Three-week-old Ashlyn Julian was crying inconsolably, and her mother, Gina Julian, knew something was terribly wrong.
“This baby, born May 16, from day one was never a huge crier, and this child had been screaming,” Gina explains. “She would go stiff and then very ‘rag-doll limp,’ and then she was not super responsive. Later that night, she projectile-vomited, at which point we said, ‘We’re going to the hospital.’”
Doctors at Children’s Mercy Hospital in Kansas City, Mo., determined baby Ashlyn had suffered a stroke, in the strictest sense of the word, from an aneurysm in the middle of her brain. It was the Director of Endovascular Neurosurgery, Koji Ebersole, MD, at The University of Kansas Hospital who, during a consultation with multiple experts, believed he could help Ashlyn by using endovascular technology — catheter-based tools delivered inside the bloodstream — to stop the bleeding. The traditional solution to cure an aneurysm in adults is surgery. Aneurysms, however, are so rare in neonates — infants less than 28 days old — that only 17 cases are recorded in the medical literature since 1949. Roughly half of the cases involved a “watch-and-see” therapy, while others entailed the more traditional surgical approach. The success rate among those cases was not encouraging. The neurosurgery team collectively was very concerned about performing an open operation on Ashlyn’s brain.
Baby Ashlyn naps following surgery, while an external ventricular drain helps drain blood from the aneurysm.
“Every drop of blood is so precious when dealing with patients this tiny,” Dr. Ebersole explains. “For this reason, any operation on a neonate is a major undertaking — let alone an operation to approach an aneurysm, an abnormality that only exists to bleed — and in the brain no less. We were very concerned. I felt strongly there was a better way if we could gain access to the aneurysm from the inside, with endovascular technology.”
While doctors were considering the possibilities for closing the aneurysm, Ashlyn suffered a second brain bleed, making the decision to move forward more urgent.
“The second bleed reiterated the aggressive nature of the problem,” Dr. Ebersole says. “The aneurysm was angry, and it was going to take her life. We were compelled to do something, and we were prepared to take on a fair amount of risk to do it.”
Alan Reeves, MD, (foreground) and Dr. Ebersole working together on a different patient’s procedure in 2012
Doctors decided they would attempt to reach the aneurysm from the inside. If they could navigate the blood vessels of Ashlyn’s body and access the aneurysm in the brain, there was a chance they could close it. If the attempt failed, the backup plan would be to rush Ashlyn into surgery for the traditional approach.
The procedure would depend first on interventional neuroradiologist and Assistant Professor Alan Reeves, MD. Using a high-resolution ultrasound, Dr. Reeves was able to access a tiny blood vessel near Ashlyn’s hip, gaining the initial entry into the vascular system.
“We used the smallest tools we had on hand, and it was a very delicate situation,” he says.
Once inside Ashlyn’s blood system, Dr. Ebersole used a small catheter to obtain angiographic pictures of the blood vessels of the brain and, ultimately, of the aneurysm itself. The blood vessel harboring the aneurysm appeared potentially accessible, if the smallest instruments were applied. The decision was made to proceed. This required administering a potent blood thinner — a risky maneuver in the setting of a ruptured aneurysm but a necessity to prevent a stroke resulting from blood clots forming on the surgical instruments. It was “all in” at this point, Dr. Ebersole says.
Koji Ebersole, MD, shares a moment with baby Ashlyn after the successful surgery.
He then used the smallest available microcatheter with the smallest available microwire — about the thickness of a human hair — to navigate through the blood vessels of the brain to the vessel harboring the aneurysm. The microcatheter was then meticulously advanced until access into the opening of the aneurysm was achieved.
Once the microcatheter was inside the aneurysm, deciding how to close it became simple: Of the available endovascular technologies, only surgical superglue could get the job done through such a small microcatheter. The glue was injected through the device, creating an internal cast inside the aneurysm that solidified in seconds, permanently closing the aneurysm.
Altogether, after the initial entry into the blood vessel at the hip, the aneurysm was accessed and the lifesaving superglue delivered in less than 30 minutes, with no incisions required. The aneurysm was closed with minimal additional stress to Ashlyn’s healing brain and body. The breathing tube was removed the next day.
Reporters quizzed both doctors about the sterile superglue.
Dr. Ebersole holds the microcatheter and microwire used to deploy surgical superglue.
“Medical applications for superglue have been around for decades,” Dr. Ebersole says. “The endovascular glue is the same base compound used in medicine to seal up cuts and incisions and the same base property as the superglue consumers buy at the store.”
“The glue used in Ashlyn was designed to be used in a wet environment, so it worked well inside her tiny blood vessels,” Dr. Reeves adds. “It works as a fast-acting adhesive to seal the blood vessel and aneurysm shut.”
Doctors don’t know why Ashlyn suffered a brain bleed, and her parents say it’s hard for them to comprehend. They are overwhelmed and overjoyed, however, about the successful treatment she received. As for the doctors, while both played critical roles in saving baby Ashlyn, they are quick to point out that it took a team of medical staff — nearly 100 people — working together to save the life of one tiny patient.