It looked pale and fat pulsing against the scraped side of Kaditia Sutton's head. But it was beautiful to neurosurgeon Ann Marie Flannery as she stared over the edge of her green surgical mask.
"We have a lovely artery," she said as she began to make a passageway for it through Kaditia's skull, bringing the outside artery in to give the 7-year-old a better blood supply to her brain.
Kaditia was born with Down syndrome, and one of the complications can be moyamoya disease, where the blood vessels feeding the brain are too narrow to provide an adequate blood supply.
The Abbeville, S.C., girl endured open heart surgery just after birth to repair three holes in her heart but had looked strong and healthy after that.
She had just taken first place in a relay race at school in late May when teachers called her mother and told her Kaditia, known as "Shae," had thrown up after the race.
Later that evening, her mother, Linda, noticed she was making "a smacking sound with her lips" and couldn't seem to talk.
"It was like she couldn't get the words out," Ms. Sutton said.
A trip to the emergency room confirmed she had suffered a stroke. More tests found the narrowed carotid arteries in her neck.
"The underlying problem is they are too tight, they're too small," said neurosurgery resident Karsten Fryberg. Surgery would be Kaditia's only option.
Understandably, she was not thrilled at 7 a.m. July 9 to be waiting for surgery. But a quick-acting liquid sedative seemed to take the fight out of her and left her drowsy on her mother's lap.
Crowded inside the small exam room with her were her oldest brother, Vic, 26, her sister, Yashica Brown, 23, brother-in-law Willie Brown, 23, and beloved cousin, 2-year-old Willie Jamal Brown.
"They're like brother and sister," Mrs. Brown said.
Willie Jamal's presence seemed to calm Kaditia as he grinned and watched her from across the room, not knowing she would soon leave for surgery.
Ms. Sutton seemed to be doing all right too, though she admits to she is worried about being back in the hospital.
"I thought it was pretty much over" after the heart surgeries, she said. "For her to do so well for so long and then for this to come out, it's frightening."
The fact that they can go in and repair it, however, evoked some hope in her.
"It's amazing," she said.
Dr. Fryberg squatted inside the operating room and quickly sketched out the rudiments of the surgery. On paper, it looked deceptively simple.
Take an artery from the side of the head at the temple, already supplying blood to the scalp and face, open a hole in the skull, and tuck the artery inside. Then nature takes over, with the artery branching out and forming new connections, to feed blood to the brain.
"We're just taking advantage of the body's use of that mechanism," Dr. Flannery said outside the operating room.
It takes four hours to carefully isolate the artery from surrounding connections and move it to the side, to move aside the muscle underneath and to carefully open an oval hole in the skull.
After cutting through the dura matter, the tough skin-like covering beneath the bone, the surgeon gently places the artery underneath, then sews sterile graft tissue over the hole to hold it in place.
Dr. Flannery and Dr. Fryberg chisel out grooves for the artery to fit without being pinched once the skull piece is replaced. The artery pulses as blood goes in and comes out, which is a good sign, Dr. Flannery said.
It takes another four hours to do the artery on the other side of the patient's head.
Later, as she sat in her office surrounded by orchids grown by her husband, Peter, Dr. Flannery reflects on the fifth child on whom she has done the procedure since 1994.
Other attempts at correcting moyamoya sought to make a direct connection to the brain by actually sewing arteries into blood vessels in the brain, which is difficult to do with children because the blood vessels in the brain are so small, Dr. Flannery said.
Instead, the artery will form connections on its own. The surgery has worked with both Down syndrome and sickle cell anemia patients who suffer from moyamoya.
"It's very well tolerated, which is important because these people, especially the sickle cell patients, can be quite fragile," Dr. Flannery said.
In Kaditia's case, she is going home three days after the surgery. She tries to squirm away as the bandages are removed from her head.
"She's back to her old self," Ms. Sutton said, laughing.
In the future, it may not be necessary to move the arteries. Researchers in Boston have had success getting the heart to grow new blood vessels by injecting genetic material that stimulates the production of a protein called vascular endothelial growth factor.
A similar approach could replace the procedure Dr. Flannery performed on Kaditia.
"I'm very intrigued by that," Dr. Flannery said. "I'm hopeful if it works there, it would work in the brain."
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