Creía que sus intensos dolores de cabeza se debían al estrés hasta que fue diagnosticada con una malformación arteriovenosa (MAV)
lectura de 6 min
Rosanna Garrido, de 57 años, consideró que la aparición repentina de intensos dolores de cabeza formaba parte de su estrés y ansiedad cotidianos. Sin embargo, una infección renal no relacionada con lo anterior le llevó a someterse a pruebas de imagen que probablemente explicaran los dolores de cabeza y el desalineamiento de la mirada, es decir, el hecho de que sus ojos no giraran juntos en la misma dirección.
Se le diagnosticó una malformación arteriovenosa (MAV o AVM por sus siglas en inglés), una maraña anormal de vasos sanguíneos que provoca conexiones irregulares entre las arterias y las venas del cerebro. Algunas malformaciones arteriovenosas nunca se revientan, pero en el caso de la de Garrido era muy probable que se reventaran. "Es como una bomba de tiempo dentro del cerebro", explica Italo Linfante, M.D., director médico de Neurorradiología Intervencionista de Baptist Health Miami Neuroscience Institute y de Baptist Health Miami Cardiac & Vascular Institute.
Ms. Garrido's AVM before and after embolization.
"En general estaba saludable y entonces empecé a tener unos dolores de cabeza terribles", dice la Sra. Garrido. Fue hospitalizada fuera de Baptist Health por una infección renal, y se sometió a una tomografía computarizada con contraste después de quejarse de los fuertes dolores de cabeza. Además, le dijeron que sus ojos parecían asimétricos. "Cuando me dieron la mala noticia de que tenía un problema en el cerebro, lo primero que dije fue: ¿Qué me está pasando? ¿Por qué me pasa esto ahora?".
La causa de las MAV cerebrales es un poco misteriosa. Los investigadores creen que algunas MAV pueden estar presentes al nacer, pero otras también pueden desarrollarse en etapas posteriores de la vida. Después del diagnóstico inicial, la Sra. Garrido fue referida por su médico de atención primaria al Dr. Linfante, un especialista que estaba cubierto por su seguro. El Dr. Linfante y Robert Wicks, M.D., codirector de cirugía cerebrovascular y director del Laboratorio de Anatomía Neuroquirúrgica de Baptist Health Miami Neuroscience Institute, confirmaron su diagnóstico de una MAV.
Rosanna Garrido with her daughter Nicole Garrido and her son Pedro Pablo Bisono.
Patient: ‘I was in Denial’
"By then, I had already accepted what I had -- but it was a process,” recalls Ms. Garrido. “I was in denial for a while. I told my daughter (a nurse outside of Baptist Health) that I'm not going to have surgery. I don't want to operate. It scared me. But then I reached a stage of surrender where I had two pillars. My two pillars were faith in God that everything was going to turn out well, and faith in Dr. Linfante and Dr. Wicks."
Ms. Garrido’s troubling AVM would require two surgeries – one day apart. First, Dr. Linfante performed a minimally invasive procedure called “endovascular embolization” that essentially embolizes, occluding the small malformed arteries of the “nidus” of the AVM. The embolization prepares the patient for a microsurgical resection of the AVM. Microsurgical AVM resection is an open surgery in which the neurosurgeon removes part of the skull to gain access to the abnormal vessels. Ms. Garrido’s micro surgery was performed Dr. Wicks.
"Her MRI showed an AVM that had very worrisome angiographic features." recalls Dr. Linfante. “AVMs are always a very serious pathology, but in her case the worrisome feature was that the outflow veins were very dilated. Dilated outflow cerebral veins from a large AVM are a sign that they under considerable pressure. Veins are not made to sustain such pressure. Therefore, eventually are at high risk for rupture. And when they rupture, they result in large and potentially fatal brain hemorrhage."
A ‘Nuanced Approach’ to Treating AVMs
Dr. Wicks emphasizes that Baptist Health Miami Neuroscience Institute is specially equipped to handle such complex cases of AVMs, with highly experienced teams in interventional neuroradiology and neurosurgery.
“Treating AVMs requires a nuanced approach,” explains Dr. Wicks. “I have seen patients for second opinion who have been partially treated at other institutions, and the treatment resulted in more problems than the original AVM. That’s why it’s important to be evaluated at a facility that frequently sees this rare pathology and can offer comprehensive treatment options and recommendations.”
Both Dr. Linfante and Dr. Wicks emphasize that Ms. Garrido was fortunate because her AVM was seated closer to the surface of the brain, allowing for a thorough removal via the microsurgery.
“If the AVM is resectable (able to be removed by surgery), we typically embolize the AVM so it becomes a solid block,” said Dr. Linfante. “And then the surgeons can remove it safely from the patient’s brain. In her case, it was at the very resectable because it was positioned close to the surface of the right frontal lobe. If the AVM is very deep, then it maybe difficult to remove with surgery. In this case we prefer the embolization procedure alone as cure or perhaps radiotherapy.”
Position of AVM in the Brain is a Major Factor
“When we consider what's the most effective treatment, then removing the AVM entirely is ideal,” said Dr. Wicks. “If the AVM is in an amenable location to surgically take it out, then we likely will go ahead with surgery. And there are other certain factors we look at -- How is it draining? How old is the patient? In the case of Rosanna, it seemed like surgical resection was definitely a good option.”
Ms. Garrido’s surgery to remove her embolized AVM went as smoothly as can be expected – and she has achieved a full recovery. “She was fortunate,” said Dr. Wicks. “Her surgery went really well, and it was actually not very long in terms of neurosurgeries – about four hours. Sometimes they can last eight hours or more with large AVMs.”
“With AVMs, the main concern is that they have a risk of rupturing and breaking open, causing bleeding in the brain,” said Dr. Wicks. “And that risk is thought to be increase by about 3 to 4 percent per year. That may not sound high. But, if you look ahead to 20 years, for example, the chance of it bleeding is more like 40 percent or higher. So, that's what we talked about in her case before moving forward with the surgery.”
Don’t Dismiss Severe Headaches
Dr. Linfante urges everyone to never dismiss sudden, sharp headaches that are out of the routine. “If you have the most severe headaches of your life, you have to go the emergency room,” he said. “See a doctor. Rosanna brushed these headaches off at first. But she was very fortunate to have been diagnosed.”
Ms. Garrido looks back at her medical journey with gratitude and some philosophy regarding how a person can live life on “automatic mode” and ignore vital signs – in her case, those intense headaches which she thought were mostly stress-related.
“The daily problems in which a person is immersed can be overwhelming,” she said. “Sometimes one lives in an automatic mode and I realize now that I lived my whole life in an automatic mode.”
She feels quite blessed to have been diagnosed with the AVM before rupturing, and landing in the care of Drs. Linfante and Wicks.
“I have had the luck that God has given me to have been diagnosed with this,” she said. “And then I find divine hands with all the professional expertise of Drs. Linfante and Wicks. I looked for them. I Googled them. I verified who they were. And better doctors I could not have. And, of course, both of them had everything to do with recovering my health.”