Transumbilical catheterization of cerebral arteries

Pediatric Interventional Neuroradiology: Opportunities and Challenges

Pediatric interventional neuroradiology (PINR) is a relatively new field of diagnostic and therapeutic care in the pediatric population that has seen considerable advances in recent decades. However, it is still lagging behind adult interventional neuroradiology due to a variety of reasons, including the lack of evidence validating pediatric-specific procedures, the relative absence of pediatric-specific equipment, and the challenges in establishing and maintaining PINR competencies in a relatively small number of cases. Despite these challenges, the number and variety of PINR procedures are expanding for a variety of indications, including unique pediatric conditions, and are associated with reduced morbidity and psychological stigma. Continued technological advances, such as improved catheter and microwire designs and novel embolic agents, are also contributing to the growth of the field. This review aims to increase awareness of PINR and provide an overview of the current evidence base for minimally invasive neurological interventions in children. Important considerations, such as sedation, contrast agent use, and radiation protection, will also be discussed, taking into account the distinct characteristics of the pediatric population. The review highlights the usefulness and benefits of PINR and emphasizes the need for ongoing research and development to further advance this field.

Standard umbilical artery catheters used as diagnostic and neurointerventional guide catheters in the treatment of neonatal cerebrovascular malformations

BACKGROUND

Vascular access in neonates is limited by the small size of the femoral artery and the risk of complications, including thrombosis and limb ischemia. Although umbilical artery access has been described, previous reports detail exchange of the umbilical artery catheter (UAC) for a conventional arterial sheath, which can be difficult and cumbersome. We aim to describe direct use of the UAC as the sheath and guide catheter in neonatal patients requiring endovascular treatment for life-threatening intracranial arteriovenous shunts.

METHODS

We reviewed all cases between 2016 and 2021 of neonatal intervention using a direct UAC approach. We describe our technique of utilizing UACs for cerebral angiography and neurointerventions in newborns without catheter exchange, allowing for repeated, straightforward endovascular access in neonates across multiple interventions.

RESULTS

Seven consecutive neonates underwent endovascular neurointerventional procedures for the treatment of life-threatening, high-flow arteriovenous shunts using a direct UAC access technique without procedural morbidity. Five of seven patients underwent more than one procedure in the neonatal period, between day 1 and day 10 of life.

CONCLUSIONS

Use of the UAC itself as a diagnostic catheter for cerebral angiography or as a guide catheter for neurointerventions greatly facilitates endovascular interventions in newborns and is ideal for patients requiring multiple interventions in the neonatal period. This technique helps to mitigate the risk of neonatal femoral artery access and its complications, including thrombosis, dissection, spasm, stenosis, and limb ischemia.

Umbilical vessel catheter retro-exchange technique (U-RET) for repeat use of the umbilical artery for neonatal vascular intervention: Technical note

A high flow arteriovenous shunts in newborns may require urgent endovascular treatment right immediately after delivery if high output cardiac failure is resistant to medical treatment. The umbilical approach is often the first choice of the access route for endovascular treatment in the newborn. It is, however, not infrequent that the patient has an extensive lesion, which necessitates a second session of treatment because of the limitation of the usable amount of the contrast material in one session. In such a case, re-puncturing the femoral artery is difficult and carries the risk of leg ischemia. On the other hand, leaving the umbilical sheath for the second procedure carries risks of infection, thrombosis, and vessel injury. Herein we introduce our umbilical vessel catheter (UVC) retro-exchange technique (U-RET) in which we replace the umbilical sheath to a 3.5Fr UVC at the end of the first endovascular procedure to preserve the umbilical artery access and prepare for the repeated use. We believe that this method minimizes the risks of infection and vessel injury.

Review on the current treatment status of vein of Galen malformations and future directions in research and treatment

INTRODUCTION

Vein of Galen malformations (VOGMs) represent a rare pathologic entity with often catastrophic natural history. The advances in endovascular treatment in recent years have allowed for a paradigm shift in the treatment and outcome of these high-flow shunts, even though their pathogenetic mechanisms and evolution remain in part obscure.

