Becky's 20 now (10-17-03). She's on the Dean's List in her sophmore year at Sam Houston State University, and a prize winning photographer. Her AVM was completely obliterated by the Gamma Knife treatment in 1997.
Becky Rogerson 13 Gets Gamma Knife Therapy For AVM
San Angelo, Texas, June 22, 1997.
Becky Rogerson turned 13 on October 11, 1996. She's quite an athlete, big and strong. Last year, in the seventh grade, she played soccer, basketball, volleyball, and competed in track and field at school. She also played recreational softball and select soccer. She's been very healthy. Nothing worse than a very bad splinter, and a bee sting; and then she was a difficult patient.
She went to soccer practice Thursday, June 5, 1997, and had a softball game scheduled later that night at 8:30. When we picked her up after soccer practice she said that she threw up. She had a headache and asked the coach for a Tylenol, but he didn't have one. She sat out the rest of practice and threw up on the sideline. Her head and neck hurt. She said she thought that she must have headed the ball wrong, but she didn't remember a header that hurt her. She threw up again at home, several times, and she had to hold her head at a funny angle because of the pain. She was also very lethargic and sleeply, which is unusual for Becky, especially in the early evening. We usually have to tell her repeatedly to go to bed at 11:00 o'clock.
That night Mom (Cindy) thought maybe she should take Becky to the Emergency Room to be checked out. Because of the HMO, she called Dr. Chang's service first. Dr. Jerry Schulze was covering, and after hearing the symptoms he asked what her temperature was. Cindy, an RN, didn't think it was a factor, but Dr. Schulze guessed that she was coming down with the flu. Cindy said she was considering going to the ER, but she wanted to check first. Dr. Schulze said, "Go to the ER if you really want to, but make sure you call Dr. Chang's office tomorrow." He gave Cindy the impression that he thought she was a fool.
Cindy next called Shannon West Texas Medical Center (where she works) and spoke to the Emergency Room triage nurse. She related the symptoms, and asked if the nurse thought she should come in to be checked. The nurse told her, "I can't give you any advice over the telephone."
At this point Cindy was pretty mad. She remembered working in another ER, and telling people with head injuries that if the felt nauseous or unusually sleepy, that they should come back to be checked again. Finally she said, "To hell with them. If they don't want to check her, I'll do it myself." So she got up every hour that night to make sure that she could arouse Becky, and to check her pupils.
Friday morning, Becky was still experiencing head and neck pain, Still nauseous, although she had nothing left to throw up, and she had no energy whatsoever. By 12:30 or 1:00 PM Cindy decided to call Dr. Chang. She related the symptoms to the receptionist, and was told they would call back. At 4:00PM the Doctor's office finally called back. They asked for the symptoms again, and when Cindy related them they said, "Can you come in at 4:15?" Cindy said, "You mean right now?" They said, "Yes."
When the nurse came into the examining room to take the history, she said, "So, you have a headache?" Cindy then related the whole history, and the nurse said, "You should have told them that we should call you right back." Cindy said, "I was under the impression that you would. What if it was someone without medical training? Your office should make that decision, not me." Dr. Chang also seemed upset about the call not being given higher priority, and comments were made about minimum wage help, and maybe someone would be fired over this.
Dr. Chang diagnosed a concussion, which of course Cindy already knew.
On Monday, four days after the trauma, Becky was feeling worse. Cindy called Dr. Chang, and he ordered a CAT scan that afternoon. Cindy sensed that the CAT scan showed something significant.
When Dr. Chang called to report the results of the CAT scan. He reported that it had disclosed another problem, unrelated to the concussion. There was an abnormality where arteries were connected to veins without going through capillaries. He wanted an MRI, and he referred her to a Neurosurgeon, Dr. Duarte.
An MRI and cerebral angiogram were scheduled, but then the angiogram was postponed to let a more expert Neuroradiologist, Dr. Dunnegan, conduct it.
