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Tawfiq A, Alsabban Z, Baradwan S. Multidisciplinary care of fetal vein of Galen arteriovenous malformation diagnosed via Doppler ultrasound and magnetic resonance imaging: A case report. Case Rep Womens Health 2024; 42:e00615. [PMID: 38746059 PMCID: PMC11092392 DOI: 10.1016/j.crwh.2024.e00615] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/13/2024] [Revised: 04/26/2024] [Accepted: 05/08/2024] [Indexed: 05/16/2024] Open
Abstract
Fetal vein of Galen malformation (VOGM) represents a rare congenital anomaly affecting the fetal cerebral vasculature. A 27-year-old Middle Eastern woman was referred due to intrauterine growth restriction (IUGR) and fetal cardiac anomalies identified at 35 weeks of gestation. The diagnosis of fetal VOGM with dilated neck vessels was established through a combination of color Doppler ultrasonography and magnetic resonance imaging. A multidisciplinary approach involving maternal-fetal medicine, neonatology, pediatric cardiology, and interventional radiology was implemented. Given the grave prognosis for the baby, the patient received comprehensive counseling. Subsequent monitoring revealed a non-reassuring fetal heart trace, prompting the decision to perform a cesarean section. The newborn, a girl, was admitted to the neonatal intensive care unit for further management but she died shortly thereafter, with heart failure and intracranial hemorrhage identified as the probable causes of death. In summary, the diagnosis and management of VOGMs demand specialized expertise and a collaborative, multidisciplinary approach to optimize patient care and outcomes.
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Affiliation(s)
- Afaf Tawfiq
- Department of Obstetrics and Gynecology, King Faisal Specialist Hospital and Research Centre, Jeddah, Saudi Arabia
| | - Zehour Alsabban
- Department of Radiology, King Faisal Specialist Hospital and Research Centre, Jeddah, Saudi Arabia
| | - Saeed Baradwan
- Department of Obstetrics and Gynecology, King Faisal Specialist Hospital and Research Centre, Jeddah, Saudi Arabia
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2
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Kaplan JS, Dardanelli EP, Requejo F, Mackintosh C, Lipsich JE. Use of greyscale and Doppler ultrasound in initial evaluation and follow-up of neurovascular malformations in children. Pediatr Radiol 2024; 54:347-356. [PMID: 38191809 DOI: 10.1007/s00247-023-05846-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/13/2023] [Revised: 12/26/2023] [Accepted: 12/27/2023] [Indexed: 01/10/2024]
Abstract
Pediatric intracranial arteriovenous shunts are rare vascular malformations that can be diagnosed prenatally or postnatally, as an incidental finding or due to complications. We propose a review of cerebral vascular malformations in newborns and infants with special emphasis on neurosonography and Doppler ultrasound as the first diagnostic method. Sonography can thus contribute in the planning of further studies that are always necessary, and in post-therapy follow-up.
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Affiliation(s)
- Julio S Kaplan
- Department of Radiology, Hospital de Pediatría J.P. Garrahan, Combate de los Pozos 1881 (C 1425 AAM), Buenos Aires, Argentina.
| | - Esteban P Dardanelli
- Department of Radiology, Hospital de Pediatría J.P. Garrahan, Combate de los Pozos 1881 (C 1425 AAM), Buenos Aires, Argentina
| | - Flavio Requejo
- Department of Neuroradiology, Hospital de Pediatría J.P. Garrahan, Combate de los Pozos 1881 (C 1425 AAM), Buenos Aires, Argentina
| | - Cecilia Mackintosh
- Department of Radiology, Hospital de Pediatría J.P. Garrahan, Combate de los Pozos 1881 (C 1425 AAM), Buenos Aires, Argentina
| | - José E Lipsich
- Department of Radiology, Hospital de Pediatría J.P. Garrahan, Combate de los Pozos 1881 (C 1425 AAM), Buenos Aires, Argentina
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3
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Buratti S, Orbach DB, Muthusami P, Robertson F. Editorial: Vein of galen malformation: a scientific and clinical journey targeting the best outcome. Front Pediatr 2023; 11:1323889. [PMID: 38027306 PMCID: PMC10656608 DOI: 10.3389/fped.2023.1323889] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/18/2023] [Accepted: 10/23/2023] [Indexed: 12/01/2023] Open
Affiliation(s)
- Silvia Buratti
- Neonatal and Pediatric Intensive Care Unit, Acceptance and Emergency Department, IRCCS Istituto Giannina Gaslini, Genoa, Italy
| | - Darren B. Orbach
- Neurointerventional Radiology, Boston Children’s Hospital, Boston, MA, United States
| | - Prakash Muthusami
- Interventional Radiology, University of Toronto and the Hospital for Sick Children, Toronto, ON, Canada
| | - Fergus Robertson
- Department of Radiology, Great Ormond Street Hospital, London, United Kingdom
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M SC, Peethambar BA. A Curious Case of Proptosis and Intracranial Calcifications Caused by a Vein of Galen Aneurysmal Malformation. Cureus 2023; 15:e47453. [PMID: 38022244 PMCID: PMC10660135 DOI: 10.7759/cureus.47453] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/22/2023] [Indexed: 12/01/2023] Open
Abstract
Vein of Galen aneurysmal malformation (VGAM) is a rare, congenital, intracerebral arteriovenous malformation with a poor prognosis. This disorder commonly presents during the neonatal period and rarely in infancy and childhood. Reported here is a case of VGAM in a three-month-old female baby who presented with proptosis and intracranial calcifications, which are rare presentations of this rare entity. The diagnosis was confirmed by magnetic resonance imaging (MRI).
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Affiliation(s)
- Sandra C M
- Diagnostic Radiology, MES (Muslim Educational Society) Medical College, Perinthalmanna, IND
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5
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Nurimanov C, Makhambetov Y, Menlibayeva K, Nurakay N, Makhambetov N, Zholdybayeva E, Akshulakov S. Long-Term Outcomes of Endovascular Embolization in a Vein of Galen Aneurysmal Malformation: A Single-Center Experience. Diagnostics (Basel) 2023; 13:2704. [PMID: 37627963 PMCID: PMC10453383 DOI: 10.3390/diagnostics13162704] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/02/2023] [Revised: 08/16/2023] [Accepted: 08/16/2023] [Indexed: 08/27/2023] Open
Abstract
BACKGROUND A vein of Galen aneurysmal malformation (VGAM) is a rare congenital cerebral vascular condition with a high mortality rate if left untreated. This study describes the long-term outcomes of patients with VGAM, who were treated with endovascular embolization. METHODS This retrospective analysis focused on VGAM patients who underwent one or more endovascular embolization sessions between January 2008 and December 2022. The study included newborns and children under 18 years. Data encompassed clinical and demographic characteristics, types of endovascular embolization, treatment complications, mortality rates, and long-term outcomes. RESULTS Out of 22 VGAM cases, the majority were boys (86.36%), and the average age of the participants was 38 months, ranging from 25 days to 17 years. Endovascular embolization using liquid embolizing agents was the most common intervention (50%), and around 73% of patients underwent multiple sessions. Some patients underwent ventriculoperitoneal shunting (VPS) due to persistent hydrocephalus. In long-term outcomes, four patients (18.2%) showed developmental delays, and 16 patients (72.7%) had a positive outcome. CONCLUSIONS Combining endovascular therapy with a comprehensive management strategy significantly reduces mortality rates and improves the possibility of normal neurological development in patients.
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Affiliation(s)
- Chingiz Nurimanov
- Vascular and Functional Neurosurgery Department, National Center for Neurosurgery, Astana 010000, Kazakhstan; (Y.M.); (N.N.); (N.M.); (S.A.)
| | - Yerbol Makhambetov
- Vascular and Functional Neurosurgery Department, National Center for Neurosurgery, Astana 010000, Kazakhstan; (Y.M.); (N.N.); (N.M.); (S.A.)
| | - Karashash Menlibayeva
- Hospital Management Department, National Center for Neurosurgery, Astana 010000, Kazakhstan;
| | - Nurtay Nurakay
- Vascular and Functional Neurosurgery Department, National Center for Neurosurgery, Astana 010000, Kazakhstan; (Y.M.); (N.N.); (N.M.); (S.A.)
| | - Nursultan Makhambetov
- Vascular and Functional Neurosurgery Department, National Center for Neurosurgery, Astana 010000, Kazakhstan; (Y.M.); (N.N.); (N.M.); (S.A.)
| | - Elena Zholdybayeva
- National Scientific Shared Laboratory, National Center for Biotechnology, Astana 010000, Kazakhstan;
| | - Serik Akshulakov
- Vascular and Functional Neurosurgery Department, National Center for Neurosurgery, Astana 010000, Kazakhstan; (Y.M.); (N.N.); (N.M.); (S.A.)
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Udine M, Croci D, Wasserman J, A Noureldine MH, Monsour M, Vakharia K, Agazzi S. Vein of Galen Malformations in Adults. Clin Neurol Neurosurg 2023; 228:107671. [PMID: 36996672 DOI: 10.1016/j.clineuro.2023.107671] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/14/2022] [Revised: 02/21/2023] [Accepted: 03/11/2023] [Indexed: 03/18/2023]
Abstract
OBJECTIVE Vein of Galen Malformations (VoGM) are rare vascular malformations, typically seen in pediatric age groups. Even more rarely, VoGM's may be seen later in adulthood. In this case report and systematic review, we provide a thorough description of the current literature as well as provide a case example exploring the diagnosis, imaging, treatment, and management of VoGM in adults. METHODS In accordance with PRISMA guidelines, we performed a systematic literature search for all relevant cases and case series of VoGM in adult patients. The reference list of all articles were reviewed for additional relevant cases. Articles were included if they described a VoGM of a patient over the age of 18 years old and published in English. 149 articles were originally identified and 26 described cases met our inclusion criteria. RESULTS In our literature review we found 26 patients that met our inclusion criteria. We found 14 male patients and 12 female patients. The mean age at presentation was 37.2 years (median=34 years, SD= 13.6 years). The most common presenting symptoms of patient were headache (n = 9), seizure (n = 6), and vomiting (n = 4). Of the 12 cases which clearly reported the subtype of VoGM, the choroidal type was more frequently seen (n = 10) compared to the mural type (n = 2). In 3 patients, the VoGM was thrombosed at time of diagnosis. Of the 26 patients, endovascular treatment was performed most frequently (n = 8) but some received microsurgical treatment (n = 4) or were treated conservatively (n = 6). Other treatment modalities included (ventriculoperitoneal shunt, ventriculostomy) (n = 5). In 3 cases treatment was not specified. In comparison to VoGM seen in pediatric or neonatal populations, VoGM in adults generally resulted in more favorable outcomes with only 2 patients reported to have passed away following treatment. CONCLUSION VoGM remains a rare finding amongst the adult population. Hence, we described the clinical presentation, treatment modalities, and outcomes of the cases described in the English literature. Perhaps due to the rate of thrombosis and the unique angioarchitecture seen in adult VoGM patients, outcomes were generally more favorable than those described in the literature in pediatric or neonate VoGM patients.