AREAS COVERED

The overall management of VOGMs requires a tailored case-to-case approach, starting with in utero detection and reserving endovascular treatment for indicated cases. Lately, the advances in translational research with whole-genome sequencing and the coupling with cellular-level hemodynamics attempt to shed more light in the pathogenesis and evolution of these lesions. At the same time the advances in endovascular techniques allow for more safety and tailored technical strategy planning. Furthermore, the advances in MRI techniques allow a better understanding of their vascular anatomy. In view of these recent advances and by performing a PUBMED literature review of the last 15 years, we attempt a review of the evolutions in the imaging, management, endovascular treatment and understanding of underlying mechanisms for VOGMs.

EXPERT OPINION

The progress in the fields detailed in this review appears very promising in better understanding VOGMs and expanding the available therapeutic arsenal.

Direct percutaneous transcarotid approach for embolization of dural sinus malformation in a premature neonate: A case report

CONCLUSIONS

Direct percutaneous TCAA can be a feasible access for intracranial interventions in neonates with LBW and unavailable UA access.

Neurovascular disease and syndromes: Diagnosis and therapy in children

The pediatric neurovascular disease runs the chronologic spectrum with dramatic changes in the presentation, evaluation, and treatment from the prenatal, perinatal, and infant periods through childhood and adolescence. These diseases are often dynamic throughout this period and the dynamic continues throughout life. There are four major categories: high-flow arteriovenous shunting lesions, arterial aneurysms, low-flow vascular lesions, and vascular occlusive disease. The high-flow lesions can be subdivided into a vein of Galen malformation, non-Galenic arteriovenous fistula, dural sinus malformations and fistula, and arteriovenous malformation. Low-flow vascular lesions include cerebral cavernous malformation, developmental venous anomaly, and capillary telangiectasia. The cerebrovascular occlusive disease can be divided between arterial occlusive disease and cerebral venous sinus thrombosis. The presentation of each of these entities can be very similar, especially in younger children; however, imaging and laboratory analysis can establish the diagnosis leading to the most appropriate therapy. A multidisciplinary team, dedicated to treating pediatric cerebrovascular disease, is important in delivering the best outcomes in these complex diseases. Given the relative rarity of pediatric presentation of cerebrovascular disease, many apply adult concepts to children. A better understanding of the diseases and their difference from adults makes a critical difference in selecting the correct approach.

Vein of Galen Malformations: The Texas Children's Hospital Experience in the Modern Endovascular Era

BACKGROUND

Vein of Galen malformations (VOGM) comprise nearly a third of pediatric cerebrovascular anomalies, with potentially devastating neurological and systemic complications. Advances in endovascular therapies have dramatically improved outcomes compared to historical surgical treatments, and neurosurgeons are an essential component of the multidisciplinary critical care team.

OBJECTIVE

To retrospectively review pediatric patients with VOGM treated at Texas Children's Hospital (TCH), a quaternary referral center, over 15 yr, and present lessons learned in treating children with modern endovascular techniques.

METHODS

Charts from TCH were retrospectively reviewed for the past 15 yr. Patients with diagnosis including "Vein of Galen," "Vein of Galen malformation," "Vein of Galen aneurysmal malformation," or any abbreviations (ie, VOG, VOGM, VOGAM) were reviewed. Presentation, imaging, treatment specifics, and clinical outcomes were reported.

RESULTS

There were 18 patients with VOGM managed at TCH from 2002 to 2018 with a total of 29 embolizations. Seventeen were performed with a single embolisate (NBCA or Onyx), and 12 with a combination. A dual lumen balloon catheter was used as an adjunct in 3 embolizations. Complications occurred in 5 embolizations (24%), including hemorrhage, embolisate migration, and femoral vessel occlusion. Surviving patients were followed for a mean of 38 mo, with 12 having normal or near-normal neurological development.

CONCLUSION

VOGM can present with a myriad of neurological and systemic symptoms, potentially in extremis. Neurosurgical involvement in these cases is critical, as urgent treatment can be lifesaving. Patients may require multiple treatment sessions using a variety of endovascular tools and techniques.

