Aneurysm in a Brain Tumor: A Surprising Diagnosis Saves a Life

There is no such thing as a "typical" brain tumor. But, when particularly challenging cases arise, patients from across the country seek out neurosurgeons at Yale Medicine.

Life saver

The discovery of an aneurysm within a tumor in Kaitlin Eppinger's brain meant Yale Medicine surgeons had to perform a complex operation.  

Credit: Peter Baker

Kaitlin Eppinger had plenty of reasons to be tired in the fall of 2014. The 28-year-old Stonington resident had a newborn daughter and was in her first year as a kindergarten teacher. She also had recently been diagnosed with Lyme disease.

But this was beyond exhaustion. Eppinger’s vision sometimes blurred when she stood. Once, while talking to her classroom aide, she blacked out. Constant migraines were crippling, and mysterious. Could they be a symptom of her Lyme disease? One physician suggested they might be caused by dehydration.

Then one day, Eppinger felt tingling on one side of her face and down her arms. Her doctor told her to go to the closest emergency room. There, magnetic resonance imaging (MRI) revealed a tumor the size of an orange on her brain’s right frontal lobe. Because the tumor was so large, Eppinger was referred to Smilow Cancer Hospital at Yale New Haven.

That would prove to be a life-saving decision after Eppinger was diagnosed with a rare complication—an aneurysm in her brain tumor—that  required quick thinking by her surgical team as well as the high-tech tools available to doctors at Smilow.

Not just a brain tumor

At first, Eppinger could only think about her daughter, Violet. But she soon began making plans, leaning on family and friends for support. She shared the news with her colleagues and enlisted her in-laws to care for Violet.

“I really tried not to let myself go anywhere dark or scary,” she says. “I had to focus on this, one step at a time.”

In October 2014, three days before her 29th birthday, Eppinger and her husband visited the office of Jennifer Moliterno, MD, a Yale Medicine neurosurgeon who operates exclusively on brain tumors. Dr. Moliterno laid out a plan for surgery, and Eppinger felt reassured. “She put it simply for us: ‘This is not supposed to be there and we are going to get it out,’ ” Eppinger says. “From that point on, I trusted her completely.”

Dr. Moliterno scheduled the surgery but kept mulling some nagging questions. It was not clear why Eppinger was having vision problems, given the location of her tumor. While studying the MRI scans, Dr. Moliterno noted a small, subtle shadow inside the tumor. “It could have been some calcium within the tumor, which can be common,” she says. “But it was a little bit peculiar looking and concerning to me.” 

Dr. Moliterno thought it could be an abnormality related to a blood vessel in the brain—perhaps something supplying blood to the tumor. She ordered a CT angiogram (CTA), a test that makes blood vessels light up.

Jennifer Moliterno, MD

By spotting an aneurysm in Kaitlin Eppinger's brain tumor, Jennifer Moliterno, MD, saved her life.

Eppinger had the CTA the day before her surgery, and Dr. Moliterno saw the images at home that night. Sure enough, they showed a robust vascular supply to the tumor. They also showed something else that is exceedingly rare: a large aneurysm inside the tumor. An aneurysm is a blood-filled bulge in the wall of a blood vessel. Eppinger’s was about the size of pea.

This last-minute diagnosis was unexpected, but the timing was fortunate. Encountering the aneurysm during surgery might have caused it to rupture. Given its location deep within the tumor, it could have led to uncontrollable bleeding that would have put Eppinger’s life at risk. “This tumor was particularly large,” Dr. Moliterno says. “My thought was that the tumor required so much blood to support its growth that it weakened the wall of the blood vessel, and an aneurysm formed deep within the tumor. We had to address it because we had to remove the tumor to save her life.

Two problems, one team of doctors

Dr. Moliterno needed to make dramatic changes to a procedure scheduled to begin at 7:30 a.m. Early in the morning she alerted colleagues,  including Charles Matouk, MD, the neuroendovascular surgeon who would seal the aneurysm so she could remove the tumor safely. Now extremely complicated, the procedure would require the involvement of at least 20 people.

That morning, Dr. Moliterno told Eppinger about the aneurysm. “She told me, step by step, what she was going to do,” Eppinger says. “She was very personable, and so calm and very caring, and very interested in me and my life. She knew I had a daughter and I was just married and had a big family. I knew I would be OK with her.”

With her doctors’ approval, Eppinger took a book of photos of Violet with her into the operating room. A nurse held the photos for Eppinger to see as the anesthesia took effect. “I went under with good thoughts about my family,” she says. Her husband, her two sisters, and her parents were in the waiting room.