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Affiliation(s)
- Matthew Udine
- Morsani College of Medicine, University of South Florida, Tampa, FL, USA
| | - Davide Croci
- Morsani College of Medicine, University of South Florida, Tampa, FL, USA
| | - Jacob Wasserman
- Morsani College of Medicine, University of South Florida, Tampa, FL, USA
| | | | - Molly Monsour
- Morsani College of Medicine, University of South Florida, Tampa, FL, USA
| | - Kunal Vakharia
- Department of Neurosurgery and Brain Repair, University of South Florida, Tampa, FL, USA
| | - Siviero Agazzi
- Department of Neurosurgery and Brain Repair, University of South Florida, Tampa, FL, USA.
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Matsoukas S, Shigematsu T, Bazil MJ, Fifi J, Berenstein A. Transvenous embolization of vein of galen aneurysmal malformations with coils as a final procedure for cure: A single-institution experience of 18 years. Interv Neuroradiol 2022:15910199221135066. [PMID: 36314435 DOI: 10.1177/15910199221135066] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/16/2023] Open
Abstract
INTRODUCTION Staged, transarterial embolization (TAE) is currently considered the gold standard for the treatment of vein of Galen aneurysmal malformation (VGAM); however, as transarterial access becomes restricted, further staged TAE may become ineffective or carry an increased risk of hemorrhagic or ischemic stroke when attempting complete obliteration. OBJECTIVE To describe the first consecutive, retrospective series of VGAM treated with transvenous embolization (TVE) with coils alone, as the final treatment in staged endovascular therapy, at a single institution between January 2004 and September 2021. RESULTS A total of 10 patients with a median age of 5.5 (IQR: 9.25) years were treated with coiling TVE. Patients were treated with a median number of 5 (IQR: 2.75) TAEs prior to the final TVE treatment. Complete or near-complete immediate angiographic obliteration was achieved in eight patients. Immediate post-procedural (within 48 h) hemorrhagic complications were noted in two patients (20%), one of whom passed away while the second suffered from hemiparesis. Stereotactic radiosurgery was performed in two patients with incomplete obliteration after TVE. The median follow-up time after TVE was 17 (IQR: 9) months. At long-term follow up (17 months) for the remaining nine patients, all VGAMs were completely obliterated. Long-term clinical deterioration compared to pre-TVE was noticed in one case. CONCLUSION Transvenous coil embolization is a technically feasible but risky option, as a final-stage treatment for cure of VGAMs with restricted trans-arterial access. Although TVE with coils remains an effective therapeutic modality, we recommend continuing investigation of safer TVE techniques to achieve cure.
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Affiliation(s)
- Stavros Matsoukas
- Department of Neurosurgery, 5925Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Tomoyoshi Shigematsu
- Department of Neurosurgery, 5925Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Maximilian J Bazil
- Department of Neurosurgery, 5925Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Johanna Fifi
- Department of Neurosurgery, 5925Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Alejandro Berenstein
- Department of Neurosurgery, 5925Icahn School of Medicine at Mount Sinai, New York, New York, USA
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Yarden JA, Hauck LI, Athavale KV, McCrary AW, Campbell MJ, Hauck EF. Tricuspid regurgitation and left ventricular eccentricity as a measure of heart failure in the newborn patient with a vein of Galen malformation: illustrative case. JOURNAL OF NEUROSURGERY. CASE LESSONS 2022; 4:CASE22323. [PMID: 36461836 PMCID: PMC9552681 DOI: 10.3171/case22323] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 07/29/2022] [Accepted: 08/31/2022] [Indexed: 11/06/2022]
Abstract
BACKGROUND Successful management of a vein of Galen malformation (VoGM) in the newborn patient requires a highly coordinated team approach involving neonatologists, pediatric cardiologists, pediatric neurologists, neurosurgeons, and interventionalists. Indication and timing of catheter intervention are topics of ongoing debate. OBSERVATIONS The authors highlighted two key echocardiographic markers believed to be practical indicators regarding the need for urgent catheter embolization in neonates with a VoGM. The first and preferred parameter was the tricuspid valve regurgitation (TR) gradient, an estimate of pulmonary artery hypertension. If the TR gradient exceeds systolic blood pressure (suprasystemic pulmonary hypertension [PH], i.e., >60 mm Hg), urgent intervention should be considered in eligible newborns. The second parameter was the left ventricular end-systolic eccentricity index (EI), a newly emerging echocardiographic marker and indirect correlate of PH. As an alternative to the TR gradient, an increased eccentricity index (>1.6) suggests severe right heart compromise, requiring emergency catheter embolization of the malformation. Postoperatively, the progressive reduction of both the TR gradient and the EI correlated with recovery. LESSONS In eligible newborns, urgent embolization of a VoGM is recommended in the presence of suprasystemic TR gradients and/or increased EI >1.6.
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Affiliation(s)
| | | | | | | | - M. Jay Campbell
- Pediatric Cardiology, Duke University, Durham, North Carolina
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9
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Savage C, Hale AT, Parr MS, Hedaya A, Saccomano BW, Tsemo GB, Hafeez MU, Tanweer O, Kan P, Solomon LJ, Meila D, Dirks PB, Blount JP, Johnston JM, Rocque BG, Rozzelle CJ, Bhatia K, Muthusami P, Krings T, Jones J. Outcomes of endovascular embolization for Vein of Galen malformations: An individual participant data meta-analysis. Front Pediatr 2022; 10:976060. [PMID: 36245731 PMCID: PMC9561813 DOI: 10.3389/fped.2022.976060] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/23/2022] [Accepted: 09/15/2022] [Indexed: 11/17/2022] Open
Abstract
Introduction Understanding outcomes after Vein of Galen malformation (VOGM) embolization has been limited by small sample size in reported series and predominantly single center studies. To address these limitations, we perform an individual-participant meta-analysis (IPMA) to identify risk factors associated with all-cause mortality and clinical outcome after VOGM endovascular embolization. Methods We performed a systematic review and IPMA of VOGM endovascular outcomes according to PRISMA guidelines. Individual patient characteristics including demographic, intra/post-operative adverse events, treatment efficacy (partial or complete occlusion), and clinical outcome were collected. Mixed-effects logistic regression with random effects modeling and Bonferroni correction was used (p ≤ 0.003 threshold for statistical significance). The primary and secondary outcomes were all-cause mortality and poor clinical outcome (moderate/severe developmental delay or permanent disabling injury), respectively. Data are expressed as (mean ± standard deviation (SD)) or (odds ratio (OR), 95% confidence interval (CI), I 2, p-value). Results Thirty-five studies totaling 307 participants quantifying outcomes after endovascular embolization for VOGM were included. Follow up time was 42 (±57) months. Our analysis contained 42% neonates (<1 month) at first embolization, 45% infants (1 month ≤2 years), and 13% children (>2 years). Complete occlusion was reported in 48% of participants. Overall all-cause mortality was 16%. Overall, good clinical outcome was achieved in 68% of participants. First embolization as a neonate [OR = 6.93; 95% CI (1.99-24.08); I 2 < 0.01; p < 0.001] and incomplete embolization [OR = 10.87; 95% CI (1.86-63.55); I 2 < 0.01; p < 0.001] were associated with mortality. First embolization as a neonate [OR = 3.24; 95% CI (1.47-7.15); I 2 < 0.01; p < 0.001], incomplete embolization [OR = 5.26; 95% CI (2.06-13.43); I 2 < 0.01; p < 0.001], and heart failure at presentation [OR = 3.10; 95% CI (1.03-9.33); I 2 < 0.01; p = 0.002] were associated with poor clinical outcomes. Sex, angioarchitecture of lesion, embolization approach (transvenous vs. transarterial), and single or multistage embolization were not associated with mortality or clinical outcome. Conclusions We identify incomplete VOGM embolization independently associated with mortality and poor clinical outcome. While this study provides the highest level of evidence for VOGM embolization to date, prospective multicenter studies are needed to understand the optimal treatment strategies, outcomes, and natural history after VOGM embolization.
