Fifteen-year-old Sarah Brenzel lay awake on an operating room table as doctors slowly slid a catheter through an incision in her groin, up her femoral artery, through her aorta and, finally, up into the arteries in her brain. She started to shake. The doctor quickly reminded her that one wrong movement could puncture a vessel and cause a stroke or death. She lay still once more.
After hours of painstaking maneuvering they got to the spot: a large, oblong aneurysm in the middle cerebral artery.
For nearly three years, Brenzel ’12 had been shuttled back and forth from doctors’ offices and technicians’ labs. She was often absent from school. And she was living trapped in a chronic migraine.
She had a rap sheet of emergency room visits and a cabinet full of discarded painkillers, estrogen patches and antidepressants that had done little to eliminate her headaches but had resulted in dangerous blood pressure readings. She had been pricked and tested and scanned over and over.
She had seen pediatricians and dentists, gynecologists and cardiologists, neurologists and nephrologists, all searching for the cause of this mysterious and escalating pain.
By 2005, she had consistent headache pain with spikes of severe episodes. The Brenzel family was desperate for a doctor who could find and treat the cause more aggressively. Sarah was referred to a pediatric neurologist at Yale New Haven Hospital, Dr. Susan Levy, who changed the medication regimen and also took a look at Sarah’s family history. There she found a potential clue: a maternal grandmother who died in her 50s of an aneurysm in her brain stem. Levy realized a brain aneurysm for someone Sarah’s age was rare. Very rare. But she decided a magnetic resonance angiogram (MRA) would provide pictures of the blood vessels inside the brain that could help doctors rule out some improbable causes.
Instead, it brought one to the fore.
The MRA in November 2005 revealed an 8-millimeter, unusually formed aneurysm in the middle cerebral artery near the temporal lobe. Because that artery supplies blood to the parts of the brain that control motor, sensory and language abilities, the aneurysm was of grave concern.
“When we first got the diagnosis back, we thought well, good news and bad news,” says Jeffrey Brenzel ’01Ph.D., Sarah’s father. “The good news: we know what’s causing the headaches. The bad news: it’s an aneurysm.”
It’s been estimated that 3 million to 5 million Americans have some sort of cerebral aneurysm. Many of them will never know that one of their arteries is bulging and weak. Aneurysms don’t typically show any symptoms. Most are found by happenstance — after a car accident, looking for the source of dizziness or nerve damage — or because a family history necessitates a scan. There isn’t a definitive reason for the formation of aneurysms, but research names heredity, hypertension and trauma as some of the leading potential causes.
To understand a cerebral aneurysm, picture a balloon. If you start to blow up the balloon, the latex will stretch. The more the balloon inflates, the thinner the skin will become. If the walls get weak enough, the latex will pop and rip, letting all the air escape. In the brain, when a vessel rips because its walls are too thin, the blood from inside the vessel leaks into the brain instead of flowing where it should. The lack of blood to the rest of the brain can cause a stroke, severe brain damage or death. But up until that point, an aneurysm isn’t necessarily harmful, unless it’s causing, say, migraines or cognitive deficits, like in Sarah’s case.
Even so, doctors at several hospitals were reluctant to operate. They couldn’t definitively prove this was the cause of her headaches, and operating on an aneurysm is often more dangerous than the aneurysm itself. Robert Solomon, one of Sarah’s doctors and the chairman of neurosurgery at Columbia University and New York Presbyterian Hospital says he and his team first wanted to monitor the aneurysm to see if it was a threat to Sarah’s health and well-being. In the first six months that they observed the aneurysm, it grew by 20 percent. “I assume if an aneurysm is growing, that means it’s unstable,” he says. The instability meant it was time to operate.
“I felt like I was walking around with a time bomb in my head,” Brenzel, now 25, says. “I was reading everything as a signal of what was going on in my head.”
