Brianna Atkins was supposed to be playing in the opening game for her California high school's soccer team in January 2015 when she was overcome by a massive headache.
She was rushed to the hospital, where emergency room staff told her it was probably just the flu. But her mother, whose brother died in his teens from brain cancer after suffering similar headaches, badgered the doctors to look further.
A CAT scan revealed a mass in Atkins' brain. Doctors later told her it was a very large brain aneurysm — a bulging, weak area in the wall of an artery that supplies blood to the brain. If it ruptured, it likely would kill or disable her. Surgery to fix it came with enormous risks.
"The doctors were really straight with me, they said if you do survive you're probably going to be paralyzed or have a mental problem," Atkins, now 20, said of the surgery. "When you get news like that, you kind of find peace in it. I didn't freak out."
A month later, Atkins was in Baltimore for an experimental operation at Johns Hopkins Hospital. Neurosurgeon Alexander Coon performed an innovative, minimally invasive surgery deep inside Atkins brain using a combination of treatments, including a device meant for treating aneuryms in the large arteries of the neck.
"It's a very daring treatment," said Coon, a specialist in the cerbrovascular field in Hopkins' Department of Neurosurgery. "We spared her months of recovery and not only was this aneurysm cured but she's gone on to live a very normal life and will live a normal life because of it."
He has since performed three or four similar procedures, he said. A paper he submitted on Atkins' case to the Journal of Neurointerventional Surgery is being peer reviewed for publication. He also has given presentations on it to doctors from around the world.
"I don't want to say it's controversial, but it's highly discussed because it's a tricky thing to do," he said.
What made the surgery unique is where he used the device. The California neurologist Atkins' parents first consulted told her the size and location of the aneurysm was very problematic. It was deep near a part of the brain that controls the body's ability to breathe and stay awake. The neurologist urged the family to go to Hopkins, where she had studied with Coon.
Typically, aneurysms are closed off with coils that promote clotting or they are clipped off to block blood flow to the aneurysm. But the location meant the clipping procedure would likely damage her brain and leave her with disabilities, and the coils were likely to fall out because of the aneurysm's size.
Coon recommended using a combination of the coils and what's known as a pipeline embollization device. Approved by the U.S. Food and Drug Administration in 2011 for treating large aneurysms in the carotid artery, the device is a stent made of platinum and nickel-cobalt designed to cut off the blood flow to the aneurysm, reducing the possibility it may burst or grow further.
Combining the two procedures offered a way to secure the coils, but the trick was the device was intended for use in the arteries feeding blood into the brain not deep in the brain itself. Coon figured such surgeries had been performed in maybe a handful of cases around the world before he tried it on Atkins.
"Medicine doesn't do a great job of making devices and treatments for the exceptional, extraordinary cases because they are few and far between. It requires imagination to apply the tools we do have," Coon said. "This stent was not designed for what we used it for in Brianna, but we were able to think outside of the box."
The entire procedure was performed through an artery in the groin, threading the coils and the stent up into the brain.
Christopher S. Ogilvy, director of the Brain Aneurysm Institute at Beth Israel Deaconess Medical Center in Boston, said the stent technique is increasingly being used.
"We really need all of these techniques to treat aneurysms and pick the lowest risk and highest efficacy treatment for any given aneurysm," Ogilvy said. "Lots of time in medicine it's choosing the right tool for the right problem to give you the best results."
Brain aneurysms are more common in women and often afflict smokers or those with high blood pressure. Some are hereditary.
About two million Americans have unruptured aneurysms that they may not be aware of, according to the Aneurysm and AVM Foundation. About 30,000 of them rupture each year, killing about half of the patients and leaving two thirds of the survivors with disabilities.
Of the roughly 350 aneurysm surgeries preformed at Hopkins each year, only about two are done on people under 20, Coon said. He said it's not clear what caused Atkins' aneurysm.
Atkins immediately left school when she was diagnosed. Her parents spent the next few weeks staying up at night in shifts to watch her to make sure they could act quickly and call 911 if the aneurysm burst as she slept.
Angel Adams, her mother, called the diagnosis "devastating and scary." One doctor told her Atkins should be careful not to sneeze to prevent a rupture.
"It's hard to think that if it ruptures, she'll be dead," said Adams, of Apple Valley, Calif. "We didn't want to think that. We weren't willing to accept that as her fate. We worked around the clock making phone calls to get what needed to be done so that she would have a chance."
When Atkins woke up from the surgery, her only complication was that her left leg was immobile. But after about six hours, she regained the use of it.
"The recovery was the most painful part," she said. "We had to stay in Baltimore for a couple days after, just in case anything happened. I would stay in the hotel room in the dark because nothing helped, it was miserable. Then the headaches got less severe. Now I only get headaches when I get tired."
Atkins' teachers sent her schoolwork to do at home while she was recovering and she ended up graduating on time at the top of her class and attending her senior prom.
Atkins is now a full-time student at California State University Channel Islands, where she is studying liberal arts and education. She hopes to become a kindergarten teacher. She also works full-time as a server at a restaurant.
Atkins said her family's support was crucial to her getting through the health crisis and recovering. She said she feels lucky to have come out of the surgery unscathed.
"It was a really good experience, I got lucky with Dr. Coon," she said. "I'm really happy with where I am, I'm really grateful."