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Affiliation(s)
- Cody Savage
- Heersink School of Medicine, University of Alabama at Birmingham, Birmingham, AL, United States
| | - Andrew T. Hale
- Department of Neurosurgery, University of Alabama at Birmingham, Birmingham, AL, United States
| | - Matthew S. Parr
- Department of Neurosurgery, University of Alabama at Birmingham, Birmingham, AL, United States
| | - Alexander Hedaya
- Department of Neurology, University of Alabama at Birmingham, Birmingham, AL, United States
| | - Benjamin W. Saccomano
- Department of Neurosurgery, University of Alabama at Birmingham, Birmingham, AL, United States
| | - Georges Bouobda Tsemo
- Department of Neurosurgery, University of Alabama at Birmingham, Birmingham, AL, United States
| | - Muhammad U. Hafeez
- Department of Neurology, Baylor College of Medicine, Houston, TX, United States
| | - Omar Tanweer
- Department of Neurosurgery, Baylor College of Medicine, Houston TX, United States
| | - Peter Kan
- Department of Neurosurgery, University of Texas Medical Branch at Galveston, Galveston, TX, United States
| | - Laurent J. Solomon
- Department of Obstetrics and Fetal Medicine, Paris Descartes University, Assistance Publique-Hôpitaux de Paris, Hôpital Necker Enfants, Paris, France
| | - Dan Meila
- Department of Interventional Radiology, Helois Klinikum Krefeld, Johanna-Etienne Hospital Neuss, Neuss, Germany
| | - Peter B. Dirks
- Division of Pediatric Neurosurgery, The Hospital for Sick Children, Toronto, ON, Canada
| | - Jeffrey P. Blount
- Department of Neurosurgery, University of Alabama at Birmingham, Birmingham, AL, United States
| | - James M. Johnston
- Department of Neurosurgery, University of Alabama at Birmingham, Birmingham, AL, United States
| | - Brandon G. Rocque
- Department of Neurosurgery, University of Alabama at Birmingham, Birmingham, AL, United States
| | - Curtis J. Rozzelle
- Department of Neurosurgery, University of Alabama at Birmingham, Birmingham, AL, United States
| | - Kartik Bhatia
- Department of Medical Imaging, Sydney Children’s Hospital Network, Westmead, NSW, Australia
| | - Prakash Muthusami
- Division of Interventional Radiology, University of Toronto and the Hospital for Sick Children, Toronto, ON, Canada
| | - Timo Krings
- Division of Interventional Radiology, University of Toronto and the Hospital for Sick Children, Toronto, ON, Canada
| | - Jesse Jones
- Department of Neurosurgery, University of Alabama at Birmingham, Birmingham, AL, United States
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Pulido LF, Murcia Salazar D, Gómez Amarillo D, Useche JN, Ghotme KA. Spontaneous thrombosis of a vein of Galen malformation associated with acute sinusitis: a case report. Childs Nerv Syst 2021; 37:3271-3276. [PMID: 33595709 DOI: 10.1007/s00381-021-05072-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/15/2020] [Accepted: 02/04/2021] [Indexed: 11/25/2022]
Abstract
The vein of Galen malformation is caused by an abnormal shunting between choroidal arteries and the median prosencephalic vein during embryological development, leading to increased blood flow to the deep cerebral veins, intracranial damage, and systemic repercussions. Idiopathic spontaneous thrombosis of a vein of Galen malformation is rare, and its association with acute sinusitis has not been reported in the literature. We present the case of a girl with a postnatal diagnosis of a vein of Galen malformation at the age of 16 months, with secondary pulmonary hypertension that was adequately controlled with spironolactone. At 3 years old, while expecting elective endovascular treatment, the patient developed spontaneous thrombosis of the vein of Galen malformation, concomitant to an acute sinusitis episode, with complete resolution of the vascular malformation and secondary pulmonary hypertension. The patient continued with normal neurological development over a 5-year follow-up. We discuss the main pathophysiologic mechanisms that can explain spontaneous thrombosis of VOGMs and the patient's outcome. Awareness of different mechanisms that can lead to spontaneous thrombosis can help in the decision-making process and prompt targeted approaches to individual patients with a vein of Galen malformation.
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Affiliation(s)
- Luis Fernando Pulido
- Faculty of Medicine, Universidad de los Andes, Cra 1 N° 18A - 12, Bogotá, Colombia
| | - Diana Murcia Salazar
- Department of Radiology, Lahey Hospital and Medical Center, 41 Mall Road, Burlington, MA, USA
| | - Diego Gómez Amarillo
- Department of Neurosurgery, Fundación Santafé de Bogotá, Carrera 7 No. 117 - 15, Bogotá, Colombia
| | - Juan Nicolás Useche
- Radiology and Diagnostic Imaging Department, Fundación Santa Fe de Bogotá, Carrera 7 No. 117 - 15, Bogotá, Colombia
| | - Kemel A Ghotme
- Department of Neurosurgery, Fundación Santafé de Bogotá, Carrera 7 No. 117 - 15, Bogotá, Colombia.
- Translational Neuroscience Research Lab, Universidad de La Sabana, Autopista Norte, KM 7, Chía, Colombia, 250001.
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Primikiris P, Hadjigeorgiou G, Tsamopoulou M, Biondi A, Iosif C. Review on the current treatment status of vein of Galen malformations and future directions in research and treatment. Expert Rev Med Devices 2021; 18:933-954. [PMID: 34424109 DOI: 10.1080/17434440.2021.1970527] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Abstract
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.
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Affiliation(s)
- Panagiotis Primikiris
- Department of Interventional Neuroradiology, Jean Minjoz University Hospital, Besancon, France
| | | | - Maria Tsamopoulou
- School of Medicine, National Kapodistrian University of Athens, Greece
| | - Alessandra Biondi
- Department of Interventional Neuroradiology, Jean Minjoz University Hospital, Besancon, France
| | - Christina Iosif
- School of Medicine, European University of Cyprus, Nicosia, Cyprus.,Department of Interventional Neuroradiology, Henry Dunant Hospital, Athens, Greece
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12
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Setlur K, Priyadarshi M, Singh S, Verma A. A Masquerader of Neonatal Persistent Pulmonary Hypertension. J Pediatr 2021; 233:281-282. [PMID: 33675815 DOI: 10.1016/j.jpeds.2021.02.068] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/15/2021] [Revised: 02/24/2021] [Accepted: 02/25/2021] [Indexed: 10/22/2022]
Affiliation(s)
| | | | | | - Ankit Verma
- Department of Pediatrics, All India Institute of Medical Sciences, New Delhi, India
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13
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Bhatia K, Mendes Pereira V, Krings T, Ter Brugge K, Kortman H, Dirks P, Armstrong D, Shroff M, Muthusami P. Factors Contributing to Major Neurological Complications From Vein of Galen Malformation Embolization. JAMA Neurol 2021; 77:992-999. [PMID: 32338714 DOI: 10.1001/jamaneurol.2020.0825] [Citation(s) in RCA: 14] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Abstract
Importance Major neurological complications from the embolization of vein of Galen malformations (VOGMs) are poorly understood. We provide a detailed analysis of contributors to periprocedural neurological complications and lessons learned. Objective To assess the rate of major periprocedural neurological complications following VOGM embolization with major procedural and strategic contributors. Design, Setting, and Participants This retrospective cohort study was conducted at a quarternary referral pediatric hospital (Hospital for Sick Children; Toronto, Ontario, Canada) from January 1999 to December 2018 with a mean clinical follow-up of 44.7 months; all children with VOGM diagnosed and/or treated were eligible (n = 48). Thirty-three patients who underwent endovascular treatment were included. Interventions Endovascular staged transarterial embolization performed in 33 patients over 91 sessions. Main Outcomes and Measures The primary outcome was the rate of periprocedural neurological complications (occurring within 1 week of embolization). The secondary outcomes were mortality, long-term neurological outcomes, and contributing anatomical and management factors to neurological complications. Results Of 33 patients who underwent embolization (31 boys [64.6%]; 17 girls [35.4%]; median age at first embolization, 4 months [range, 0-29 months]), 10 patients (30.3%) developed major periprocedural neurological complications. Five of these patients died. Univariate logistic regression analyses identified internal cerebral vein drainage to the main venous sac of the VOGM and use of a microcatheter with a distal outer diameter of more than 2.0F as significant predictors of poor neurological outcomes. Lessons learned from our experience include the need to assess the internal cerebral vein drainage pattern on preprocedural magnetic resonance venography, avoidance of excessive embolization into the venous sac, treatment of more distal fistulae before proximal fistulae to avoid a sump effect, and preferably use of smaller (<2.0F outer diameter) microcatheters in neonatal embolization procedures. Conclusions and Relevance In this cohort, 10 patients with VOGM treated with embolization (30.3%) experienced major periprocedural neurological complications, half of whom died. While these outcomes are superior to historic conservative and surgical treatment results, ongoing improvements in treatment and pretreatment diagnostic approaches are needed. Awareness of the lessons learned from our experience can help to avoid similar complications in the future for this vulnerable population.
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Affiliation(s)
- Kartik Bhatia
- Department of Medical Imaging, Sydney Children's Hospital Network, Westmead, Australia.,Division of Neuroradiology, Toronto Western Hospital, Toronto, Ontario, Canada
| | - Vitor Mendes Pereira
- Division of Neuroradiology, Toronto Western Hospital, Toronto, Ontario, Canada.,Division of Neurosurgery, Toronto Western Hospital, Toronto, Ontario, Canada
| | - Timo Krings
- Division of Neuroradiology, Toronto Western Hospital, Toronto, Ontario, Canada.,Division of Neurosurgery, Toronto Western Hospital, Toronto, Ontario, Canada
| | - Karel Ter Brugge
- Division of Neuroradiology, Toronto Western Hospital, Toronto, Ontario, Canada.,Division of Neurosurgery, Toronto Western Hospital, Toronto, Ontario, Canada
| | - Hans Kortman
- Division of Neuroradiology, Toronto Western Hospital, Toronto, Ontario, Canada
| | - Peter Dirks
- Division of Neurosurgery, Hospital for Sick Children, Toronto, Ontario, Canada
| | - Derek Armstrong
- Image-Guided Therapy, Hospital for Sick Children, Toronto, Ontario, Canada
| | - Manohar Shroff
- Image-Guided Therapy, Hospital for Sick Children, Toronto, Ontario, Canada
| | - Prakash Muthusami
- Image-Guided Therapy, Hospital for Sick Children, Toronto, Ontario, Canada
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14
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Almeida-Jones M, Nawathe P, Markush D, Garg R. Atypical Causes of Severe Pulmonary Hypertension in Infancy. Glob Pediatr Health 2021; 8:2333794X211001240. [PMID: 33816711 PMCID: PMC7995297 DOI: 10.1177/2333794x211001240] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/03/2021] [Revised: 02/03/2021] [Accepted: 02/11/2021] [Indexed: 11/30/2022] Open
Affiliation(s)
| | | | - Dor Markush
- Cedars-Sinai Medical Center, Los Angeles, CA, USA
| | - Ruchira Garg
- Cedars-Sinai Medical Center, Los Angeles, CA, USA
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15
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Gupta G, Rallo MS, Goldrich DY, Narayan V, Majmundar N, Roychowdhury S, Nanda A, Wackym PA. Management of Jugular Bulb Stenosis in Pediatric Vein of Galen Malformation: A Novel Management Paradigm. Pediatr Neurosurg 2021; 56:584-590. [PMID: 34614493 DOI: 10.1159/000517653] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/04/2021] [Accepted: 06/04/2021] [Indexed: 11/19/2022]
Abstract
INTRODUCTION Pediatric vein of Galen malformations (VOGMs) are fistulous intracranial malformations arising congenitally within the choroidal fissure that can present with an array of neurological and cardiac sequelae. Associated venous stenosis may result in intracranial venous hypertension and ischemia leading to severe, irreversible cerebral injury. Management of neonatal VOGMs typically involves staged embolization and angioplasty/stenting for relief of venous stenosis. Rarely, jugular foraminal narrowing has been identified as causing jugular bulb stenosis. CASE PRESENTATION We present the case of a 22-month-old female diagnosed with VOGM prenatally who displayed persistent intracranial venous hypertension despite multiple neuroembolization procedures during the neonatal period. Following initial reduction in arteriovenous shunting, she once again developed venous hypertension secondary to jugular bulb stenosis for which angioplasty was attempted. Failure of angioplasty to relieve the venous hypertension prompted skull base imaging, which revealed jugular foraminal ossification and stenosis. Microsurgical jugular foraminotomy followed by balloon angioplasty and stenting significantly reduced jugular pressure gradients. Restenosis requiring re-stenting developed postoperatively at 9 months, but the patient has remained stable with significant improvement in cortical venous congestion. DISCUSSION/CONCLUSION This case demonstrates the efficacy of microsurgical decompression of the jugular foramen and endovascular angioplasty/stenting as a novel treatment paradigm for the management of intracranial venous hypertension in the setting of VOGM.