Every time she sneezed, she wondered if the vessel would explode. Every headache made her wonder if a stroke would follow. The stress of the aneurysm combined with the severity of the symptoms and the number of doctor visits eventually forced her to withdraw from her junior year of high school.
Because she was no longer at school and had to be removed from all physical activities that could worsen her condition, Sarah lost touch with friends and the typical life of a teenager. To pass the time, she logged into some old video game accounts her brother had set up when they were younger. Neopets — recognized predominantly as a children’s game where players can care for virtual animals — caught her attention. It turned out there was an underground economy in the game that had to do with purchasing and selling items for points. Sarah, a petite and athletic blonde, had never been much of a gamer, that had always been her brother’s realm, but with so much free time she quickly moved up the ranks as slim_shady_63 (a nod to a brief and embarrassing period when she was a fan of Eminem, she jokes), and other players took notice.
Once doctors noticed the aneurysm was growing and surgery was inevitable, they insisted she be confined to her Connecticut home to avoid the risk of illness or an injury to her head. As doctors debated the best course of action, she stayed in her home day-in, day-out for three months, with the exception of trips to doctors’ offices.
“After two months of being home and not leaving the house, I went out for a short walk by myself around the cul-de-sac my house was on. I was so winded. I hadn’t felt like I was in that bad of condition while I was in the house, but as soon as I went outside, I had to stop and sit on the curb. It was pretty alerting.”
The situation wasn’t great for her physical condition, but it did allow Sarah to improve her video gaming considerably. “To play well, you need to devote all day, every day to it or you fall behind,” she explains. She had plenty of free time and quickly became a whiz at Neopets, an expert at acquiring rare and lucrative items. She also found a community of gamers in Unreal Tournament, a first-person shooter game. In that game, a team-speak headset allowed users to communicate while they played and a community chat room let them continue messaging even when they weren’t playing. The friends she had lost from school she replaced with those online who knew little of her medical saga.
“It was just nice to have someone to come home and talk to and not have them see me with my head shaved or with a huge dressing on my groin area,” Sarah says.
Even once she realized others in the group were active online for similar medical issues, she said they didn’t discuss it much, preferring instead to let the online world be their refuge. “We were all there for a similar reason, to just coexist and be friends.”
In order to operate on an aneurysm, the plan of attack first has to be clear. Several treatments can work to stop blood flow to an aneurysm. For many, a clip that pinches off the opening of the aneurysm is sufficient. In that case, the aneurysm is effectively separated from the vessel, which stops the pressure on the weakened walls and allows blood to flow normally through the artery. To go back to the balloon example, it’s like tying off the open end, ensuring no more air can inflate the balloon and weaken its walls. It effectively removes the risks.
Sarah’s aneurysm presented several obstacles. First, her age. Though Solomon has done more than 2,000 aneurysm operations in his career, only 10 to 15 of those have been on teenagers. The rarity of the diagnosis for a teenager was a bit daunting, but he suspected that her brain might be more malleable and receptive to treatment.
“The brain of a young person like that can withstand a lot of problems and still not be irreversibly injured,” he says. “Young people tend to make excellent recoveries from any type of surgery on the brain.”
But Sarah’s aneurysm was oddly shaped and would prove difficult to operate on. It was elongated and did not have a singular opening that doctors could shut off from the healthy artery. It was as if one whole side of the artery had just puffed out.
“She had a very unusual type of aneurysm that is not typical of what we see in adults,” Solomon says. “The whole artery was expanded, not just a single bubble coming off the side of an otherwise normal artery. . . . We couldn’t just cut off the artery because that artery was supplying blood to important parts of her brain.”
Doctors thought they could possibly use a coiling procedure, which involves packing the bulge with platinum coils so blood flow can no longer push on the weak walls and cause enlargement. But they feared that filling the section with coils could block the vessel entirely and Sarah would lose the brain functionality associated with that pathway.