Transarterial and transvenous access for neurointerventional surgery: report of the SNIS Standards and Guidelines Committee

The purpose of this publication is to provide a comprehensive review on the techniques and tools used for vascular access in neurointerventional procedures. Using published literature, we reviewed data on access methods, sites, tools, and techniques for neurointerventions. Recommendations are provided based on quality of data/levels of evidence and, where appropriate, expert consensus. While tools and techniques continue to be developed, current literature and experience supports certain principles regarding vascular access for neurointerventional procedures.

Coil and Onyx embolization of a torcular herophili dural arteriovenous fistula in a full-term neonate with advanced heart failure using a transumbilical approach

Neonatal dural arteriovenous fistulas (DAVFs) are rare, but if left untreated will advance to life-threatening neurological and cardiovascular compromise. Endovascular treatment is the preferred treatment modality for DAVFs. The goal of endovascular therapy is to obliterate feeding vasculature and prevent secondary complications. Endovascular access can be difficult to obtain in a neonate. The authors present the case of a full-term, normal birth weight neonate with severe congestive heart failure secondary to a congenital DAVF of the torcular herophili that was successfully treated with transumbilical arterial coil embolization and a liquid embolic agent.

Endovascular treatment of pediatric intracranial arteriovenous shunt

Intracranial arteriovenous shunts (ICAVS) in young children are characterized by frequent high-flow fistulas. In association with high-flow fistulas and the physiological condition of the developing brain and heart, each ICAVS type tends to present at a certain age with unique symptoms. Vein of Galen aneurysmal malformation (VGAM) and dural sinus malformation with arteriovenous (AV) shunt tend to present in the neonate with high output cardiac failure. In infancy, VGAM, pial arteriovenous fistula (AVF) and infantile dural AVF (DAVF) tend to present with hydrodynamic disorder such as macrocephaly, ventriculomegaly, prominent facial veins, and developmental delay. Pial AVF, AV malformation, and infantile DAVF can present with focal neurological signs such as seizure or hemorrhage at older ages. Endovascular treatment is currently the first choice of treatment for most pediatric ICAVS. The treatment goal should be defined on a patient-by-patient basis, according to the unique physiological condition of the child.

Is jugular bulb stenosis in vein of Galen aneurysmal malformation associated with bony remodeling of the jugular foramina?

OBJECTIVE The etiology of jugular bulb stenosis (JBS) or occlusion in the context of vein of Galen aneurysmal malformations (VGAMs) is unknown. It can lead to decompensation of a lesion that was previously clinically stable. The aim of this study was to describe the natural history of JBS or occlusion in VGAM and to determine whether there is an association with bony remodeling of the jugular foramina. METHODS The authors identified all cases of JBS greater than 70% bilaterally involving patients seen at The Hospital for Sick Children between January 2007 and June 2014. The foramen diameters were measured on sagittal CT imaging, on a slice passing at the level of the jugular vein. The jugular foramen diameters were also compared to measurements obtained in a matched population of the same age group who had no VGAM and had undergone cerebral CT for a reason other than vascular disease. RESULTS Eight patients (6 male and 2 female) with bilateral JBS were included in this series. The median duration of clinical follow-up was 2.5 years (IQR 1.7-4.2 years). JBS was associated with bony narrowing the jugular foramina in 7 of the 8 patients over time. Between 1 and 2 years of age, patients with a VGAM demonstrated jugular foramen narrowing in comparison with a matched population (p = 0.015). CONCLUSIONS Jugular bulb stenosis or occlusion in VGAM may be associated with narrowing of the jugular foramina. These conditions seem to have a male predominance. If treatment is required, bony narrowing of the jugular foramina should be taken into account when deciding whether angioplasty and stent placement or surgical bypass might be appropriate therapeutic options.

Transumbilical arterial embolization of a large dural arteriovenous fistula in a low-birth-weight neonate with congestive heart failure

PURPOSE

The purpose of this study was to report transumbilical arterial embolization of a large dural arteriovenous fistula (AVF) in a low-birth-weight neonate with congestive heart failure (CHF).