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Affiliation(s)
- Gaurav Gupta
- Department of Neurosurgery, Rutgers Robert Wood Johnson Medical School, New Brunswick, New Jersey, USA
| | - Michael S Rallo
- Department of Neurosurgery, Rutgers Robert Wood Johnson Medical School, New Brunswick, New Jersey, USA
| | - David Y Goldrich
- Division of Otology and Neurotologic Skull Base Surgery, Department of Otolaryngology, Head and Neck Surgery, Rutgers Robert Wood Johnson Medical School, New Brunswick, New Jersey, USA
| | - Vinayak Narayan
- Department of Neurosurgery, Rutgers Robert Wood Johnson Medical School, New Brunswick, New Jersey, USA
| | - Neil Majmundar
- Department of Neurosurgery, Rutgers Robert Wood Johnson Medical School, New Brunswick, New Jersey, USA
| | - Sudipta Roychowdhury
- Department of Neurosurgery, Rutgers Robert Wood Johnson Medical School, New Brunswick, New Jersey, USA.,Department of Radiology, Robert Wood Johnson University Hospital, New Brunswick, New Jersey, USA
| | - Anil Nanda
- Department of Neurosurgery, Rutgers Robert Wood Johnson Medical School, New Brunswick, New Jersey, USA
| | - P Ashley Wackym
- Division of Otology and Neurotologic Skull Base Surgery, Department of Otolaryngology, Head and Neck Surgery, Rutgers Robert Wood Johnson Medical School, New Brunswick, New Jersey, USA
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16
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Cordova EG, Levy P, Kheir JN, Orbach DB, Barnewolt C, Estroff JA. Vein of Galen Malformation. Neoreviews 2020; 21:e678-e686. [PMID: 33004561 DOI: 10.1542/neo.21-10-e678] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/11/2023]
Affiliation(s)
- Erika G Cordova
- Department of Newborn Medicine, Boston Children's Hospital and Harvard Medical School, Boston, MA
| | - Philip Levy
- Department of Newborn Medicine, Boston Children's Hospital and Harvard Medical School, Boston, MA
| | - John N Kheir
- Department of Cardiology, Boston Children's Hospital and Harvard Medical School, Boston, MA
| | - Darren B Orbach
- Division of Neurointerventional Radiology, Maternal Fetal Medicine Center, Boston Children's Hospital and Harvard Medical School, Boston, MA
| | - Carol Barnewolt
- Department of Radiology, Maternal Fetal Medicine Center, Boston Children's Hospital and Harvard Medical School, Boston, MA
| | - Judy A Estroff
- Department of Radiology, Maternal Fetal Medicine Center, Boston Children's Hospital and Harvard Medical School, Boston, MA
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17
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Lubicz B, Christiaens F. Endovascular treatment of intracranial vascular malformations in children. Dev Med Child Neurol 2020; 62:1124-1130. [PMID: 32533582 DOI: 10.1111/dmcn.14589] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 05/04/2020] [Indexed: 11/26/2022]
Abstract
Paediatric intracranial vascular malformations are rare and different from adult ones in vascular anatomy, pathophysiology, and symptoms. Their impact on the brain and their symptoms will differ in the antenatal period, in neonates, infants, and children. Clinical presentation includes seizures, focal neurological deficit, haemorrhage, congestive heart failure, hydrovenous disorder, and developmental delays. These malformations are thus associated with a poor prognosis if left untreated. Therefore, aggressive management is generally recommended and must be performed by a multidisciplinary team with extensive experience. Endovascular treatment is the first-choice treatment for most paediatric intracranial vascular malformations. Indication and timing for treatment should be decided on the basis of a careful assessment of neurological symptoms, growth and development, cardiac and other systemic manifestations, and imaging of the malformation and the brain tissue. WHAT THIS PAPER ADDS: Paediatric intracranial vascular malformations are rare, but their prognosis is poor if left untreated. Improved clinical, anatomical, and pathophysiological understanding of these complex lesions has improved prognosis.
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Affiliation(s)
- Boris Lubicz
- Department of Interventional Neuroradiology, Erasme University Hospital, Brussels, Belgium
| | - Florence Christiaens
- Department of Pediatric Neurology, Erasme University Hospital, Brussels, Belgium
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18
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Arko L, Lambrych M, Montaser A, Zurakowski D, Orbach DB. Fetal and Neonatal MRI Predictors of Aggressive Early Clinical Course in Vein of Galen Malformation. AJNR Am J Neuroradiol 2020; 41:1105-1111. [PMID: 32467186 DOI: 10.3174/ajnr.a6585] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/05/2020] [Accepted: 04/03/2020] [Indexed: 11/07/2022]
Abstract
BACKGROUND AND PURPOSE Neonates with vein of Galen malformations are split into 2 cohorts: one needing urgent neonatal embolization, with relatively high mortality and morbidity even with expert care, and a cohort in which embolization can be deferred until infancy, with far better prognosis. We aimed to identify brain MR imaging characteristics obtained from fetal and early neonatal scans that can predict the clinical presentation. MATERIALS AND METHODS Patients with vein of Galen malformations were stratified into a neonatal at-risk cohort if the patient needed urgent neonatal intervention or if neonatal death occurred; or an infantile treatment cohort if they were stable enough not to require treatment until >1 month of age. Twelve vascular MR imaging parameters, measured by 2 independent observers, were systematically correlated with the need for early neonatal intervention and/or neonatal mortality. RESULTS A total of 32 neonatal patients (21 patients in the neonatal at-risk cohort, 11 in the infantile treatment cohort) were identified. Maximal mediolateral diameter (area under the curve = 0.866, P < .001) and cross-sectional area (area under the curve = 0.836, P = .002) at the narrowest point of the straight or falcine sinus were most predictive of clinical evolution into the neonatal at-risk cohort. There were 15 patients who had fetal MRIs (10 in the neonatal at-risk cohort and 5 in the infantile treatment cohort). Here too, maximal mediolateral diameter (area under the curve = 0.980, P = .003) and cross-sectional area (area under the curve = 0.941, P = .007) at the narrowest point of the straight or falcine sinus were highly predictive of the neonatal at-risk cohort. CONCLUSIONS Early neonatal and fetal MR imaging can be readily used for accurate early risk stratification, assisting in directing resources, timing treatment decisions, and identifying appropriate cohorts for novel interventions.
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Affiliation(s)
- L Arko
- From the Departments of Neurosurgery (L.A., M.L., A.M., D.B.O.)
| | - M Lambrych
- From the Departments of Neurosurgery (L.A., M.L., A.M., D.B.O.)
| | - A Montaser
- From the Departments of Neurosurgery (L.A., M.L., A.M., D.B.O.)
| | | | - D B Orbach
- From the Departments of Neurosurgery (L.A., M.L., A.M., D.B.O.) .,Neurointerventional Radiology (D.B.O.), Boston Children's Hospital, Harvard Medical School, Boston, Massachusetts
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19
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Giorgi L, Durand P, Morin L, Miatello J, Merchaoui Z, Lambert V, Boithias C, Senat MV, Stos B, Maurey H, Adamsbaum C, Tissières P, Saliou G, Spelle L, Ozanne A. Management and Outcomes of Neonatal Arteriovenous Brain Malformations with Cardiac Failure: A 17 Years' Experience in a Tertiary Referral Center. J Pediatr 2020; 218:85-91.e2. [PMID: 31870606 DOI: 10.1016/j.jpeds.2019.10.090] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/14/2019] [Revised: 10/27/2019] [Accepted: 10/31/2019] [Indexed: 11/29/2022]
Abstract
OBJECTIVES To assess the management and outcomes of neonatal arteriovenous brain malformations (mostly vein of Galen malformations) complicated by cardiac failure in the era of prenatal diagnosis and endovascular treatment in a tertiary referral center. STUDY DESIGN This observational study included 77 living newborn infants with arteriovenous brain malformations with cardiac failure, admitted to our referral center from 2001 to 2017. All infants underwent cardiovascular evaluation including echocardiogram and brain magnetic resonance imaging. Long-term survivors had standard neurocognitive assessments. RESULTS Infants were admitted to the neonatal intensive care unit at a median of 5 days of age (including 18 inborn patients since 2009). Sixty transarterial shunt embolizations were performed in 46 patients during their first month (at a median age of 7.5 days) or postponed beyond the first month in another 10 long-term survivors. Embolization was not performed in 21 infants, including 19 nonsurvivors with severe brain injury, uncontrolled cardiac failure, or multiple organ failure. Cardiac failure requiring vasopressor infusion occurred in 48 patients (64%) during the hospitalization. Infants who survived the first month underwent a median of 3 embolization sessions. Among the 51 survivors, 21 had a good outcome and 19 had a poor outcome at follow-up (median age, 5.3 years); 11 children were lost to follow-up. CONCLUSIONS In the era of multidisciplinary prenatal diagnosis, using a standardized care protocol, 47% of liveborn infants with an arteriovenous shunt malformation with cardiac failure experienced a favorable outcome.
