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January 25. 2013 11:28PM

Surgeon says toddler defied odds after pencil lodged in her head


Olivia Smith and mom Susie Smith share a moment with Lt. Janet Chamberlain of the New Boston Fire Department, who was among the first responders to reach Olivia after she was injured by a pencil in her head. Firefighter Lt. Rick Riendeau looks on. (Simon Rios/Union Leader Correspondent)
NEW BOSTON - When Olivia Smith was flown to Boston Children's Hospital by helicopter, the baby girl's parents experienced one of the most tense moments in their lives.

Falling from a reclining chair in her New Boston home, the colored pencil Olivia was using travelled through her eye cavity and penetrated several inches into both hemispheres of her brain.

Some 50 doctors worked on the case, from ER staff to neurosurgeons to pediatric radiologists. They all agreed that the trajectory of the pencil was nothing short of remarkable - it narrowly missed an array of vital areas in the brain that could have been fatal or neurologically devastating.

"It made my eyes definitely open to everything else that goes on that you don't think about," said Susie Smith, Olivia's mom. "You think about your day to day stuff. We're so lucky. She's lucky. And I'm lucky."

The accident was nearly three weeks ago, and Olivia was released from the hospital Wednesday morning.

Dr. Darren Orbach, the division chief of interventional radiology at Boston Children's Hospital, plans to publish a paper about the medical response that ensued that Sunday.

"If you can consider someone lucky who has a pencil go through her brain, you have to consider this girl remarkably lucky," Orbach said.

He kept using the word, "remarkable," the same thing first responders called "miraculous," saying it was all thanks to the "mind-boggling trajectory" of the pathway the pencil took.

"If you asked me to sit down with a patient's scan and draw a line that would go from one end of the brain to the other, avoiding every major blood vessel and even avoiding critical areas of the brain. I would be hard-pressed to find a pathway that would cause so little injury."

Orbach is a neurointerventionalist, treating problems with cerebral and spinal blood vessels using catheter-based techniques. It was 2:30 on a Sunday afternoon when Orbach received the call - he and his his wife were at Best Buy.

"We knew that this little girl was being flown in from New Hampshire with this incredible sounding story of having fallen head first onto a pencil, which penetrated her (eye socket) and then both hemispheres of her brain," he said.

According to the initial scans from Catholic Medical Center - where Olivia was transported before being flown to Children's - the pencil had not caused any intracranial bleeding.

At Children's Hospital, Olivia was given a CT angiogram scan, a higher quality image that looks specifically at blood vessels. The scan confirmed that there were no injuries to the brain's blood vessels.

The result was "absolutely remarkable," Orbach said, "because the pencil crossed from essentially the right eye through the entirety of both hemispheres of the brain, and ended up just in front of the left ear. So it literally crossed the whole head and missed just vessel after vessel."

Orbach was still standing in Best Buy when all this was conveyed to him. He started developing a plan with his colleagues and made his way to the hospital.

When he arrived, the sight of a pencil protruding from a little girl's eye socket, "was so violent and jarring," unlike anything he'd seen before. Orbach described the pencil's path.

"If you just count in order the vessels that were missed, from the superior ophthalmic vein on the right side. the fact the eye itself was missed. to the internal cerebral artery branches in the front of both hemispheres, then the internal carotid artery on the left and then the middle cerebral artery on the left, and then it stopped just short of a very large vein on the surface of the brain. if any of those had been hit this could have been a fatal injury."

Orbach said no one at the hospital, which has the largest pediatric neurosurgery program in the world, had seen anything like it before.

The team agreed that the first step would be to get an angiogram, a procedure done with a catheter placed through a leg artery, going into the blood vessels of the neck, which supply the brain. In the procedure the blood vessels are injected with a dye that allows a high resolution image of further vessels.

The move was to ensure there were no injuries to the vessels, which would require attention before all else.

Orbach said the part of the brain penetrated by the pencil is "very crowded with important stuff." The basal banglia carries a band of fiber, where the major motor pathway travels. The area was spared for the most part, but it was affected by the pencil, leaving Olivia with some weakness that she rapidly recovered from.

Though the angiogram was "remarkably normal," Orbach said there was a subtle narrowing of the left middle cerebral artery, exactly where the pencil missed it by millimeters, resulting in a mild stroke. Orbach said there were two other areas in the MRI that depicted likely strokes resulting from decreased blood supply.

"After that the question was how to remove the pencil, and typically we would remove a foreign object in the (operating room) because there is a chance of having major bleeding."

Because the pencil had penetrated so far, its removal could have caused bleeding or other complications in the brain, and that would have required brain surgery. Fortunately, it wasn't necessary.

Instead of using the operating room, the medical team opted for a joint procedure with neurosurgery and interventional radiology.

As the pencil was being removed Orbach kept a micro-catheter (the size of angel hair pasta) in the left internal carotid artery. If he saw an injury develop at any point, the pull would be stopped and intervention conducted with the catheter.

Once it crossed the brain's midline and the tip was in the right hemisphere, the catheter was switched to the right artery, ready to intervene in case of hemorrhaging.

"We did the initial angiogram, (the neurosurgeon) started pulling, she would stop, I would do another angiogram and make sure everything looked good, and then she kept on going."

The pencil was pulled out slowly, taking doctors about 40 minutes from start to finish before it was out of her head.

He said by the time Olivia left the hospital it was difficult to see anything wrong on the neurological scans.

"I expect her to essentially make a full recovery, because of her age and how well she's doing right off the bat," Orbach said, adding that one of the real gratifications of working in pediatrics is that since the young brain has so much plasticity, patients tend to bounce back quickly.

Seeing Olivia the day after the procedure, eating ice cream and smiling with her mom in bed, was one of the most memorable moments of his career, Orbach said. Though it's not rare to see children make radical recoveries in a short time, Olivia's case was the most extreme Orbach (and most of the doctors on the case) had ever witnessed.



srios@newstote.com

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