CASE PRESENTATION

A female neonate was delivered by cesarean section at 31 weeks of gestation. Her birth weight was 1538 g and Apgar scores were 6 at both 1 and 5 min. Because of dyspnea and retracted respiration immediately after birth, she required mechanical ventilation. Ultrasound revealed right cardiac overload and a large cystic mass at the posterior brain. Magnetic resonance imaging on day 1 showed a large dural AVF (dural sinus malformation with arteriovenous (AV) shunts) at the torcular herophili. Umbilical artery and vein catheterization were performed on the same day for neurointervention. CHF prompted emergency embolization on day 8. The transfemoral arterial route could not be used because of its small size and compromised femoral artery blood flow. Transumbilical arterial embolization shrank the AV shunts markedly, resulting in clinical improvement, thus requiring no further intervention. Follow-up angiography at 4 months confirmed no residual AVF. Her growth and development were normal at the last follow-up at age 4 years.

CONCLUSION

This patient apparently was the lowest birth weight neonate with a large AVF successfully treated by embolization, which is usually performed through the transfemoral arterial route. The transumbilical arterial route is an alternative for neonates with birth weight <2000 g and very small femoral arteries.

Decreased Superior Sagittal Sinus Diameter and Jugular Bulb Narrowing Are Associated with Poor Clinical Outcome in Vein of Galen Arteriovenous Malformation

BACKGROUND AND PURPOSE

Few clinical and imaging findings are known to be associated with poor outcome in neonates and infants with vein of Galen arteriovenous malformations. In the present consecutive series of 35 patients, we evaluated both the diameter of the superior sagittal sinus at onset and the diameter of the jugular bulb on follow-up as potential factors related to poor outcome.

MATERIALS AND METHODS

Thirty-five consecutive neonates and infants who were prospectively collected in a single-center data base were included in this review. Outcome was assessed by using the Bicêtre Outcome Score. Both the absolute diameter of the superior sagittal sinus and its ratio to the biparietal diameter were measured at onset, compared with age-matched controls, and correlated to patient outcome.

RESULTS

The diameter of the superior sagittal sinus at onset and its ratio to the biparietal diameter were significantly smaller in the vein of Galen arteriovenous malformation population compared with the matched population (P = .0001) and were correlated significantly with a risk of poor clinical outcome (P = .008). Development of jugular bulb narrowing was also related to poor clinical outcome (P < .0001).

CONCLUSIONS

Decreased superior sagittal sinus diameter may reflect a decrease of cerebral blood flow due to cerebral arterial steal and intracranial hydrovenous disorders. This finding may be considered cerebral blood flow deterioration and thus taken into consideration in the management decisions for patients with vein of Galen arteriovenous malformations. Likewise, our data suggest that progressive jugular bulb narrowing may indicate earlier intervention to prevent severe narrowing.

Neuro-Interventions for the Neonates with Brain Arteriovenous Fistulas: With Special Reference to Access Routes

Neonatal neuro-intervention is challenging. The purpose of this article is to report the neuro-intervention for the neonates with brain arteriovenous fistulas (AVFs), with special reference to access routes. Fifteen neonates (12 boys and 3 girls) who underwent neuro-intervention within the first 14 days of life were -included. Their diagnoses included vein of Galen aneurysmal malformation (6), dural sinus malformations with arteriovenous (AV) shunts (6), pial AVF (2), and epidural AVF (1). Birth weight ranged from 1,538 g to 3,778 g (mean 2,525 g). Neuro-interventions, especially access routes, in the neonatal periods (< 1 month) were retrospectively reviewed. All neonates presented with severe cardiac failure. In total, 29 interventions (mean 1.9) were performed within 1 month. Although 12 neonates with birth weight more than 2,700 g could be treated through transfemoral arterial routes, 3 neonates with birth weight less than 2,200 g could not be treated successfully by femoral arterial routes. Interventions were performed through 19 femoral arterial, 3 femoral venous, 2 umbilical arterial, 3 umbilical venous, 3 transcardiac, and 2 direct carotid routes. Their overall outcomes were six good recovery, one moderate disability, two severe disabilities, one vegetative state, and five deaths with a mean follow-up period of 7 years 2 months. Neuro-intervention for the neonates with birth weight more than 2,700 g can be performed by femoral arterial routes using a 4F sheath. For those with birth weight less than 2,200 g, however, alternative access routes are required.