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Affiliation(s)
- Laetitia Giorgi
- Division of Pediatrics and Neonatal Intensive Care, Paris-Saclay University Hopsitals, Bicêtre Medical center Assistance publique-hôpitaux de Paris, France; Department of Pediatrics Neurology, Paris-Saclay University Hospitals, Bicêtre medical center, Assistance Publique Hôpitaux de Paris, France
| | - Phillippe Durand
- Division of Pediatrics and Neonatal Intensive Care, Paris-Saclay University Hopsitals, Bicêtre Medical center Assistance publique-hôpitaux de Paris, France.
| | - Luc Morin
- Division of Pediatrics and Neonatal Intensive Care, Paris-Saclay University Hopsitals, Bicêtre Medical center Assistance publique-hôpitaux de Paris, France
| | - Jordi Miatello
- Division of Pediatrics and Neonatal Intensive Care, Paris-Saclay University Hopsitals, Bicêtre Medical center Assistance publique-hôpitaux de Paris, France
| | - Zied Merchaoui
- Division of Pediatrics and Neonatal Intensive Care, Paris-Saclay University Hopsitals, Bicêtre Medical center Assistance publique-hôpitaux de Paris, France
| | - Virginie Lambert
- Department of Obstetrics and Gynecology, Paris-Saclay University Hospitals, Bicêtre medical center, Assistance publique-hôpitaux de Paris, France
| | - Claire Boithias
- Department of Obstetrics and Gynecology, Paris-Saclay University Hospitals, Bicêtre medical center, Assistance publique-hôpitaux de Paris, France
| | - Marie Victoire Senat
- Department of Obstetrics and Gynecology, Paris-Saclay University Hospitals, Bicêtre medical center, Assistance publique-hôpitaux de Paris, France
| | - Bertrand Stos
- Department of Obstetrics and Gynecology, Paris-Saclay University Hospitals, Bicêtre medical center, Assistance publique-hôpitaux de Paris, France
| | - Hélène Maurey
- Department of Pediatrics Neurology, Paris-Saclay University Hospitals, Bicêtre medical center, Assistance Publique Hôpitaux de Paris, France
| | - Catherine Adamsbaum
- Department of Pediatrics Radiology, Paris-Saclay University Hospitals, Bicêtre medical center, Assistance publique-hôpitaux de Paris, France
| | - Pierre Tissières
- Division of Pediatrics and Neonatal Intensive Care, Paris-Saclay University Hopsitals, Bicêtre Medical center Assistance publique-hôpitaux de Paris, France
| | - Guillaume Saliou
- Department of Interventional Neuroradiology Neuro Brain vascular center, Paris-Saclay University Hospitals, Bicêtre medical center, Assistance publique-hôpitaux de Paris, France; Department of Diagnostic and Interventional Neuroradiology, Lausanne University Hospital, CHUV-UNIL, Lausanne, Switzerland
| | - Laurent Spelle
- Department of Interventional Neuroradiology Neuro Brain vascular center, Paris-Saclay University Hospitals, Bicêtre medical center, Assistance publique-hôpitaux de Paris, France
| | - Augustin Ozanne
- Department of Interventional Neuroradiology Neuro Brain vascular center, Paris-Saclay University Hospitals, Bicêtre medical center, Assistance publique-hôpitaux de Paris, France
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20
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Malarbi S, Gunn-Charlton JK, Burnett AC, Prentice TM, Williams A, Mitchell P, Wray A, Hunt RW. Outcome of vein of Galen malformation presenting in the neonatal period. Arch Dis Child 2019; 104:1064-1069. [PMID: 31122925 DOI: 10.1136/archdischild-2018-316495] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/01/2018] [Revised: 04/30/2019] [Accepted: 04/30/2019] [Indexed: 11/03/2022]
Abstract
OBJECTIVE Vein of Galenaneurysmal malformation (VGAM) is a rare but important congenital malformation presenting to neonatal intensive care units (NICUs), and with a change from surgical to endovascular management, survival for this condition has improved. However, there is little reported about the medical management decisions of infants with this condition and the associated long-term neurodevelopmental outcomes. We aim to report a single centre experience of both acute treatment and long-term outcomes of VGAM for those infants admitted to our NICU soon after birth. DESIGN Retrospective cohort study over a 15-year period from 2001 to 2015 inclusive. SETTING A quaternary NICU at The Royal Children's Hospital, Melbourne, Australia. PARTICIPANTS 24 newborn infants referred for management of VGAM. There were no eligibility criteria set for this study; all presenting infants were included. INTERVENTIONS None. MAIN OUTCOMES MEASURES Clinical neuroimaging data were gathered. Surviving children were formally assessed with a battery of tests administered by a neuropsychologist and occupational therapist/physiotherapist at various ages across early to middle childhood. RESULTS Fifteen neonates with VGAM did not survive beyond their NICU admission. 10 of these were not offered endovascular intervention. Of the nine surviving infants, only one had a normal neurodevelopmental outcome. CONCLUSIONS The mortality of VGAM presenting in the neonatal period was high, and rates of normal neurodevelopmental outcome for survivors were low. These findings contribute to our understanding of which neonates should be treated and highlights the importance of providing clinical neurodevelopmental follow-up to survivors beyond their infant years.
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Affiliation(s)
- Stephanie Malarbi
- Neonatal Medicine, The Royal Children's Hospital Melbourne, Parkville, Victoria, Australia
| | - Julia K Gunn-Charlton
- Neonatal Medicine, The Royal Children's Hospital Melbourne, Parkville, Victoria, Australia.,Clinical Sciences, Murdoch Children's Research Institute, Melbourne, VIC, Australia
| | - Alice C Burnett
- Neonatal Medicine, The Royal Children's Hospital Melbourne, Parkville, Victoria, Australia.,Clinical Sciences, Murdoch Children's Research Institute, Melbourne, VIC, Australia
| | - Trisha M Prentice
- Neonatal Medicine, The Royal Children's Hospital Melbourne, Parkville, Victoria, Australia.,Clinical Sciences, Murdoch Children's Research Institute, Melbourne, VIC, Australia.,School of Population and Global Health, University of Melbourne, Parkville, Victoria, Australia
| | - Amy Williams
- Neonatal Medicine, The Royal Children's Hospital Melbourne, Parkville, Victoria, Australia
| | - Peter Mitchell
- Department of Radiology, The Royal Melbourne Hospital, Melbourne, VIC, Australia
| | - Alison Wray
- Department of Neurosurgery, The Royal Children's Hospital, Melbourne, VIC, Australia
| | - Rod W Hunt
- Neonatal Medicine, The Royal Children's Hospital Melbourne, Parkville, Victoria, Australia.,Clinical Sciences, Murdoch Children's Research Institute, Melbourne, VIC, Australia.,Department of Paediatrics, University of Melbourne, Melbourne, VIC, Australia
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21
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Manjila S, Bazil T, Thomas M, Mani S, Kay M, Udayasankar U. A review of extraaxial developmental venous anomalies of the brain involving dural venous flow or sinuses: persistent embryonic sinuses, sinus pericranii, venous varices or aneurysmal malformations, and enlarged emissary veins. Neurosurg Focus 2019; 45:E9. [PMID: 29961384 DOI: 10.3171/2018.5.focus18107] [Citation(s) in RCA: 21] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
This paper is a narrative review of extraaxial developmental venous anomalies (eDVAs) of the brain involving dural venous flow or sinuses: persistent embryonic sinuses, sinus pericranii, enlarged emissary veins, and venous varices or aneurysmal malformations. The article highlights the natural history, anatomy, embryology, imaging, clinical implications, and neurosurgical significance of these lesions, which the authors believe represent a continuum, with different entities characterized by distinct embryopathologic features. The indications and surgical management options are discussed for these individual intracranial pathologies with relevant illustrations, and a novel classification is proposed for persistent falcine sinus (PFS). The role of neurointervention and/or microsurgery in specific cases such as sinus pericranii and enlarged emissary veins of the skull is highlighted. A better understanding of the pathophysiology and developmental anatomy of these lesions can reduce treatment morbidity and mortality. Some patients, including those with vein of Galen malformations (VOGMs), can present with the added systemic morbidity of a high-output cardiac failure. Although VOGM is the most studied and classified of the above-mentioned eDVAs, the authors believe that grouping the former with the other venous anomalies/abnormalities listed above would enable the clinician to convey the exact morphophysiological configuration of these lesions, predict their natural history with respect to evolving venous hypertension or stroke, and extrapolate invaluable insights from VOGM treatment to the treatment of other eDVAs. In recent years, many of these symptomatic venous malformations have been treated with endovascular interventions, although these techniques are still being refined. The authors highlight the broad concept of eDVAs and hope that this work will serve as a basis for future studies investigating the role of evolving focal venous hypertension/global intracranial hypertension and possibilities of fetal surgical intervention in these cases.
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Affiliation(s)
- Sunil Manjila
- 1Department of Neurosurgery, McLaren Bay Region Medical Center, Bay City, Michigan
| | - Timothy Bazil
- 1Department of Neurosurgery, McLaren Bay Region Medical Center, Bay City, Michigan
| | - Matthew Thomas
- 1Department of Neurosurgery, McLaren Bay Region Medical Center, Bay City, Michigan
| | - Sunithi Mani
- 2Department of Radiology, Christian Medical College, Vellore, Tamil Nadu, India; and
| | - Matthew Kay
- 3Department of Medical Imaging, University of Arizona College of Medicine, Tucson, Arizona
| | - Unni Udayasankar
- 3Department of Medical Imaging, University of Arizona College of Medicine, Tucson, Arizona
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22
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Runck F, Maurer CJ, Bode M, Lochbihler H, Kuršumović A, Berlis A. Occlusion of a mural type vein of Galen malformation in a 10-month-old boy with three Woven EndoBridge (WEB 17) and two coils. BMJ Case Rep 2019; 12:12/4/e014652. [PMID: 30988102 DOI: 10.1136/bcr-2018-014652] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022] Open
Abstract
We report the case of a 10-month-old boy with an enlarged head circumference and severe motor developmental delay. MRI showed a vein of Galen malformation (VGAM) with a heavily dilated median prosencephalic vein. Digital subtraction angiography confirmed a mural type VGAM with three feeding arteries arising from the posterior cerebral arteries. Due to the short length of the feeding arteries and the high flow, occlusion of the feeding vessels with detachable coils was not possible because of repeated coil dislocation into the dilated vein. Embolization of the three feeding vessels was then performed with a Woven EndoBridge single layer device (WEB SL17). In two arteries complete occlusion was accomplished with the WEB alone and in one artery additional deployment of two coils was necessary. Follow-up imaging at day 1 after treatment as well as 3 and 9 months after embolization showed persistent occlusion.
