In the summer of 2021, Nicholas Friedman, then 17, was enjoying time in Hawaii when he began getting severe headaches.

“I didn't think too much of it and figured they’d go away,” said Friedman, a swimmer from the Lake Norman area of Charlotte who collects comics and loves go-kart racing and trampoline parks. “But they didn’t really go away.”

Around the same time, he started having small seizures as well as an unexplained numbness in his body that would come and go several times a day.

“With the seizures, I would not necessarily black out, but I’d go into a state where I wouldn’t listen to anyone,” he said. “I didn’t really pass out, but I would lean my head back and (later) forget everything that happened during those two or three minutes. Then, I would wake up.”

Dr. Ziad Hage
Dr. Ziad Hage

Ultimately, it was the numbness that led him to the ER at Novant Health Presbyterian Medical Center, recalled Dr. Ziad Hage, the board-certified and fellowship-trained cerebrovascular and endovascular neurosurgeon at Novant Health Brain & Spine Surgery - Cotswold who would operate on Friedman.

Hage leads cerebrovascular neurosurgery for the Novant Health Charlotte region and specializes in skull base surgery, cerebrovascular and endovascular neurosurgery – a less-invasive way to treat problems with blood vessels, such as aneurysms.

An aneurysm is an abnormal bulge in the wall of a blood vessel. It can burst, causing internal bleeding and often leading to death. In 2022, medical teams treated dozens of brain aneurysms at Presbyterian Medical Center, which also has top certification as a comprehensive stroke center.

neuro neurology MS brain health multiple sclerosis

When you know something isn't right: get to your doctor.

Start here

Brain aneurysms often don’t cause symptoms, so people may not know they have one – even if it’s large. But Friedman had symptoms. In that way, he was lucky.

When a patient has the symptoms Friedman had, doctors often suspect a tumor. But he had an aneurysm. In fact, he had what doctors call a “giant” aneurysm, based on its size (2.6 centimeters) and complexity.

A 10-minute window

When Friedman came to the ER on June 24, 2021, he first had a CT scan, which showed a large, rounded lesion on the left side of his brain that seemed to have some swelling. Next, an MRI mapped the size of the lesion. Some times physicians take a wait-and-see approach to aneurysm. But in Friedman’s case, Hage determined that was too risky. He needed to operate. And while it wasn’t emergency surgery, there was a sense of urgency to it. The operation needed to happen within days – not weeks or months. Hage performed surgery on June 29, 2021 – just five days after Friedman had come to the ER.

Hage was out of town but returned to Charlotte to perform the intricate surgery.

“When it comes to making the decision to treat brain aneurysms, there are two main ways to go about it,” Hage said. “We either do open brain surgery or endovascular treatment, which is less-invasive.”

An angiogram – an X-ray photograph of blood vessels – allowed doctors to look at Friedman’s brain blood vessels and plan treatment. In his case, the main vessel feeding the aneurysm was narrowed down at one point substantially – that’s called a stenosis. So, the endovascular approach was deemed too risky.

“We had to bite the bullet,” said Hage. To prevent giving Friedman a stroke, Hage had to shut off the blood flow to the brain and treat the aneurysm in 10 minutes or less to preserve full brain function. He treated the aneurysm by “trapping” it with clips, effectively shutting off the blood flow to a major area on the left side of the brain – the part that controls speech, memory and understanding.

“I used a special device called an ultrasonic aspirator to suck out all the clot,” Hage said. “And then it became easy for me to put the clips on and reconstruct the base of the aneurysm – shut it off completely – while keeping the native, or parent vessels, open. Once that was completed, we did an intraoperative angiogram – something we generally do in the angiogram suite – while still in the OR. It showed the aneurysm was completely gone.”

The entire operation took about five hours and involved Hage and seven others in the OR.

If left untreated, Friedman’s aneurysm could have ultimately led to a severe brain bleed, which may have led to disability or even death.

Hage scans

Friedman's CT scan showed a swelling lesion on the left side of his brain.

Hage Patient hospital

The operation took around 5 hours. An aspirator was used to suck out the clot to make it easier for Dr. Hage to reconstruct the base of the aneurysm.

Delivering the best for patients

Unrelated to Friedman’s surgery, Hage was the first surgeon in North Carolina to perform minimally invasive surgical evacuation of a deep brain bleed using a state-of-the-art controlled neuro-suction device. It’s an intricate procedure that involves the surgeon making, with the help of a camera, an opening in the forehead the size of a pencil. See story and video here.

Hage’s patients have referred to him as a hero. “My pledge is to always deliver the best and most up-to-date care for my patients, combining state-of-the-art technology with utmost compassion,” he said.