Pediatric central nervous system vascular malformations

Pediatric central nervous system (CNS) vascular anomalies include lesions found only in the pediatric population and also the full gamut of vascular lesions found in adults. Pediatric-specific lesions discussed here include infantile hemangioma, vein of Galen malformation and dural sinus malformation. Some CNS vascular lesions that occur in adults, such as arteriovenous malformation, have somewhat distinct manifestations in children, and those are also discussed. Additionally, children with CNS vascular malformations often have associated broader vascular conditions, e.g., PHACES (posterior fossa anomalies, hemangioma, arterial anomalies, cardiac anomalies, eye anomalies and sternal anomalies), hereditary hemorrhagic telangiectasia, and capillary malformation-arteriovenous malformation syndrome (related to the RASA1 mutation). The treatment of pediatric CNS vascular malformations has greatly benefited from advances in endovascular therapy, including technical advances in adult interventional neuroradiology. Dramatic advances in therapy are expected to stem from increased understanding of the genetics and vascular biology that underlie pediatric CNS vascular malformations.

Neurocognitive improvements following endovascular repair of vein of Galen malformation in a child

Cognitive regression is a well-described presentation of vein of Galen aneurysmal malformations (VGAMs) in childhood. However, it remains unclear whether successful treatment of the malformation can reverse cognitive regression. Here, the authors present the case of a 5-year-old girl with a VGAM that was treated with staged endovascular embolization procedures. Comprehensive neurocognitive assessments were completed before intervention and approximately 6 years after initial presentation. There were significant age-matched improvements in this child's neurocognitive profile over this period. The authors believe that timely and successful treatment of VGAM in children may not only stabilize the associated cognitive deterioration but, in some cases, may ameliorate these deficits. Details of this case and a discussion of neurocognitive deficits related to VGAM are presented.

Radiological and clinical features of vein of Galen malformations

BACKGROUND

Vein of Galen malformations (VOGMs) are rare and complex congenital arteriovenous fistulas. The clinical and radiological features of VOGMs and their relation to clinical outcomes are not fully characterized.

OBJECTIVE

To examine the clinical and radiological features of VOGMs and the predictors of outcome in patients.

METHODS

We retrospectively reviewed the available imaging and medical records of all patients with VOGMs treated at the University of California, San Francisco between 1986 and 2013. Radiological and clinical features were identified. We applied the modified Rankin Scale to determine functional outcome by chart review. Predictors of outcome were assessed by χ(2) analyses.

RESULTS

Forty-one cases were confirmed as VOGM. Most patients (78%) had been diagnosed with VOGM in the first year of life. Age at treatment was bimodally distributed, with predominantly urgent embolization at <10 days of age and elective embolization after 1 year of age. Patients commonly presented with hydrocephalus (65.9%) and congestive heart failure (61.0%). Mixed-type (31.7%) VOGM was more common in our cohort than purely mural (29.3%) or choroidal (26.8%) types. The most common feeding arteries were the choroidal and posterior cerebral arteries. Transarterial embolization with coils was the most common technique used to treat VOGMs at our institution. Functional outcome was normal or only mildly disabled in 50% of the cases at last follow-up (median=3 years, range=0-23 years). Younger age at first diagnosis, congestive heart failure, and seizures were predictive of adverse clinical outcome. The survival rate in our sample was 78.0% and complete thrombosis of the VOGM was achieved in 62.5% of patients.

CONCLUSIONS

VOGMs continue to be challenging to treat and manage. Nonetheless, endovascular approaches to treatment are continuing to be refined and improved, with increasing success. The neurodevelopmental outcomes of affected children whose VOGMs are treated may be good in many cases.