That’s when one of the consulting doctors came up with an idea: What if Dr. Philip Meyers, an interventional radiologist at Columbia, were to anesthetize the aneurysm, thereby simulating what would happen if doctors were to shut down that vessel? Sarah would take a baseline cognitive exam before the treatment and another after the anesthesia was administered. By comparing the results, doctors would know exactly which functions could be hindered by the surgery before they went through with it. If there was no serious impairment, they could coil the aneurysm then and there, and that would be the end of the aneurysm saga. If they did notice a significant difference, doctors would have to go back to the drawing board and assess more invasive procedures.
The process would take several hours and would begin in Sarah’s hip, in the femoral artery. Dr. Meyers would slowly and painstakingly work a catheter all the way up Sarah’s brain in order to numb the vessel. And because Sarah needed to take the verbal test as soon as the vessel was numb, she had to stay awake for the entire process.
And so, in February 2006, Sarah was lying flat on an operating room table, eyes gazing upward, while a catheter loaded with an anesthetic snaked through her body. Meyers got to the affected artery and administered the anesthetic. He also blew up a balloon within her artery to temporarily clog it. Once it was blocked, doctors repeated the baseline neurological tests.
“What do you use to drive a nail into a board?” a doctor asked Sarah.
Sarah remembers being able to see a hammer in her mind, she could see the letters that spelled hammer, but she could not think of or say the word hammer.
“When I was on the table, it didn’t seem like a big deal. I couldn’t say things but I thought, ‘Oh, I’ll figure it out.’”
But it was a big deal. After just a few tests, Meyers concluded the discrepancy between the results was too severe to continue with the coiling procedure. Sarah would lose too many language skills. Sarah begged him to go through with it, not realizing her verbal skills had deteriorated to that of a stroke victim.
“You feel normal. You think your communication is normal, but from the objective perspective of [Dr. Meyers], it was much more severe,” she says.
The medical team removed the balloon, extracted the catheter and sent Sarah home, the aneurysm still growing in her brain.
The doctors determined there was only one remaining option: a bypass. It would involve shaving a part of Sarah’s head and extracting a blood vessel from her scalp. They’d sew one end of the new vessel on the original artery, upstream from the aneurysm, and the other end to a section immediately after it. The two pieces would be spliced together using a thread so small that is invisible to the naked human eye. Once it was attached, they would reroute the blood flow to use the bypass loop instead of the part with the aneurysm, and Sarah could likely return to normal life. There were risks of course — stroke, permanent brain damage, death — but it was the only option left, says Solomon. He also was optimistic that Sarah’s young brain would respond favorably to the bypass.
Doctors posed surgery as the recommended option but said Sarah could also choose to wait while they continued monitoring the aneurysm, although it could rupture at any time. They explained all the risks in either situation. At age 16, Sarah made the decision to go through with the surgery.
On May 23, 2006, doctors prepared Sarah for surgery by icing her body to slow blood flow. They hoped this would give them enough time to operate and reroute the stream without depriving her brain of blood and causing a stroke. They bolted her head to the table — leaving two screw-shaped scars near the base of her skull, though they’re now covered by her grown-out hair — to ensure her head could not, would not move at any point during the surgery. Any minute shift could drastically change Sarah’s outcome.
First, they dissected the superficial temporal artery, the one they would implant, from the scalp. Then they sawed an opening in her skull and removed the bone. Meticulously, slowly, Solomon massaged the brain folds to reveal the affected vessel. A bulging artery, like a blown out tire, stared back at him.
The time in the waiting room during the operation was excruciating, Jeff Brenzel says. Doctors had predicted the procedure would be three or four hours, but as hours five, six and seven ticked by, worry set in.
“Columbia Presbyterian is one of the top places for cerebrovascular surgery in the country, so this particular doctor and this particular facility see some of the most complicated cerebrovascular surgeries,” Jeff says. “There were lots of families there waiting. It’s a busy place. Of course, the entire time you’re waiting, there are doctors coming out and talking to families. Some families are getting bad news, some families are getting good news. In this kind of place, they all had different problems, obviously, the people being operated on, but in this kind of place, bad news is generally very bad news.
