Cerebrovascular Disease and Stroke

Patient Stories | David and Arteriovenous Malformation (AVM)

Pediatric Stroke Survivor Returns to Cincinnati Children’s as Intensive Care Unit Nurse

David Moskowitz was 17 years old when he suffered a rare pediatric stroke. 

Within days, the seemingly healthy high school senior went from playing lacrosse to battling for his life. 

He survived–thanks to his doctors, nurses and care team from across Cincinnati Children’s–and now enjoys paying it forward as a full-time nurse in the pediatric intensive care unit (PICU) at Cincinnati Children’s.  

“They saved my life, and I’m forever grateful,” says David, recalling the most difficult time in his life. “And they were amazing in helping me transition [from the hospital] to living a normal life again.”

For David, the transition included six months of grueling occupational therapy and physical therapy (OTPT). But he persevered, overcame challenges and difficulties, and four years later, he graduated from the University of Cincinnati College of Nursing and achieved his dream of becoming a PICU nurse. 

Back inside the same PICU where he spent a month after his brain bleed and stroke, David strives to provide the same great care for his patients that his nurses provided for him years ago. 

“I like being able to communicate with a patient one-on-one. Getting to know them, really figuring out what works best for each patient and just personalizing the care,” he says. “[My nurses] did a really great job of that for me, and I want to do that for the patients that I take care of.”

A Life and Death Situation Leads to Arteriovenous Malformation (AVM) Diagnosis

His doctors and family agree, David’s accomplishments represent a remarkable recovery and turnaround from when he first received the official diagnosis of an inoperable arteriovenous malformation (AVM). 

The AVM, which is essentially a tangle of blood vessels with an abnormal connection between arteries and veins, was wrapped around David’s brain stem. High-pressure blood flow from the arteries was bypassing capillaries that feed David's brain and instead going directly to his veins and back to the heart, which caused his brain bleed and the potential for the AVM to burst again. 

His pediatric endovascular neurosurgeon, Sudhakar Vadivelu, DO, knew the only option was to stabilize the AVM as soon as possible. 

“His [AVM] was definitely in an area that was quite dangerous, which limited what we could do, like open surgery,” says Dr. Vadivelu, who was concerned that if the AVM ruptured or showed any more growth, David could die. 

As a first step, Dr. Vadivelu and his team performed a mapping of the abnormal brain blood vessels through a diagnostic cerebral angiogram. This X-ray-guided procedure allowed him to create a map of David’s AVM and determine what arteries could be blocked safely using a glue-like substance.  

David’s AVM was highly dynamic and kept changing his symptoms within hours each day, alerting Dr. Vadivelu’s planned approach to plug up the abnormal blood vessels. 

Due to the location of the AVM, Dr. Vadivelu knew David needed to begin a definitive treatment plan sooner than later. This plan would include stereotactic radiosurgery (a form of radiation treatment) that would slowly kill the AVM over the course of three years. 

But before David could begin radiosurgery, Dr. Vadivelu had to treat David’s volatile AVM as best as he could. 

“I took away the blood vessels with the most risk in causing the AVM to re-rupture. With this thought, I could slow down the flow rate of the AVM enough so that it was safe for him to go on to our definitive radiosurgery treatment,” says Dr. Vadivelu, recalling the successful procedure. 

With David’s AVM stabilized, Dr. Vadivelu and Luke Pater, MD, a radiation oncology specialist from the University of Cincinnati College of Medicine, performed stereotactic radiosurgery a month later. In May 2021, an angiogram showed the overall treatment was successful, and David’s AVM had gone away. 

Released from Hospital, Long Road to Recovery Begins

David was released weeks after initial radiosurgery but still faced a long road to recovery. He couldn’t move, having lost mobility in the right side of his body, and his vision was severely compromised. Still, David worked hard each day during six months of OTPT.  

“It was the most exhausting time of my life, by far,” says David. “I would go to bed exhausted, and I’d wake up exhausted.” 

But he was committed to finishing high school. And despite the short and long-term effects of his stroke, David began attending the University of Cincinnati College of Nursing in August of 2018.

Four years later, he graduated. Excited for the future ahead, David also recognizes (along with his doctors and parents, Sara and Jim) that as a patient with a background of hereditary hemorrhagic telangiectasia (HHT), there is a risk of other AVMs forming.

In HHT, abnormal connections occur between blood vessels. According to Dr. Vadivelu, HHT patients sometimes have small or developing AVMs which require monitoring with noninvasive MRIs (magnetic resonance imaging) every six months. David is no exception. 

“So [David] has a small tangle that’s not showing high flow shunting, but the vessels look a little abnormal and small,” explains Dr. Vadivelu. “It’s not showing the definition of an AVM, but we have to have concern that this could change over time. And that’s why medical follow-up is extremely important.”

And it’s why David’s parents, as parents are prone to do, will continue to worry about their son and hope he remains healthy.  

“My fear is that it’s micro now, but what if it changes?” asked Sara. “You don’t know.”

Uncertainty remains, but what David and his family (including twin brother, Jack, and older sister, Hannah) do know is they are years removed from one of the scariest moments in their lives and David  received the best care possible at Cincinnati Children’s.

“Cincinnati Children’s was a fantastic hospital. My doctors and the PICU staff—I wouldn’t be here today and where I am without them taking care of me,” says David. “They were so compassionate and kind. And fantastic care for not only me but [also] my family during that tough time.” 

(Published August 2022)