Connecticut’s only hybrid neurosurgery suite

The hybrid neurological suite at the Smilow Cancer Hospital gives Yale Medicine’s Department of Neurosurgery an important advantage. Smilow is the only hospital in Connecticut— and one of the few in the world—to offer this technology, allowing complex procedures to be performed in one suite. In most other hospitals, Eppinger’s two surgeries would have been performed in separate parts of the hospital by separate teams using different equipment. Simply transporting the patient from one space to the other might take hours, Dr. Matouk says.

To contact Yale Medicine's Department of Neurosurgery, click here.

scans

Charles Matouk, MD, and Jennifer Moliterno, MD, review the scans of Kaitlin Eppinger's brain.

Working under high magnification and using X-ray guidance, Dr. Matouk began what would be a three-hour procedure to seal the aneurysm to prevent it from bleeding. After inserting a needle into Eppinger’s groin, he sent catheters through her body and up to her brain. Then, watching his progress on a screen, he inserted a catheter tip into the aneurysm.

The situation called for creative thinking. All tumors require a blood supply for growth; Eppinger’s had accumulated many blood vessels that reached deep inside the tumor. It would be too dangerous to treat the aneurysm with the typical embolization approach, which involves filling the aneurysm with metallic thread, or coils, to keep out the blood. Instead, Dr. Matouk used a special glue to fill the tumor and aneurysm. This effectively closed the aneurysm and choked off the tumor’s blood supply, allowing Dr. Moliterno to remove the tumor. “It worked out fantastically,” Dr. Matouk says.

Dr. Moliterno’s work was far from finished. Halting the blood supply to the tumor could cause both the tumor and Eppinger’s brain to swell. Even a few moments of this could be critical. If Eppinger had needed to be transported from one part of the hospital to another, she might have faced grave danger. “She could have had life-threatening issues in the time it would take to get her from another part of the hospital to the operating room for me to take out the tumor,” Dr. Moliterno says.

In the hybrid operating room, the switch took minutes.

An aggressive phase two

The next step was for Dr. Moliterno to perform a craniotomy—making an incision behind Eppinger's hairline, temporarily removing a section of her skull, and opening the inside covering of the brain. Dr. Moliterno spent several hours performing delicate microsurgery to remove the tumor.

Dr. Moliterno called this phase of the procedure “pretty standard,” but in truth there is nothing simple about brain surgery. When a tumor has worked its way deep into the brain, it takes great skill and concentration to extract it without damaging surrounding areas. Eppinger’s tumor was in the area of the brain that controls motor skills such as hand-eye coordination, conscious thought, emotion and personality. Also, it had become apparent that the reason for Eppinger’s vision problems was that the tumor had been drawing its blood supply from her eyes.
 
With Eppinger’s life in her hands, Dr. Moliterno tuned out everything else. “I am a very focused person, and I become even more so in the operating room,” she says. “I don’t even notice that the day is going by or that I haven’t eaten. I find the time I get tired is after the surgery, when I know I have completed what I came there to do.”

Dr. Moliterno completed her work at about 7 p.m.—though one small part of the tumor remained because it was dangerously close to an important vein. Eppinger would need radiation treatments to kill it.

“It was certainly an unusual case,” Dr. Moliterno says. “But there are always going to be curve balls and things you don’t expect. I find paying attention to detail allows me to better anticipate these things.”

Recovery and renewal

Eppinger spent three days in the hospital, including one in the intensive care unit. Her husband and family were with her at all times. At first, one eye was swollen shut, but that resolved itself and she was soon ready to go home.

There were difficulties ahead. At the next visit, Dr. Moliterno had to tell Eppinger about the pathology report, which showed that her tumor was malignant. “I just immediately started crying,” Eppinger says. The next meeting was upbeat, however. Dr. Moliterno told her patient that the tumor board at Smilow had discussed her case and had a plan. She would start radiation treatments in December and would be monitored with MRIs and CT scans to check for recurrence.

Eppinger took off the rest of the school year from teaching, deeply grateful to fellow teachers who donated 320 sick days so that she could heal. She completed her radiation treatments in February, juggling appointments with caring for her daughter. It was exhausting at times, but she did her best to take care of her health. “I didn’t catch a cold,” she says. “I didn’t have the flu. I wasn’t sick at all.”

Meanwhile, she says, she reordered her priorities. Now she tries to be less of a perfectionist. And she has put new energy into activities she finds healing, including hiking, running, yoga, and time with her husband and daughter.
 
Eppinger works hard to keep negative feelings in check. “There are periods of time where I feel fuzzy-headed, and I think I have a heightened sense of when something doesn’t feel right,” she says. “But I never let myself do the ‘what if?’ thinking.”
 
She keeps in touch with Dr. Moliterno via email, and the two exchange photos of their children. Her family asks about the doctor frequently. “Dr. Moliterno saw me as a person, not a cancer patient,” Eppinger says. “I knew that she would get me better so that I could continue being a mother to my daughter. I was so lucky to have her for my doctor. I think I hit the lottery, really.”