“We saw some very tough family scenes in the five or six hours we were in the room. And of course we saw families go through some tremendous relief. You can imagine how keyed up you would be waiting to see your doctor come through the doors. When Bob Solomon finally came through the doors, it looked to me like he had been in some kind of fight.”
Jeffrey recounts that Dr. Solomon quietly walked in with a blank facial expression and slumped down next to Sarah’s mom, Sally. He took her hand and quietly said, “She’s going to be fine. The operation went well. It was just more difficult than we expected.”
Three days later, Sarah was discharged from the hospital. A month later she took a walk outdoors. Then saw a friend. Then went to Six Flags. By August, she was playing softball once more, though in a limited capacity. Even with a quick recovery and the medical issues behind her, some of the psychological wounds were not yet healed. She had dropped out of school and would need to start her junior year over again that fall at a new school. She didn’t leave the house often because she still had a large bald spot from the operation and didn’t want to face any inquisitive stares.
In an effort to get Sarah out of the house, Jeff asked her to attend a lecture at Yale, where he was dean of admissions. Bing Gordon, chief creative officer at the video game developer and publisher Electronic Arts (EA), was on campus to talk about gaming. Despite her interest in the field, she refused to go. Her dad was relentless and eventually forced her to attend.
Gordon remembers Sarah vividly. She was the only girl in a room of 30 Yale computer science nerds and came up to him afterward with questions. He was charmed. “If you ever come to California with your dad on one of his trips,” he told her, “come on and I’ll give you a tour, and you can see how video games are made.”
She was enthusiastic, so he offered her a one-week high school internship at EA. “I like to give them a project that at the end of the week they can present to 30-year-olds. Like a thesis,” Gordon says. He had a project in mind about Sims: Castaway for Wii, but it became clear that her experience with Neopets could translate well to Sims Animals. He offered her the option of the two projects. She said she’d do both.
In the summer of 2007, Sarah flew to San Francisco to do the two projects for EA. Near the end of the week, she asked for an extension so she could continue her research. Gordon acquiesced and watched her work around the clock for days on end. He expected a 5-minute pitch, but instead, 16-year-old Sarah gave a 45-minute analysis to a room of 20 EA employees. At the end, an MBA in the crowd snipped, “Well, that sounds pretty simplistic.”
Gordon remembers that without missing a beat the confident intern responded, “No, I’m afraid you have that wrong,” and she continued to explain the economics behind games like Pokemon and Neopets. Then, Gordon knew Sarah would be a good hire. So did Chip Lang, the head of EA’s Hasbro division. He thought Sarah’s knowledge of Neopets could transfer to Littlest Pet Shop Online, so he asked her to return the following summer to work with him. In total, she would complete five internships with EA before graduating from college and beginning work there full-time.
In between internships, Sarah started at Notre Dame. She declared a psychology major, based on her personal experience and interest in the field of neuroscience. But as she kept getting internships with EA, she added a Film, Television and Theatre major, thinking it would help in that industry. It quickly edged out psychology as her primary course of study.
Once she graduated from ND in 2012, Sarah began a full-time position in EA’s Chief Creative Office. The rotation there is unique: Five new college grads are selected to work with 10 experienced gaming veterans on the most novel products coming out of the company. The idea is that the elder mentor the younger, and the younger revitalize the elder. Together, the group worked with Comcast to create a streaming game service that could replace the need for gaming systems like Xbox or PlayStation and would allow subscribers to play such games as FIFA and Madden from their cloud-connected cable box.
As they were wrapping up the project, Sarah was ready to devote her time to a singular game. As she looked for something fresh, Zynga, another gaming company in San Francisco, came on her radar. She hadn’t been interested in developing their franchises like FarmVille or Words with Friends, but an innovative game proposal from the firm’s new CEO intrigued her.