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Affiliation(s)
- Frank Runck
- Department of Diagnostic and Interventional Radiology and Neuroradiology, Universitätsklinikum Augsburg, Augsburg, Germany
| | - Christoph J Maurer
- Department of Diagnostic and Interventional Radiology and Neuroradiology, Universitätsklinikum Augsburg, Augsburg, Germany
| | - Markus Bode
- Department of Neurosurgery, Universitätsklinikum Augsburg, Augsburg, Germany
| | - Harald Lochbihler
- Department of Pediatric Surgery, Universitätsklinikum Augsburg, Augsburg, Germany
| | - Adisa Kuršumović
- Department of Neurosurgery, Donauisar Klinikum Deggendorf, Deggendorf, Germany
| | - Ansgar Berlis
- Department of Diagnostic and Interventional Radiology and Neuroradiology, Universitätsklinikum Augsburg, Augsburg, Germany
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23
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Spazzapan P, Milosevic Z, Velnar T. Vein of Galen aneurismal malformations - clinical characteristics, treatment and presentation: Three cases report. World J Clin Cases 2019; 7:855-862. [PMID: 31024957 PMCID: PMC6473122 DOI: 10.12998/wjcc.v7.i7.855] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/19/2018] [Revised: 03/04/2019] [Accepted: 03/16/2019] [Indexed: 02/05/2023] Open
Abstract
BACKGROUND The vein of Galen aneurismal malformations (VGAM) are rare arteriovenous malformations of the embryonic choroid plexus. They represent about 30% of paediatric neurovascular disorders and show diverse characteristics. The VGAM is constituted by a midline dilated venous structure that receives blood from abnormal macroscopic or microscopic arteriovenous shunting vessels. Two types of VGAM exist, the choroidal and the mural. The treatment represents a challenge with the therapeutic objective to preserve the normal brain development without creating new neurological deficits.
CASE SUMMARY We present three cases of VGAM in the early postnatal period and their treatment. All patents were treated with the endovascular technique, which was successful. According to our experience, the endovascular technique is a safe and efficient mode of VGAM treatment.
CONCLUSION The objective of treatment aims to child’s normal neurological development. A proper selection of patients and a thorough diagnostic workup is of vital importance. When the endovascular treatment is performed, the primary aim is not a complete VGAM exclusion at one time, which could produce a sudden reversal of blood flow with consequent venous infarction and ischemia. The aim is therefore to occlude as much of the VGAM as needed to relieve the congestive cardiac failure, to gain time and to create the conditions for a normal maturation of the neurovascular system. With the use of endovascular techniques, which represent not only the first choice of treatment but also the only safe therapeutic modality, the natural history of VGAM and their risks may be avoided safely.
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Affiliation(s)
- Peter Spazzapan
- Department of Neurosurgery, University Medical Centre Ljubljana, Ljubljana 1000, Slovenia
| | - Zoran Milosevic
- Department of Radiology, University Medical Centre Ljubljana, Ljubljana 1000, Slovenia
| | - Tomaz Velnar
- Department of Neurosurgery, University Medical Centre Ljubljana, Ljubljana 1000, Slovenia
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24
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Issa R, Barakat A, Salman R, Naffaa L. Vein of Galen Malformation, a cause of Intracranial Calcification: Case Report and Review of Literature. J Radiol Case Rep 2019; 13:13-18. [PMID: 31565173 DOI: 10.3941/jrcr.v13i3.3456] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
Intracranial calcifications in the pediatric population can have many etiologies including neoplastic, infectious, neurodegenerative, metabolic, or cerebrovascular abnormalities. We present the case of a 2-year-old boy with vein of Galen malformation, a rare cause of intracranial calcifications with a review of literature.
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Affiliation(s)
- Rayane Issa
- Department of Diagnostic Radiology, American University of Beirut Medical Center, Beirut, Lebanon
| | - Andrew Barakat
- Department of Diagnostic Radiology, American University of Beirut Medical Center, Beirut, Lebanon
| | - Rida Salman
- Department of Diagnostic Radiology, American University of Beirut Medical Center, Beirut, Lebanon
| | - Lena Naffaa
- Department of Diagnostic Radiology, American University of Beirut Medical Center, Beirut, Lebanon
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El Mekabaty A, Pearl MS, Mershon B, Berkowitz I, Gailloud P, Huisman TAGM. Susceptibility weighted imaging in infants with staged embolization of vein of Galen aneurysmal malformations. J Neuroradiol 2018; 46:214-221. [PMID: 30423378 DOI: 10.1016/j.neurad.2018.09.009] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/24/2017] [Revised: 05/07/2018] [Accepted: 09/24/2018] [Indexed: 10/27/2022]
Abstract
BACKGROUND AND PURPOSE The vein of Galen aneurysmal malformation (VGAM) is a rare congenital vascular malformation with a higher morbidity and mortality, especially in neonates. Ultrasound, CT and MR are usually used in diagnosis and treatment monitoring of these disorders. In this current study, we aim to examine utility of SWI in evaluation of treatment response in infants with VGAM. MATERIALS AND METHODS We performed a retrospective chart analysis of children with VGAM in our institution between January 2008 and December 2016. Inclusion criteria included; confirmed VGAM on DSA; available SWI sequence at baseline and at follow up after at least a single embolization session; age at initial MR of 18 years or younger. Signal intensity and Angioarchitecture of VGAM and cerebral veins on SWI, as well as hydrocephalus and clinical outcome were evaluated. RESULTS Of 11 patients identified with VGAM in our institution, 5 children (3 males and 2 females) satisfied the inclusion criteria. The average age at initial MR was 29 days (range 1-120). Fourteen MRI were available for review. All children had VGAM of mural type. Intramedullary veins were dilated and SWI-hypointense in all children, while subependymal and sulcal veins were dilated and SWI-hypointense in 4 patients on initial MRI. On the first available follow up MRI, cerebral veins have mostly normalized in 4 children and remained mostly dilated and SWI-hypointense in 1 child; even after complete treatment of the VGAM. CONCLUSION Our preliminary findings show that SWI seems to offer a beneficial non-invasive tool in evaluating passive venous congestion patterns in pediatric patients with VGAM. It remains to be determined in larger studies, the clinical significance of these SWI changes.
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Affiliation(s)
- Amgad El Mekabaty
- Division of Interventional Neuroradiology, Russell H. Morgan Department of Radiology and Radiological Science, Johns-Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Monica S Pearl
- Division of Interventional Neuroradiology, Russell H. Morgan Department of Radiology and Radiological Science, Johns-Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Bommy Mershon
- Department of Anesthesiology and Critical Care, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Ivor Berkowitz
- Department of Anesthesiology and Critical Care, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Philippe Gailloud
- Division of Interventional Neuroradiology, Russell H. Morgan Department of Radiology and Radiological Science, Johns-Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Thierry A G M Huisman
- Division of Pediatric Radiology and Pediatric Neuroradiology, Russell H. Morgan Department of Radiology and Radiological Science, Johns-Hopkins University School of Medicine, Baltimore, Maryland, USA.
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Terada A, Komiyama M, Ishiguro T, Niimi Y, Oishi H. Nationwide survey of pediatric intracranial arteriovenous shunts in Japan: Japanese Pediatric Arteriovenous Shunts Study (JPAS). J Neurosurg Pediatr 2018; 22:550-558. [PMID: 30052118 DOI: 10.3171/2018.5.peds18123] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/22/2018] [Accepted: 03/10/2018] [Indexed: 11/06/2022]
Abstract
The authors performed a nationwide study in Japan to evaluate the annual detected rate of pediatric intracranial arteriovenous (AV) shunts such as brain AV malformations (BAVMs), pial AV fistulas (PAVFs), vein of Galen aneurysmal malformations (VGAMs), and dural AV fistulas (DAVFs). These rates were revealed for the first time and showed that VGAM, DAVF, and PAVF were relatively common but that BAVMs were extremely rare in neonates and infants.
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Affiliation(s)
- Aiko Terada
- Departments of1Neurosurgery and.,2Neurointervention, Osaka City General Hospital, Osaka
| | | | | | - Yasunari Niimi
- 3Department of Neuroendovascular Therapy, St. Luke's International Hospital, Tokyo; and
| | - Hidenori Oishi
- Departments of4Neuroendovascular Therapy and.,5Neurosurgery, Juntendo University Faculty of Medicine, Tokyo, Japan
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Lecce F, Robertson F, Rennie A, Heuchan AM, Lister P, Bhate S, Bhattacharya J, Brew S, Kanagarajah L, Kuczynski A, Peters MJ, Ridout D, Schmitt A, Toolis C, Vargha-Khadem F, Ganesan V. Cross-sectional study of a United Kingdom cohort of neonatal vein of galen malformation. Ann Neurol 2018; 84:547-555. [PMID: 30155909 PMCID: PMC6221157 DOI: 10.1002/ana.25316] [Citation(s) in RCA: 33] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/29/2018] [Revised: 08/22/2018] [Accepted: 08/23/2018] [Indexed: 11/08/2022]
Abstract
OBJECTIVE Describe the course and outcomes in a UK national cohort of neonates with vein of Galen malformation identified before 28 days of life. METHODS Neonates with angiographically confirmed vein of Galen malformation presenting to 1 of 2 UK treatment centers (2006-2016) were included; those surviving were invited to participate in neurocognitive assessment. Results in each domain were dichotomized into "good" and "poor" categories. Cross-sectional and angiographic brain imaging studies were systematically interrogated. Logistic regression was used to explore potential outcome predictors. RESULTS Of 85 children with neonatal vein of Galen malformation, 51 had survived. Thirty-four participated in neurocognitive assessment. Outcomes were approximately evenly split between "good" and "poor" categories across all domains, namely, neurological status, general cognition, neuromotor skills, adaptive behavior, and emotional and behavioral development. Important predictors of poor cognitive outcome were initial Bicêtre score ≤ 12 and presence of brain injury, specifically white matter injury, on initial imaging; in multivariate analysis, only Bicêtre score ≤ 12 remained significant. INTERPRETATION Despite modern supportive and endovascular treatment, more than one-third of unselected newborns with vein of Galen malformation did not survive. Outcome was good in around half of survivors. The importance of white matter injury suggests that abnormalities of venous as well as arterial circulation are important in the pathophysiology of brain injury. Ann Neurol 2018;84:547-555.