Intra-arterial transplantation of human umbilical cord blood mononuclear cells in neonatal hypoxic-ischemic rats

Based on preclinical findings, cellular therapy has become a promising therapeutic approach for neonatal hypoxia-ischemia (HI). However, before translation into the clinical setting, new and effective routes of cell delivery must be determined. Intra-arterial (IA) delivery is an attractive route of cellular administration but has never been used in neonatal HI rats.

AIMS

In this study, we investigated the feasibility of IA transplantation of human umbilical cord blood (HUCB) mononuclear cells for the treatment of long-term behavior dysfunction and brain lesion after neonatal HI.

MAIN METHODS

Seven-day-old rats were subjected to a HI model and the animals received HUCB mononuclear cells into the left common carotid artery 24 h after HI insult.

KEY FINDINGS

At 9 weeks post-HI, intra-arterially transplanted HUCB mononuclear cells significantly improved learning and long-term spatial memory impairments when evaluated by the Morris water maze paradigm. There was no effect of neonatal HI insult or IA procedure on body weight and on motor coordination and balance when evaluated by the accelerating rotarod test. Cellular transplantation by the IA route did not restore neonatal HI-induced brain damage according to stereological volume assessment. Furthermore, HUCB mononuclear cells were tracked in the injured brain and peripheral organs of HI transplanted-rats by nested polymerase chain reaction analysis at different time points.

SIGNIFICANCE

Our findings contribute to the translational knowledge of cell based-therapy in neonatal HI and demonstrate for the first time that IA transplantation into rat pups is a feasible route for cellular delivery and prevents long-term cognitive deficits induced by experimental neonatal HI.

Addressing challenges in 4 F and 5 F arterial access for neurointerventional procedures in infants and young children

BACKGROUND

Among the technical challenges involved in safely performing neuroendovascular procedures in infants are limitations on the size of femoral arterial access catheters. Restricting groin access to 4 F and 5 F systems constrains the range of procedures that can potentially be performed.

METHODS AND RESULTS

We present here a consecutive series of transfemoral angiographic procedures in children with no permanent and one transient case of groin morbidity related to femoral access. We illustrate two strategies for using 4 F and 5 F systems for interventions in a manner that enables such techniques as balloon assisted coil embolization and the deployment of triaxial catheter systems to be used.

CONCLUSIONS

Extremely low groin morbidity is achievable using rigorous parameters around femoral catheterization in children. With creative approaches to working within the limitations of the access vessel size, complex endovascular neurointerventions are possible, even in the youngest infants.

Transcardiac cerebral angiography in a child

The authors present a case in which transfemoral venous, transcardiac cerebral angiography was performed. In this 5-year-old girl with PHACE syndrome, both transfemoral and transbrachial arterial routes could not be used due to aortic interruption and aneurysmal dilation and small looping of the proximal portion of bilateral subclavian arteries. A 5-F balloon-tipped double-lumen catheter was advanced to the right atrium of the heart from the femoral vein. The catheter was then advanced to the left atrium through the patent foramen ovale and was further advanced to the left ventricle and then to the ascending aorta. The balloon catheter was exchanged for a 4-F catheter. Bilateral common carotid angiography was performed without difficulty. This transcardiac approach is useful in the unusual situation in which both femoral and brachial arterial routes are not available.

Vein of Galen malformations in neonates: new management paradigms for improving outcomes

BACKGROUND

Untreated patients with symptomatic neonatal presentation of vein of Galen aneurismal malformations (VGAMs) carry almost 100% morbidity and mortality. Medical management and endovascular techniques for neonatal treatment have significantly evolved.

OBJECTIVE

To evaluate the clinical and angiographic outcomes of modern management of neonates with refractory heart failure from VGAMs.

METHODS

From 2005 to 2010, 16 neonatal patients with VGAM presented to our institution. Medical care from the prenatal to perinatal stages was undertaken according to specified institutional guidelines. Nine patients with refractory heart failure required neonatal endovascular intervention. All patients were treated by transarterial deposition of n-butyl cyanoacrylate into fistula sites. Short- and long-term angiographic studies and clinical outcomes were reviewed.

