interview conducted by Ivanhoe Broadcast News in August 2022.
When Mr. Hernandez came to you, did he have three inside of his brain?
MASCITELLI: Well, he had an arterial venous malformation, which is an abnormal connection between arteries and veins inside the brain. And on the arteries that were feeding the malformation, they had developed aneurysms over time. So, that was, like, weak spots on the walls of those arteries. And he came in with bleeding from one of those aneurysms.
Charles Hernandez said he felt it after he ran into the truck in this neighborhood. How long, prior to that, has the damage been going on?
MASCITELLI: I wouldn’t say that he had damage going prior to that. I would say that this problem was probably developing over a long period of time. We suspect that a lot of patients are even born with the AVM, and they have a variable time when they present. Some will present when they’re kids, and some not till later in adulthood. But over time, the stress of the AVM, the high flow in the artery, some of the arteries develop aneurysms, and that’s what happened in his case.
Can you describe the stress associated with the bundle of blood vessels that happens during AVM?
MASCITELLI: It’s a bundle of abnormal vessels. There’s a high-flow arterial blood going to it, and that’s an extra stress on that blood vessel. That blood vessel can then have a weakness on the wall and form an aneurysm.
Is an aneurysm simply when it breaks away?
MASCITELLI: Well, not necessarily. An aneurysm is just the weakness and that balloon that forms off the side of the vessel wall. We can see aneurysms that are both unruptured and ruptured. So, it depends on how the patient presents to us.
Did he have one ruptured and two unruptured?
MASCITELLI: Exactly.
When you were performing this surgery, were you doing it both remote and standing at the table?
MASCITELLI: It’s always standing at the table, but it’s two different settings. We wanted to coil the aneurysm, so that would be a minimally invasive technique that we did in a room like this with an angiography, where we go in, either through the artery of the groin or the wrist up with a catheter into the brain, and then use X-ray guidance to find the aneurysm and then fill it with coils. Then, we use that same technique to block off blood vessels going to the AVM, which is called embolization, where we go with a little catheter to the AVM, and we block off some of the blood vessels with a glue-like substance. That’s all done here in the angiography suite with minimally invasive techniques. Ultimately, for removal of the AVM, that’s done in the open surgical operating room, which most people have a visual picture of the operating room where we make an incision and use a microscope then to go into the brain and remove the AVM. He had three stages.
When you’re going in in the surgery, he said you went in through the back of his head. Is that true?
MASCITELLI: Yes.
How deep into his head did you go and then what did you do when you got there?
MASCITELLI: His AVM was on the top and the back and it was on the surface, which makes things a little bit easier, surgically, to get an AVM removed off the surface of the brain rather than deep down in the center of the brain. And once he was in position and we were open and we got to the brain’s surface, then it was just a matter of coagulating and cutting the arteries that go to the AVM and then removing it.
Can you describe the usage of the glue again during the angiography?
MASCITELLI: That happens before the open surgery. We do that to reduce the amount of blood flow going to the AVM and it facilitates, making surgery a little bit easier, less blood loss.
When you’re getting ready to go into a patient’s head, for most of us that’s the scariest thing ever. What are you thinking as a physician when you walk into that O.R.?
MASCITELLI: Usually, I start thinking about the case days before, sometimes weeks before. Discussing it. Running it over in my head. Thinking, what’s it going to look like? What are the steps? Playing it out in my head ahead of time. That way, when the time comes and we get there, I already have a playbook and ready to get it done. Just as you get more and more experience and do it repetitions, you get more and more comfortable taking care of doing these cases every day.
How long is the surgery and what is the recovery time?
MASCITELLI: His surgery, I would guess, probably lasted about four or five hours. It’s intermediate length case. Then, the recovery after that is somewhat dependent on how bad was the hemorrhage beforehand? If it was a bad hemorrhage, sometimes patients can be in the hospital for weeks to months. If it was a minor hemorrhage, then they can usually get mobilized, go to rehab, or go to back home pretty quickly.
Is he OK to get back to normal activities, like biking?
MASCITELLI: Yeah, he should. I mean, he’s over a year removed from this. And between the coiling and the glue and the surgery, his AVM is gone, and all the aneurysms are gone. He’s basically got a clean bill of health, in terms of his brain.
How common is the AVM? How common is the surgery? Where does he fit into the spectrum of really bad off or not so bad off?
MASCITELLI: AVMs are not quite as common as aneurysms on their own. But we do see a fair amount of them. Some of them present to us unruptured. Like, the patient might get an MRI because they have a headache, and we see them in the clinic, and they have an AVM. And many of them come in ruptured, like his. On the scale of bad to good, for someone who has a ruptured AVM, he’s on the good side. The rupture didn’t cause that much damage and we were able to treat him without causing any worsening problems with the treatment.
For people who don’t want to have this happen to them, i.e., a stroke, what kind of symptoms do they look for?
MASCITELLI: AVMs are tough because many times they cause no symptoms until they rupture, in which case it’s a very bad headache. But sometimes, they’ll cause a seizure. If you have a seizure, you can get worked up. Rarely do they run in families where multiple family members have them. So, if multiple family members have them, then you should get worked up. But other than that, unfortunately, sometimes, they’re just caught by chance.
As a surgeon, what is the feeling that you get after helping somebody through this?
MASCITELLI: It’s definitely why we do the job. I mean, it’s those outcomes that keep us going. Certainly, this is a tough line of work. Neurovascular surgery is some of the highest risk surgery out there. I have some patients who have not done as well, and those stick with me. But it’s the cases like this, where we have an excellent outcome, that keep us going and make us want to continue doing this work.
END OF INTERVIEW
This information is intended for additional research purposes only. It is not to be used as a prescription or advice from Ivanhoe Broadcast News, Inc. or any medical professional interviewed. Ivanhoe Broadcast News, Inc. assumes no responsibility for the depth or accuracy of physician statements. Procedures or medicines apply to different people and medical factors; always consult your physician on medical matters.
If you would like more information, please contact:
Natalie Gutierrez
Natalie.gutierrez@baptisthealthsystem.com
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