Zynga is a developer of social games, games that let you play with others remotely through social media and mobile devices. It’s lodged in a six-floor warehouse in the South of Market district in San Francisco. Inside, Zynga provides three meals a day to all its employees, has an on-site gym with free classes, hosts social mixers and happy hours to help connect its 1,900 employees, and allows employees to bring their pets to work. It’s lively and quirky and creative — a perfect mirror of Brenzel’s personality.
What her team is working on is still under wraps, but the mobile app will provide something new to Zynga’s clientele. As a producer, the 25-year-old helps manage the day-to-day workflow of the 16-person team. She does market research and influences decisions that determine how this product can become profitable. She organizes trials of the game, manages freelance contracts, creates presentations to give within the company, helps oversee spending and budget, and is one of the glue people who keeps right-brained creatives and left-brained programmers all speaking the same language.
She has what Gordon calls a magic personality. “One way to tell if someone is a leader is if other people want to hang out with them,” he says. True enough, at a Zynga event, people flock to her. From the head chef of the company to Words with Friends developers to recruiters, they all gravitate to her sphere to chat with her over a pint of Zynga-brewed beer, and then follow her when she campaigns to go out for Thai food after work. She’s obviously the life of every party but is also intensely driven.
With that drive comes goals. Sarah has two missions pertaining to the gaming world. The first is to break the notion that women can’t game. She explains that before the advent of social gaming, your typical user was a 13- to 30-year-old male. But smart phones and low time-commitment games such as Words with Friends have leveled the playing field and removed the nerd stigma for women. Nowadays, you’re just as likely to see a 40-year-old woman logging in as a 16-year-old boy.
Her second goal is to eradicate the belief that games aren’t useful.
“There’s a lot of lash back about gaming in a lot of different ways,” Brenzel says. “One, that people waste their time and rot their minds playing games. Then also that it can have an influence on violent behavior, especially the shooter games.”
What’s overlooked, she says, is that video games can have a positive influence on behavior, too. When she became interested in working in the gaming industry, she was invited to a retreat with advisers for a conference for Games for Health, a group of health care and game development professionals trying to improve patient treatment.
“When you’re completely engaged in something, you absorb it better,” Sarah says, explaining that if you can get someone immersed in a game, you can subtly deliver information to help them to better understand their illness and their treatment, without force-feeding them medical literature or lectures. “If you really walk that line between fun and educational, then people won’t be able to tell they’re eating broccoli. It’s like broccoli with cheese on it. They’ll be having fun while also gaining the benefit of the game.”
Zynga’s nonprofit, Zynga.org, allows her even more access to professionals in this budding field. Right now the group is partnering with Adam Gazzaley, a professor of neurology, physiology and psychiatry at the University of California San Francisco, whom Sarah met at that Games for Health retreat, to try to answer the question: “Can you get the benefits of prescription medicine from playing games?” Initial studies suggest the answer may be yes. Gazzaley’s lab has been responsible for Project: Evo, a game designed to counteract mental aging and decline; and Glass Brain, an app that allows users to don a cap with EEG electrodes and then watch a 3-D model of their brain activity and connectivity in real time. The collaboration between Zynga and the Gazzaley Lab produced its first game, a meditation app, in fall 2014, and the team is working on other mobile games to bridge the fields of neuroscience and gaming.
Sarah summarized it best in a Facebook post last May: “Being withdrawn from high school for a year of quarantine, several surgeries and recovery, at the time, was a devastating part of my life. Now looking back, I see that not being able to leave my house for almost a year was a blessing, because it immersed me in the magical world of video games. Those few difficult years have transformed my life into the remarkable thing that it is now, by equipping me with the knowledge to move to California and work my dream job.
“I wish I knew back then that the bad would turn into unimaginable good, and that eventually I would be more grateful for that challenge than anything else in my life. I don’t talk about this often, but the contrast of that day to today is extraordinarily affecting. In 8 years, the scars have healed, and then some.”
Tara Hunt is an associate editor of this magazine.