RESULTS

Control of heart failure was achieved in 8 patients. One premature baby died shortly after treatment. Long-term angiographic follow-up shows total or near-total angiographic obliteration in all 8 patients. One patient has a mild hemiparesis from treatment. Another has a mild developmental delay. One patient developed a severe seizure disorder and developmental delay. Overall, 66.7% patients have normal neurological development with near-total or total obliteration of the malformation.

CONCLUSION

Treatment of refractory heart failure in neonatal VGAM with modern prenatal, neurointensive, neuroanesthetic, and pediatric neuroendovascular care results in significantly improved outcomes with presumed cure and normal neurological development in most.

Endovascular treatment of vein of Galen aneurysmal malformation: management strategy and 21-year experience in Toronto

OBJECT

The treatment of vein of Galen aneurysmal malformation (VGAM) is among the most challenging of all the neurovascular disorders.

METHODS

Between 1984 and 2005, 26 consecutive patients with VGAMs were treated by the authors' group, and their data were prospectively collected; 12 patients presented with congestive heart failure (CHF) and 10 had hydrocephalus. Five patients did not undergo endovascular treatment because of minimal symptoms or severe comorbidities. Twelve patients underwent embolization for refractory CHF requiring ventilation: 7 of these 12 patients had the procedure in the neonatal stage (5 survived), and 5 were treated in infancy or childhood following successful aggressive medical treatment (4 survived). The other 9 patients underwent endovascular surgery to treat a progressively enlarging head circumference; there was imaging evidence of ventricular enlargement and/or signs of developmental delay (6 underwent surgery in infancy and 3 in childhood; 1 patient died).

RESULTS

The survival rate in this series was 76.9% (20 of 26). Fourteen (66.7%) of 21 patients who underwent endovascular treatment had no developmental delay. An analysis of various factors demonstrated that comorbidities and embolization effect (procedure success and long-term effect) were prognostic factors of survival. In addition, the patient's age at embolization was significantly higher in those with developmental delay than in those without (559.86 ± 535.43 days vs 94.83 ± 95.77 days, respectively; p = 0.028).

CONCLUSIONS

The authors conclude that neonatal VGAMs can be treated successfully with a strategic approach integrating antenatal diagnosis, endovascular surgery, treatment at intensive care facilities, and the cooperative efforts of different specialties. In the authors' experience, patients in whom VGAM was diagnosed and managed in infancy or childhood had more than 90% long-term survival.

Cerebral diagnostic and therapeutic angiography for neonatal arteriovenous fistulas

SUMMARY

Cerebral diagnostic and therapeutic angiography for neonatal arteriovenous fistulas is reported. Three neonatal boys with vein of Galen aneurysmal malformation (1 patient) and dural arteriovenous fistulas (2 patients) presented severe congestive heart failure soon after birth, and were treated by transarterial and/or transvenous embolization using various access routes. In the neonatal period, umbilical approach and direct cervical approach provide unique access routes in addition to the usual transfemoral route. Characteristics of neonatal angiography are discussed.

Transumbilical embolization of hepatic arteriovenous malformation in a neonate with heart failure

A newborn infant presented with severe heart failure due to a large hepatic arteriovenous malformation (AVM). Umbilical artery (UA) access was safely used for immediate diagnosis and for embolization.

Nurses' guide to early detection of umbilical arterial catheter complications in infants

Umbilical arterial catheters (UAC) are routinely used in the care of critically ill newborns. Complications related to UACs include vascular compromise, hemorrhage, complications related to malposition, severance of the catheter itself, and infection. This article is Part II in a series dedicated to assessing infants with an umbilical catheter. Part I focused on infants with umbilical venous catheters; this article will focus on the physical assessment relevant to infants with an UAC. Complications related to UACs can occur during any phase of treatment: insertion, while indwelling, or after discontinuing the catheter. Review of clinical signs of complications along with clinical photographs, will assist caregivers in promptly recognizing UAC-related complications.