We saw Dr. Luis Duarte, the Neurosurgeon, on Thursday, one week after the original trauma. He conducted a thorough office exam. He discovered some apparant loss of field of vision in the right eye. He ordered a more thorough test. He also ordered neck X-rays which hadn't been done before. He showed us the CAT scan pictures, and explained what a Arteriovenous Malformation (AVM) was. It's a congenital condition in which there is an abnormal direct connection between the arteries and the veins. The blood pressure is too high for the veins, since it has not been reduced by passing through capillaries. The unresticted blood flow through this abnormal shunt steals blood flow from surrounding areas of the brain, impairing their function. The blood vessels respond to the abnormal flow by growing bigger, and longer, and wrapping around themselves. Untreated it will probably eventually hemorrage. The chance of a hemorrage is about 2% every year. If it hemorrages, the chance of death is 10%.
Dr. Duarte explained that therapy was probably necessary considering Becky's young age, and the cummulative impact of the 2% per year probability of hemorrage. He explained the three therapy options;
Embolization (often used in conjunction with one of the other treatments) where glue, plastic spheres, etc. are introduced by catheter into the AVM to block the abnormal blood flow.
Gamma Knife or other stereotacic radiosurgery; where a single dose of many radiation beams are focused on the abnormality, causing it to scar, wither, and close off the abnormal blood flow. This is highly effective, but takes two to three years to be completely effective. This option is especially useful if the AVM or drainage veins are deep in the brain, or involve eloquent areas of the the brain, where surgery is more risky and difficult.
Conventional surgery where a surgeon physically closes and/or removes the AVM from the brain. This involves all of the surgical risks of infection, anaesthesia, and the lengthy recovery process from major surgery. This procedure eliminates any possibility of hemorrage from the AVM since the AVM is removed.
On Monday, June 16, a MRI was done by Dr. Donnegan, the Radiologist, which confirmed the findings of the CAT scan. He did not mention radiosurgery as an option.
On Wednesday, June 18, Dr. Donnegan did a cerebral angiogram, which reconfirmed the findings. Becky was a very good patient for this procedure, and needed very little sedation. Her mother, on the other hand, was very unhappy about not being allowed to be present during the the test. After reviewing the results, Dr. Donnegan thought that surgery would be necessary. Dr. Duarte thought that based on the estimated size (3.5cm x 3.5cm x 2cm) and location, radiosurgery was possible.
He will submit the case to Dallas, where we hope to have that procedure performed.
Update 24 June 1997
Field of vision test yesterday confirms initial finding. There is a loss of vision in the upper right quadrant of both eyes. Dr. Duarte will overnight files to Gamma Knife Center in Dallas. We should know in a week to 10 days whether and when they can do the procedure. Becky is very anxious to go to camp. She has gone to this camp every year of her life, and has many friends there that she only sees once a year. She is very unhappy about having four pins inserted in her skull to hold the frame in place for the Gamma Knife procedure.
Update 29 July 1997
Dr. Duarte sent the file to the Gamma Knife Center at Presbyterian Hospital in Dallas. We got a call from them on Tuesday, July 1. They scheduled Becky for the radiosurgery therapy Monday July 7.
We received an orientation on the procedure on Sunday July 6, and pre-registered with the hospital. On Monday we arrived at 5:00 AM. Becky found that the worst part of the procedure was starting the IV. After that everything went smoothly. She had been concerned about the angiogram. The one in San Angelo had been painful. This time she received more sedation than during the angiogram in San Angelo, and it was a less extensive angiogram, because they knew what they were looking for. She had the frame on for about four hours. The entire staff was wonderful. Dr. Weiner was the principal physician.
We left the hospital about 6:00PM and we all went out to dinner. Becky was very tired and sleepy the next day when we drove home to San Angelo.
Four days after the radiosurgery Becky left for camp. Dr. Weiner said there is no evidence that the outcome is any better when they turn the patient into an invalid, so he released her to all normal activities. She flew to NY Friday, July 11, where her grandmother picked her up, and drove her to New Hampshire on Sunday July 13.
Becky reports feeling well, but had some hair loss, which she is unhappy about. After camp she is visiting a friend in Hartford CT for another week. We are looking forward to her return home, Tuesday, August 5.
She will have follow-up MRIs every six months for three or four years. We hope they will show complete obliteration of the AVM, but there is a substantial chance that it will not be completely obliterated. If that's the case we'll have to deal with that when time comes.
© Copyright 1997 Kurt and Beck