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For patients with aneurysms and arteriovenous malformations (AVMs) as well as other neurovascular problems of the brain and spinal cord. Including the Neurovascular News; - A newsletter with information regarding carotid endarterectomy to prevent stroke, transient ischemic attack or TIA; brain aneurysms; arteriovenous malformations and other vascular lesions affecting the brain and spinalcord with information on the MGH Brain AVM and Aneurysm Center.
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From Shaping the MGH -- November 1994. Copyright the Trusteees of Massachusetts General Hospital, 1994
"It was probably the scariest thing I've ever experienced," Kimberly Austin recalls. She and a friend were taking a break from driving back from the Berkshires to Boston and had sat down to eat in a turnpike restaurant. Suddenly Kimberly found herself lying on the floor, looking up at her terrified friend. She had suffered a seizure.

Until that first seizure last December, 24-year-old Kimberly Austin had no idea that anything was wrong. But after the frightening episode in the restaurant, she continued to experience lingering weakness and mild paralysis in her arm. Her physicians found she had a cavernous malformation (also called an angioma), an area of abnormally enlarged blood vessels in the brain. The seizures -- both major generalized seizures and smaller focal seizures that affected her arm -- were caused by this abnormality.

Such malformations can be surgically removed, but Kimberly and her physicians initially decided to watch and wait because the affected area was immediately adjacent to the part of the brain controlling her arm. If an operation caused damage to that area permanent paralysis could result.

Because she was moving to Boston, Kimberly came to Walter Koroshetz, MD, an MGH neurologist, for follow-up. Although she was taking anticonvulsive medication, she continued to have occasional seizures and trouble with her arm. Further examination discovered that bleeding had caused the malformation to enlarge. The time for waiting was past, and Kimberly was referred to Christopher Ogilvy, MD, director of the MGH Brain Aneurysm/AVM (arteriovenous malformation) Center, who specializes in the repair of blood vessels inside the brain.

Dr. Ogilvy explains that Kimberly's kind of problem has only recently been recognized. "In the days before MRI and CT scans, people with these malformations often were misdiagnosed with multiple sclerosis (MS) or other neurological problems. They could be left with recurring, sometimes worsening weakness, paralysis or seizures for the rest of their lives. Now we're often able to remove the malformation before any permanent damage is done."

Because of the location of the abnormality, Dr. Ogilvy called upon his neurosurgical colleague Rees Cosgrove, MD, to assist with Kimberly's treatment. Dr. Cosgrove has been collaborating with members of the MGH Radiology Department who use the latest imaging techniques to create three-dimensional brain maps for surgical planning.

Although the general anatomy of the brain -- including where specific functions are located -- is well understood, each brain is unique. The location of areas responsible for motion and sensation can change slightly from person to person, and the pattern of folds and furrows on the brain's surface also differs between individuals.

A well-established neurosurgical technique called cortical mapping allows surgeons to confirm the function of specific areas during the actual operation. But to reduce the possibility that surgery might damage critical brain areas, Dr. Cosgrove suggested that Kimberly undergo preoperative brain mapping.

"Most decisions about how you're going to do a procedure should be made before you enter an operating room," he says. "Knowing precisely where an abnormality is beforehand allows us to do operations that are smaller, less extensive and, we hope, less damaging to healthy tissue."

Produced by combining data from three types of MR images, this view of Kimberly Austin's brain shows the location of the blood vessel malformation (yellow) close to areas controlling her right hand (green) and foot (red).

Such maps are now being created with powerful computer technology that fuses information from different types of images into a single picture. Developed at MGH the program combines data from standard MRI exams, which detail the brain's anatomy, MR angiography, which shows the position of blood vessels, and a new MRI technique that reveals brain function (see stroke story).

Bradley Buchbinder, MD, an MGH neuroradiologist who creates the fused images, explains that while technology to integrate information from different kinds of images has been around for a while, MGH researchers have taken the lead in applying it to patient care. For Kimberly's operation, functional MRI images taken as she moved her arm or leg pinpointed exactly which areas the surgeons should avoid to remove the malformation without affecting her ability to move.

Although apprehensive about having brain surgery, Kimberly also was fascinated by the planning process. "The hardest part for me was deciding to have the operation. Once I made that decision, I was able to look at things a little more objectively," she says. "Dr. Cosgrove told me about the imaging that would be done before surgery and how that would be reinforced by cortical mapping. That made me feel better about everything."

Even so, Kimberly solicited two additional opinions before making her final decision. One doctor advised against having the procedure, but the other was clearly supportive. "He told me I was going to be fine and that I was in the best of hands," she recalls. "He said that if I were his daughter, he'd tell me to get it done."

Both Drs. Cosgrove and Ogilvy collaborated on the operation. Dr. Cosgrove performed the cortical mapping, which involves electrically stimulating the surface of the brain to identify areas involved in motion and sensation while the patient is under local anesthesia. "It's a tried-and-true method that validates the imaging, which is still an experimental procedure," he explains. Dr. Ogilvy then proceeded to remove the malformation.

While the brain imaging techniques used in planning Kimberly's surgery are still experimental, Dr. Cosgrove is excited about their potential. "We've done this kind of planning with 18 patients so far, and in each case the results we get from image fusion are exactly what we find in the operation. That's pretty remarkable."

He notes that initial investigations have focused only on the limited area of the brain involved with voluntary motion and touch. "What is going to be most exciting is developing an ability to explore complex human thought processes with these techniques," he says.

The MGH researchers have taken first steps in that direction by starting to map areas involved in language. Randall Reed Benson, MD, a neurological research fellow, is working with Drs. Buchbinder and Jiang to investigate how functional MRI can identify parts of the brain activated in such specific tasks as creating lists or thinking of verbs.

These studies and other cutting-edge research being carried out at the MGH Nuclear Magentic Resonance Center have the potential for answering major questions about how the brain works and how it is affected by disease. But as federal funds for basic medical research continue to be cut back, donor support becomes more critical than ever. Supporting the MGH Fund for Medical Discovery, which provides fellowships for graduate or postdoctoral training and money for new research projects, is one way to help ensure that the work continues.

Kimberly spent four days in the hospital after her operation, and then several weeks recuperating at her parents' home. Three months later, having had no further seizures, she returned to work and began resuming her normal, active life. At that time she said: "Right after the operation, my arm still felt strange and there were certain movements I couldn't do. But now I'm knitting, drawing and writing. I don't have the strength I used to, but it's coming back.

"The possibility that I could have actually lost the use of my arm never felt quite real to me," she adds. "I did think about it right before the surgery, but I really trusted Dr. Ogilvy and Dr. Cosgrove. They are both so caring, and they spent so much time with me and my parents, explaining what was going to be done and answering all our questions. Having to go through this was no fun, but everyone at the MGH was just great."

Kimberly Austin with her friend Lisa Roman.

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