Spontaneous thrombosis of vein of Galen aneurysmal malformation after ventriculoperitoneal shunting

Aneurysmal dilatation of the vein of Galen (AVG) is a common finding in vascular malformations that involve the Galenic system and spontaneous thrombosis is very rare. Although the presentation of the cases may differ with the age, the mortality and morbidity is high in all age groups. Here, we present a case of AVG in a six-month-old boy. The patient underwent insertion of a ventriculoperitoneal shunt. Surveillance of the lesion with subsequent MRI revealed spontaneous thrombosis of the AVG with excellent clinical outcome. Proposed mechanisms of spontaneous thrombosis include slow flow shunts, obstruction of the venous outflow or obstruction of the feeding artery. The case is discussed with the relevant literature.

Endovascular Treatment of Dural Sinus Malformation With Arteriovenous Shunt in a Low Birth Weight Neonate-Case Report-

A boy was born at 36 weeks gestation weighing 2,135 g, with a prenatal diagnosis of dural sinus malformation with arteriovenous shunts. Congestive heart failure and anuria at birth prompted emergency intervention. Transfemoral-transvenous coil embolization was performed on day 1, resulting in partial occlusion of the huge venous pouch with a total length of 2,355 cm of detachable coils. Transarterial glue embolization on days 7, 23, and 42 was required due to persistent heart failure. Transarterial embolization was performed by common carotid puncture because the transfemoral route could not be used due to the small size and compromised blood flow of the femoral artery. Transarterial embolization reduced the arteriovenous shunts markedly and resulted in clinical improvement. Early treatment of a high flow dural arteriovenous fistula in a low birth weight neonate can achieve an excellent result with an acceptable neurological outcome.

Interventional neuroangiography in neonates

Two neonates with either vein of Calen aneurysmal malformation or dural sinus malformation (congenital dural arteriovenous fistula at the torcular herophili) are reported. In neonatal interventional neuroangiography, special attention should be paid to body temperature, contrast material, infusion fluid, heparin, and angio-equipment. In the neonatal period, the umbilical approach provides unique access routes to both arterial and venous sides of the cerebral circulation. Among them, transumbilical venous, transcardiac approach through the foramen ovale allows transarterial intervention from the venous side.

Successful transcutaneous arterial embolization of a giant hemangioma associated with high-output cardiac failure and Kasabach-Merritt syndrome in a neonate: a case report

We describe the case of a patient with a neonatal giant cutaneous hemangioma with high-output cardiac failure and Kasabach-Merritt syndrome and successfully treated with transcutaneous arterial embolization aimed at controlling severe congestive heart failure and consumption coagulopathy. A patient was admitted to the neonatal care unit on the first day of age because of a large hemangioma on his right lateral chest wall and respiratory distress, associated with cardiac failure resulting from arteriovenous shunting. On the second day of age the platelet count decreased to 5.7 x 10(4)/microliter and fibrinogen level was 85 mg/dl. The values of prothrombin time and activated partial thromboplastin time were prolonged. Intravenous predonisone therapy was started immediately, but bleeding tendency was getting worse and the evidence of congestive heart failure persisted. On the third day the patient then underwent embolization of feeding arteries with microcoils. The cardiac failure and thrombocytopenic coagulopathy had improved significantly without complications. We conclude that transcutaneous arterial embolization is an effective and safe treatment in this neonate and should be considered for the treatment of control high-output cardiac failure and coagulopathy in infants with hemangioma and Kasabach-Merritt syndrome.

Transumbilical embolization of a congenital dural arteriovenous fistula at the torcular herophili in a neonate. Case report

A neonate, in whom a congenital cerebral vascular anomaly had been diagnosed prenatally, exhibited progressive high-output congestive heart failure soon after birth. Cerebral angiography revealed a congenital dural arteriovenous fistula (AVF) with a huge dural lake located at the torcular herophili. In addition to the meningeal blood supply, an unusual pial blood supply from all cerebellar arteries was observed to feed the fistula. The patient was treated by repeated transarterial and transvenous embolization through the umbilical venous route. To the authors' knowledge, neither the existence of a congenital dural AVF at the torcular herophili presenting with an enormous pial blood supply or the technique of trans-umbilical venous intervention has been reported in the literature.