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Affiliation(s)
- Francesca Lecce
- Developmental Neurosciences Programme, UCL Great Ormond Street Institute of Child Health, London
| | - Fergus Robertson
- Radiology Department, Great Ormond Street Hospital for Children NHS Foundation Trust, London
| | - Adam Rennie
- Radiology Department, Great Ormond Street Hospital for Children NHS Foundation Trust, London
| | | | - Paula Lister
- Critical Care Department, Great Ormond Street Hospital for Children NHS Foundation Trust, London
| | - Sanjay Bhate
- Neurology Department, Great Ormond Street Hospital for Children NHS Foundation Trust, London
| | - Jo Bhattacharya
- Radiology Department, Royal Hospital for Sick Children, Glasgow
| | - Stefan Brew
- Radiology Department, Great Ormond Street Hospital for Children NHS Foundation Trust, London
| | - Lakshmi Kanagarajah
- Radiology Department, Great Ormond Street Hospital for Children NHS Foundation Trust, London
| | - Adam Kuczynski
- Department of Neuropsychology, Great Ormond Street Hospital for Children NHS Foundation Trust, London
| | - Mark J Peters
- Radiology Department, Great Ormond Street Hospital for Children NHS Foundation Trust, London
| | - Deborah Ridout
- Population, Policy, and Practice Programme, UCL Great Ormond Street Institute of Child Health, London, United Kingdom
| | - Anne Schmitt
- Radiology Department, Great Ormond Street Hospital for Children NHS Foundation Trust, London
| | - Claire Toolis
- Neurology Department, Great Ormond Street Hospital for Children NHS Foundation Trust, London
| | - Faraneh Vargha-Khadem
- Developmental Neurosciences Programme, UCL Great Ormond Street Institute of Child Health, London.,Department of Neuropsychology, Great Ormond Street Hospital for Children NHS Foundation Trust, London
| | - Vijeya Ganesan
- Developmental Neurosciences Programme, UCL Great Ormond Street Institute of Child Health, London.,Neurology Department, Great Ormond Street Hospital for Children NHS Foundation Trust, London
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Deepti S, Juneja R, Devarajan Sebastian LJ. Endovascular management of vein of Galen aneurysmal malformation in a neonate. Ann Pediatr Cardiol 2018; 11:304-307. [PMID: 30271022 PMCID: PMC6146857 DOI: 10.4103/apc.apc_33_18] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/18/2022] Open
Abstract
A term baby presented on the 7th day of life in cardiogenic shock due to vein of Galen aneurysmal malformation. A successful embolization of the malformation was performed through transarterial route on day 12 of life after a period of initial stabilization.
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Affiliation(s)
- Siddharthan Deepti
- Department of Cardiology, Cardiothoracic Centre, All India Institute of Medical Sciences, New Delhi, India
| | - Rajnish Juneja
- Department of Cardiology, Cardiothoracic Centre, All India Institute of Medical Sciences, New Delhi, India
| | - Leve Joseph Devarajan Sebastian
- Department of Neuroimaging and Interventional Neuroradiology, CN Centre, All India Institute of Medical Sciences, New Delhi, India
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Yoon NK, Scoville JP, Taussky P. Adenosine-induced cardiac standstill for endovascular treatment of pediatric vein of Galen malformations. J Neurosurg Pediatr 2018; 21:380-383. [PMID: 29372854 DOI: 10.3171/2017.10.peds17488] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/13/2023]
Abstract
Vein of Galen malformations are congenital high-flow vascular malformations that often present with heart failure, hydrocephalus, developmental delay, and intracranial hemorrhage. Because open surgical treatment is associated with high morbidity and mortality, endovascular embolization is increasingly becoming the preferred method of intervention. However, embolization of these lesions can be difficult because of their high-flow nature. The use of adenosine-induced cardiac standstill for treatment of vein of Galen malformations has not been previously described in neonates. The authors describe 3 treatments in 2 patients that demonstrate that the use of adenosine is well tolerated and allows safe transarterial embolization of high-flow vein of Galen malformations in the pediatric population.
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30
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Duran D, Karschnia P, Gaillard JR, Karimy JK, Youngblood MW, DiLuna ML, Matouk CC, Aagaard-Kienitz B, Smith ER, Orbach DB, Rodesch G, Berenstein A, Gunel M, Kahle KT. Human genetics and molecular mechanisms of vein of Galen malformation. J Neurosurg Pediatr 2018; 21:367-374. [PMID: 29350590 DOI: 10.3171/2017.9.peds17365] [Citation(s) in RCA: 24] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
Vein of Galen malformations (VOGMs) are rare developmental cerebrovascular lesions characterized by fistulas between the choroidal circulation and the median prosencephalic vein. Although the treatment of VOGMs has greatly benefited from advances in endovascular therapy, including technical innovation in interventional neuroradiology, many patients are recalcitrant to procedural intervention or lack accessibility to specialized care centers, highlighting the need for improved screening, diagnostics, and therapeutics. A fundamental obstacle to identifying novel targets is the limited understanding of VOGM molecular pathophysiology, including its human genetics, and the lack of an adequate VOGM animal model. Herein, the known human mutations associated with VOGMs are reviewed to provide a framework for future gene discovery. Gene mutations have been identified in 2 Mendelian syndromes of which VOGM is an infrequent but associated phenotype: capillary malformation-arteriovenous malformation syndrome ( RASA1) and hereditary hemorrhagic telangiectasia ( ENG and ACVRL1). However, these mutations probably represent only a small fraction of all VOGM cases. Traditional genetic approaches have been limited in their ability to identify additional causative genes for VOGM because kindreds are rare, limited in patient number, and/or seem to have sporadic inheritance patterns, attributable in part to incomplete penetrance and phenotypic variability. The authors hypothesize that the apparent sporadic occurrence of VOGM may frequently be attributable to de novo mutation or incomplete penetrance of rare transmitted variants. Collaboration among treating physicians, patients' families, and investigators using next-generation sequencing could lead to the discovery of novel genes for VOGM. This could improve the understanding of normal vascular biology, elucidate the pathogenesis of VOGM and possibly other more common arteriovenous malformation subtypes, and pave the way for advances in the diagnosis and treatment of patients with VOGM.
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Affiliation(s)
| | | | | | | | | | | | | | - Beverly Aagaard-Kienitz
- 2Department of Neurological Surgery, University of Wisconsin, Madison, Wisconsin; Departments of
| | | | - Darren B Orbach
- 4Neurointerventional Radiology, Boston Children's Hospital, Harvard Medical School, Boston, Massachusetts
| | - Georges Rodesch
- 5Service de Neuroradiologie Diagnostique et Thérapeutique, Hôpital Foch, Suresnes, France; and
| | - Alejandro Berenstein
- 6Department of Neurosurgery, Icahn School of Medicine at Mount Sinai, New York, New York
| | - Murat Gunel
- 1Department of Neurosurgery.,7Department of Genetics.,8Centers for Mendelian Genomics and Yale Program on Neurogenetics, and
| | - Kristopher T Kahle
- 1Department of Neurosurgery.,8Centers for Mendelian Genomics and Yale Program on Neurogenetics, and.,9Department of Pediatrics and Cellular & Molecular Physiology, Yale School of Medicine, New Haven, Connecticut
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31
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Affiliation(s)
- James F Meschia
- Cerebrovascular Division, Department of Neurology, Mayo Clinic, Jacksonville, FL, USA
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32
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Hosmann A, El-Garci A, Gatterbauer B, Bavinzski G, Knosp E, Gruber A. Multimodality Management of Vein of Galen Malformations-An Institutional Experience. World Neurosurg 2018; 112:e837-e847. [PMID: 29408495 DOI: 10.1016/j.wneu.2018.01.172] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/04/2017] [Revised: 01/22/2018] [Accepted: 01/23/2018] [Indexed: 11/26/2022]
Abstract
BACKGROUND The vein of Galen aneurysmal malformation (VGM) is a rare intracranial arteriovenous fistula with a dramatic manifestation during infancy and 100% mortality without treatment. Therapeutic strategies for VGMs have changed over time as a result of advances in endovascular techniques. We present our experience and multimodality approach within the last 4 decades. METHODS A retrospective analysis and angiographic review were performed of patients with VGM between 1975 and 2016 at our institution. RESULTS Eighteen consecutive patients were identified, including 10 with choroidal and 8 with mural VGMs. In 37 endovascular interventions, a transarterial approach was mostly performed (82.8%). One patient was initially treated surgically and received 2 Gamma Knife treatments after multiple embolizations. The preferred embolization agent was histoacryl for choroidal VGMs and a combination of coils and histoacryl for mural VGMs. Total occlusion was achieved in 87.5% of mural VGMs and 11.1% of choroidal VGMs. Cerebral hemorrhages and infarction occurred only in patients younger than 1 month. At a median follow-up interval of 4.6 years, good outcome was achieved in 53.8% and poor outcome in 46.2%, with an overall mortality of 16.7%. Poor outcome was significantly associated with choroidal-type VGMs, age <1 month at first embolization, and incomplete occlusion. CONCLUSIONS Endovascular embolization using a transarterial approach is the therapy of choice. Gamma Knife radiosurgery can be considered as second-line therapy in a multimodal approach. Whereas treatment within the first month of life is associated with the highest mortality and complications, we did not detect any severe adverse events thereafter.
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Affiliation(s)
- Arthur Hosmann
- Department of Neurosurgery, Medical University of Vienna, Vienna, Austria
| | - Ahmed El-Garci
- Department of Neurosurgery, Medical University of Vienna, Vienna, Austria
| | | | - Gerhard Bavinzski
- Department of Neurosurgery, Medical University of Vienna, Vienna, Austria
| | - Engelbert Knosp
- Department of Neurosurgery, Medical University of Vienna, Vienna, Austria.
| | - Andreas Gruber
- Department of Neurosurgery, Medical University of Vienna, Vienna, Austria; Department of Neurosurgery, Kepler Universitätsklinikum, Johannes Kepler University Linz, Linz, Austria
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Superselective transvenous embolization with Onyx and n-BCA for vein of Galen aneurysmal malformations with restricted transarterial access: safety, efficacy, and technical aspects. Childs Nerv Syst 2017; 33:2003-2010. [PMID: 28689342 DOI: 10.1007/s00381-017-3499-6] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/28/2017] [Accepted: 06/23/2017] [Indexed: 10/19/2022]
Abstract
PURPOSE AND METHODS Superselective transvenous embolization (TVE) with liquid embolic agents is a new concept in treatment of vein of Galen aneurysmal malformations (VGAM). We performed ten sessions of TVE in VGAM patients with restricted transarterial access. In this paper, we assessed clinical and angiographic outcomes of the proposed treatment and discussed three different TVE techniques with regard to morphology of the shunt and outflow tract. Safety and avoidance-of-complication tips were also discussed. RESULTS Patient age ranged from 4 to 51 months. There were eight patients with choroidal VGAMs, seven of them were successfully treated with Onyx, and in one case, transvenous catheterization failed. In three cases, adjunctive coiling of draining vein was performed. In three cases, normal deep cerebral veins were connected to the outflow part of malformation; they were preserved during embolization in all cases. Six-month follow-up angiography demonstrated angiographic cure in six cases, and partial occlusion in one. There were two patients with mural VGAMs: both were treated with n-BCA. Partial occlusion was achieved in both cases. There was no procedure-related permanent morbidity or mortality. Oculomotor deficit due to quadrigeminal ischemia occurred in one case, and resolved completely after 3 weeks. CONCLUSION TVE with liquid embolic agents is a safe and effective salvage method for VGAMs with restricted transarterial access, previously considered as poor candidates for endovascular treatment.
