Neurosurgery Saves a Young Boy’s Life
n a crisp day in late September, 8-year-old Caden Kemmerer was on the playground of his elementary school during recess. Suddenly, he collapsed at the bottom of a slide. Alarmed, his friends gathered around, and when he didn’t get up, they ran to the teacher for help. It was one of many actions that fateful day that saved Caden’s life.
Caden’s mother, Alex Mendel, was at home in Montgomery, NJ, when the phone rang. It was the school principal. “I thought, ‘This can’t be good,’ because she never calls us,” she says. She rushed to the school, where she found her usually lively, energetic son, a budding soccer player, still lying on the ground. Several police officers and school staff stood by. Squinting, Caden cried, “Mommy, the sun’s in my eyes.”
Even though Caden was conscious and speaking, the police officers intuitively knew the situation was dire. “One of the officers said to call my pediatrician and ask what hospital we should go to,” Mendel recalls. “But as I was dialing, he said, ‘Forget it. We’re calling the helicopter.’” They began measuring the playground but found it too small to accommodate the helicopter landing. Somehow — Mendel is not sure how — her son was moved to the athletic field of the local high school, a larger space.
The police drove Mendel to Robert Wood Johnson University Hospital (RWJUH), the nearest Level 1 trauma center, where Caden had been airlifted and rushed into surgery. Neurosurgeon Rachana Tyagi, MD, would oversee his care. As director of the Pediatric Neurosurgery Program at Robert Wood Johnson Medical School, Tyagi specializes in tumors, trauma, spinal cord deformities and the like — anything that can go wrong with the brain. “I treat all age groups, but my specialty and primary interest is pediatrics,” she explains. “About 80 percent of my patients are children.” Tyagi loves children and has five of her own. She describes herself as “action-oriented. I’m a hands-on person and that’s why I went into surgery. I love the instant gratification of doing an operation and seeing the patient get better.”
Tyagi initially sought a career in computer science, but couldn’t resist the lure of the brain. She describes its plasticity as “amazing. When the brain is injured, it has a remarkable capacity to adjust and develop new neural pathways,” she explains. “That’s particularly true for children’s brains, because they’re still growing. Children heal and recover more quickly than adults.”
In Caden’s case, the police officers’ instincts had proven correct. By the time the helicopter arrived at the hospital, he was comatose and deteriorating rapidly. As the mother of four athletic boys, Mendel is accustomed to cuts and scrapes, many requiring trips to the doctor. But this was different. “The emergency room was frantic, with so many people working on him,” she recalls. “They wouldn’t let me see him. They weren’t sure he was going to make it.”
Caden had fallen a few months ago, and initially Mendel thought he might be suffering from the effects of that concussion. Unfortunately, his diagnosis was much worse. He had an arteriovenous malformation, or AVM, an abnormal connection between the arteries and veins in the brain that likely had formed before birth. In an AVM, the arteries in the brain connect directly to the veins without having capillaries connecting them. The resulting pressure damages the veins and can cause bleeding. “Patients with AVMs are typically symptom-free until bleeding occurs or they have a seizure,” says Tyagi.
Just a few years ago, a patient like Caden might not have survived. However, advances in imaging, surgical techniques and medications have greatly improved the odds for patients with AVMs and traumatic brain injuries. New tools include microcatheters that can deliver miracle medicines to targeted areas of the brain where it would be too dangerous to operate. Caden was fortunate to have access to a medical
center with a highly trained neurosurgical team and the latest imaging technology. An added bonus — the opportunity to recuperate at a
specialized pediatric facility: Bristol-Myers Squibb Children’s Hospital (BMSCH). Adjacent to RWJUH, it is the state’s largest and most comprehensive pediatric hospital.
Over the next 24 hours, Caden was in and out of the operating room for several procedures. Tyagi removed part of the blood clot that had formed in his brain, as well as portions of his skull to relieve pressure. To stop the bleeding, interventional radiologist Sudipta Roychowdhury, MD, performed an embolization with Onyx, a medication sometimes referred to in lay terms as “brain glue.” It is used to treat AVMs as well as aneurysms. Using fluoroscopy to guide its placement, Onyx is injected into the injured vessels, where it solidifies, closing off the AVM. In Caden’s case, a great deal of damage had already been done. Sometime that first day, he had a stroke, which would greatly complicate his chances of recovery.
“The next day, my patient was worse,” says Tyagi. Comparing Caden to Congresswoman Gabrielle Giffords, currently recovering from a gunshot wound to the head, she added, “Following an injury to the brain, whether it’s an AVM, trauma or stroke, you know the brain is going to swell. When it does, you have to relieve the pressure.” That meant removing part of his cerebellum, the part of the brain that affects coordination.
“His parents were very worried about it causing significant neurologic deficits,” she says. “I promised his mom that Caden would get better and be able to play soccer again. She made me pinky swear to that.”
Following the surgery, Caden was kept in a medically induced coma for almost three weeks, remaining in intensive care. Mendel and her husband Carl kept vigil at the hospital. After the first two weeks, Carl returned to work. At her husband’s suggestion, Mendel launched a blog to keep friends and family informed of Caden’s condition. He had several complications, including a serious infection and a blood clot in his arm. “A few times the doctors told us he was close to death,” says his mother. But with a combination of excellent medical care and a bit of luck, he gradually improved.
When Caden finally woke up, he was the same child, but very different, says his mother. He was on a respirator and couldn’t talk or sit up. “All he could do was blink, so at first, I would ask him questions that he could answer by blinking for ‘yes,’” states Mendel. “Then he began moving his thumb, so ‘yes’ became the thumbs up.”
On October 21, Caden left BMSCH for Children’s Specialized Hospital for a few months of intensive rehabilitation. He went home in late December to continue physical and occupational therapy several times a week as an outpatient. He’ll soon begin home schooling and the family looks forward to the day when he’ll return to school. “That day will be a reality,” says Tyagi confidently.
“At first the rehabilitation team was concerned with the slow pace of his recovery,” says his mother. “But he has to re-learn everything. The doctors and therapists say that could take a year or two. He’s making steady progress. His speech is returning and his vocabulary is better than it ever was.”
“Caden is a great success story,” says Tyagi. “He’s doing really well. While he may have some issues with coordination, he’ll be fully functional. And I expect to see him back on the soccer field. “