Endovascular treatment of mural-type vein of Galen malformations

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Object. In this study the authors report on the results of endovascular treatment for mural-type vein of Galen malformations (VGMs) in a group of infants.

Methods. Eight children (six infants and two neonates) who suffered from symptoms caused by a mural-type VGM were treated by means of endovascular therapy. Their age at the time of treatment ranged from 13 days to 19 months (mean 7.6 months). Two neonates and three infants who presented with hydrocephalus and increased head circumference, one of whom was stabilized with a shunt, underwent elective closure of the malformations 3, 4, 6, 6, and 13 months later, respectively. Two patients presented with hemorrhage; one had an intraventricular hemorrhage (IVH) on the 1st day of life and one, a 5-month-old infant, suffered a large parenchymal hemorrhage and an IVH; both patients were immediately cured by means of endovascular techniques. One child presented with a seizure and cortical venous drainage that were treated immediately. Eleven separate treatment sessions were conducted; eight via transarterial femoral access and the remaining three via a transvenous approach. Two patients were treated by using transfemoral transvenous embolization with fibered coils, and one patient required a transtorcular transvenous approach to permit complete closure of the fistula with electrolytically detachable coils. The embolic devices used included silk suture emboli (three patients), electrolytically detachable coils (three patients), and fibered platinum coils (seven patients). In seven patients, complete closure was demonstrated on postembolization arteriographic studies. The eighth patient had stagnant flow in a giant 6-cm varix treated with arterial and venous coils but has not yet undergone follow-up studies. Late follow-up arteriography was performed in four patients at times ranging from 11 to 24 months postprocedure. In one patient, thrombosis of the malformation and shrinkage of the varix were confirmed on follow-up computerized tomography scanning. The remaining three patients have not yet undergone follow-up angiographic examination. Two asymptomatic complications occurred, including separation of the distal catheter, which was removed with a snare device, and a single platinum coil that embolized to the lung, producing no symptoms in 101 months of clinical follow up. The follow-up period ranged from 3 to 105 months, with a mean of 52 months.

Conclusions. Endovascular therapy is the treatment of choice for mural-type VGMs and offers a high rate of cure with low morbidity.

Article Information

Address reprint requests to: Van V. Halbach, M.D., Department of Radiology, Neurointerventional Section, University of California at San Francisco, 505 Parnassus Avenue, Room L352, San Francisco, California 94143–0628.

© AANS, except where prohibited by US copyright law.

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Figures

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    Case 1. A and B: Left vertebral arteriogram, anteroposterior (A) and lateral (B) projections, demonstrating two separate connections (curved arrows) between the lateral posterior choroidal branches of the PCA and the midline prosencephalic vein. C: Arteriogram showing selective microcatheter injection after placement into the distal fistula (see corresponding arteriogram [B]). D: Postembolization selective arteriogram obtained after placement of platinum coils and silk suture into the fistula site, demonstrating complete fistula closure. Note reflux into the distal anterior cerebral artery (straight black arrow) through the limbic arcade and continued patency of the medial posterior choroidal artery (long thin arrow). E: Left vertebral injection arteriogram, lateral projection, obtained 14 months postprocedure demonstrating persistent and complete closure of the VGM.

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    Case 3. A: Unenhanced CT scan demonstrating acute hemorrhage in the right thalamus and internal capsule with IVH. B and C: Left vertebral injection arteriograms, lateral (B) and anteroposterior (C) projections, demonstrating a mural-type VGM supplied by a single enlarged lateral posterior choroidal artery. A high-grade stenosis is present in the draining falcine sinus (straight arrow). D: Left vertebral arteriogram, Towne's projection, obtained after embolization with silk suture, demonstrating complete obliteration of the fistula site. Complete and persistent closure of the VGM was confirmed on a 12-month follow-up arteriogram.

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    Case 7. Left and Center: Left VA injection arteriograms, lateral projection (left) and Towne's projection (center), demonstrating a large vessel arising from the PCA communicating with the prosencephalic vein. A second smaller connection was demonstrated from the right PCA. The point of the fistula is localized by a short straight arrow. Right: Left VA injection arteriogram, Towne's projection, postembolization demonstrating complete closure of the fistula by means of multiple electrolytically detachable fibered and pushable platinum coils (short straight arrows) placed in the prosencephalic vein and left fistula.

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