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Joo W, Mercier P, Kheradmand S, Shirani P, Sarhan A, Elbabaa SK, Edgell RC. Vein of Galen malformation treated with the Micro Vascular Plug system: case report. J Neurosurg Pediatr 2017; 19:729-733. [PMID: 28338447 DOI: 10.3171/2016.12.peds16305] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
This case report describes the use of the Micro Vascular Plug (MVP) system in a mural-type vein of Galen aneurysmal malformation, resulting in successful occlusion of the cerebrovascular fistula. This result was confirmed with immediate cessation in blood flow and 6-month follow-up angiography. The unique characteristics of the MVP provide potential advantages over current embolic techniques for occlusion of high-flow, fistulous, intracranial vessels such as those seen in the vein of Galen aneurysmal malformation, and may represent a valuable addition to the currently available options.
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Affiliation(s)
- Woojin Joo
- St. Louis University School of Medicine, St. Louis, Missouri; and
| | - Philippe Mercier
- St. Louis University School of Medicine, St. Louis, Missouri; and
| | - Shiva Kheradmand
- Midwestern University Arizona College of Osteopathic Medicine, Glendale, Arizona
| | - Peyman Shirani
- St. Louis University School of Medicine, St. Louis, Missouri; and
| | - Ahmed Sarhan
- St. Louis University School of Medicine, St. Louis, Missouri; and
| | - Samer K Elbabaa
- St. Louis University School of Medicine, St. Louis, Missouri; and
| | - Randall C Edgell
- St. Louis University School of Medicine, St. Louis, Missouri; and
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Puvabanditsin S, Mehta R, Palomares K, Gengel N, Silva CFD, Roychowdhury S, Gupta G, Kashyap A, Sorrentino D. Vein of Galen malformation in a neonate: A case report and review of endovascular management. World J Clin Pediatr 2017; 6:103-109. [PMID: 28224101 PMCID: PMC5296625 DOI: 10.5409/wjcp.v6.i1.103] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/02/2016] [Revised: 08/12/2016] [Accepted: 11/02/2016] [Indexed: 02/06/2023] Open
Abstract
Vein of Galen malformation (VOGM) is a rare congenital vascular malformation caused by the maldevelopment of its embryonic precursor, the median prosencephalic vein of Markowski. VOGM results in neonatal morbidity and mortality, and premature delivery does not improve the outcome. We report a term female neonate in whom a vein of Galen malformation was diagnosed prenatally at 37 wk of gestation during a growth ultrasound and confirmed by fetal magnetic resonance imaging. Signs of cardiac decompensation were evident in the fetus. Multiple interventional radiology embolizations of the feeding vessels were performed successfully on days 7, 10, 12, 14 and 19. A review of the literature on the endovascular management of neonates with these malformations is presented herein.
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37
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Yan J, Gopaul R, Wen J, Li XS, Tang JF. The natural progression of VGAMs and the need for urgent medical attention: a systematic review and meta-analysis. J Neurointerv Surg 2016; 9:564-570. [PMID: 27091749 DOI: 10.1136/neurintsurg-2015-012212] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/05/2015] [Revised: 03/20/2016] [Accepted: 03/25/2016] [Indexed: 11/04/2022]
Abstract
BackgroundVein of Galen aneurysmal malformations (VGAMs) are congenital disorders that may require emergency treatment and some may cause sudden death before medical attention is provided. Some patients also have a spontaneous thrombosis.ObjectiveTo understand the natural progression of VGAMs through a systematic literature review.MethodsWe examined PubMed to identify studies published between July 1973 and March 2015. We determined the proportion of patients with VGAM who died before receiving medical attention, who received emergency treatment, or had a spontaneous thrombosis. We pooled estimates of proportions with corresponding 95% CIs calculated using the raw (ie, untransformed) proportions.ResultsThe 31 studies obtained described the outcome of 754 patients with VGAM. The probability of sudden death risk was 4% (95% CI 1% to 7%; I2=51.6%); of an emergency operation was 46% (95% CI 34% to 58%; I2=93.2%); and of spontaneous thromboses 1% (95% CI 0% to 2%; I2=0%) of cases. Differences between age and clinical outcomes of patients with spontaneous thromboses were significant according to the rank test (Mann–Whitney U test, Z=−2.398, p=0.016), both having a linear correlation (χ2 test, p=0.022).ConclusionsOver time, the rate of preoperative sudden death in patients with VGAM gradually declined and the rate of emergency operations gradually increased. The outcome of patients with early spontaneous thromboses was good. Our study provides a definitive description of the natural progression of VGAMs and the need for urgent medical attention.
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Affiliation(s)
- Jun Yan
- Department of Cerebrovascular Diseases, The Second Affiliated Hospital of Guilin Medical University, Guilin City, Guangxi Zhuang Autonomous Region, China
| | - Roodrajeetsing Gopaul
- Department of Neurosurgery, The First Affiliated Hospital of Guangxi Medical University, Nanning, Guangxi Zhuang Autonomous Region, China
| | - Jing Wen
- Department of Rheumatism, The First Affiliated Hospital of Guangxi Medical University, Nanning, Guangxi Zhuang Autonomous Region, China
| | - Xi-Sheng Li
- Department of Neurosurgery, The First Affiliated Hospital of Guangxi Medical University, Nanning, Guangxi Zhuang Autonomous Region, China
| | - Jing-Feng Tang
- Department of Cerebrovascular Diseases, The Second Affiliated Hospital of Guilin Medical University, Guilin City, Guangxi Zhuang Autonomous Region, China
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Madhuban A, van den Heuvel F, van Stuijvenberg M. Vein of Galen Aneurysmal Malformation in Neonates Presenting With Congestive Heart Failure. Child Neurol Open 2016; 3:2329048X15624704. [PMID: 28503603 PMCID: PMC5417289 DOI: 10.1177/2329048x15624704] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/21/2015] [Revised: 10/14/2015] [Accepted: 11/27/2015] [Indexed: 11/16/2022] Open
Abstract
The authors report the case of a neonate presenting with signs of a congenital cardiac disease. Echocardiography showed a structural normal heart, right-to-left ductal flow, a dilated superior caval vein, and reversed diastolic flow in the proximal descending aorta. Brain magnetic resonance imaging showed a vein of Galen arteriovenous malformation. This highlights the importance of considering an intracranial cause in the differential diagnosis of neonatal congestive heart failure.
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Affiliation(s)
- Andjenie Madhuban
- Department of Pediatrics, Radboud University Medical Center, Nijmegen, the Netherlands
- Andjenie Madhuban, Department of Pediatrics, Radboud University Medical Center, 6500 HB Nijmegen, PO Box 9101, the Netherlands.
| | - Freek van den Heuvel
- Department of Pediatrics, Beatrix Children’s Hospital, University Medical Center Groningen, Groningen, the Netherlands
| | - Margriet van Stuijvenberg
- Department of Pediatrics, Beatrix Children’s Hospital, University Medical Center Groningen, Groningen, the Netherlands
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KOMIYAMA M, TERADA A, ISHIGURO T. Neuro-Interventions for the Neonates with Brain Arteriovenous Fistulas: With Special Reference to Access Routes. Neurol Med Chir (Tokyo) 2016; 56:132-40. [PMID: 26853455 PMCID: PMC4791307 DOI: 10.2176/nmc.oa.2015-0336] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/17/2015] [Accepted: 01/11/2016] [Indexed: 11/20/2022] Open
Abstract
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.
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Affiliation(s)
- Masaki KOMIYAMA
- Department of Neuro-Intervention, Osaka City General Hospital, Osaka, Osaka
| | - Aiko TERADA
- Department of Neuro-Intervention, Osaka City General Hospital, Osaka, Osaka
| | - Tomoya ISHIGURO
- Department of Neuro-Intervention, Osaka City General Hospital, Osaka, Osaka
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Chen D, Liu B, Jin C, Cao Y, Han H, Deng X. Basal vein in the posterior incisural space: An anatomical comparison based on autopsy, digital subtraction angiography and computed tomographic venography. JOURNAL OF X-RAY SCIENCE AND TECHNOLOGY 2016; 24:319-327. [PMID: 27002908 DOI: 10.3233/xst-160555] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/05/2023]
Abstract
BACKGROUND During surgical procedures, the basal vein in the posterior incisural space is susceptible to obstruction. In such circumstances, venous infarction can occur along with venous damage. OBJECTIVE The aim of this study was to correlate the microanatomy of the basal vein in the posterior incisural space with the digital subtraction angiography (DSA) and computed tomographic venography (CTV). METHODS Twenty cadavers and 42 patients were examined in this study. The head of each cadaver was injected with blue-colored gelatin via the internal jugular veins. Venograms for each patient were obtained from the venous phases of DSA or CTV. RESULTS Compared to the cadavers, in the patients, DSA and CTV revealed 90% and 95% of the basal vein, respectively. According to difference of entrance, three types of basal veins were identified. No statistical difference of typing was found among the cadavers, DSA images and CTV images. On three sides of the cadavers and one side of the CTV images, the basal vein entered the straight sinus through the meningeal vein in the tentorium cerebelli. CONCLUSIONS Preoperative DSA and CTV are useful in the design of individualized surgical approaches and the preservation of the basal vein in the posterior incisural space.
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Affiliation(s)
- Dan Chen
- Department of Neurosurgery, The Third People's Hospital of Hefei, Hefei, Anhui, China
| | - Bin Liu
- Department of Radiology, The First Affiliated Hospital of Anhui Medical University, Hefei, Anhui, China
| | - Chuanbing Jin
- Department of Neurosurgery, The Third People's Hospital of Hefei, Hefei, Anhui, China
| | - Yongsheng Cao
- Department of Neurosurgery, The Third People's Hospital of Hefei, Hefei, Anhui, China
| | - Hui Han
- Department of Anatomy, Anhui Medical University, Hefei, Anhui, China
| | - Xuefei Deng
- Department of Anatomy, Anhui Medical University, Hefei, Anhui, China
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