Endovascular Management of Vein of Galen Aneurysmal Malformations Presenting in the Neonatal Period

MR angiography in another neonate (case 1) with VGAM and cardiac symptoms.

A, Lateral MR angiography immediately after birth shows numerous dilated arteries and a large VGAM centrally (not seen well in this image, better shown on T2-weighted images). Note significant contribution (arrow) from subfornical branch, as in figure 1.

B, Lateral projection of a DSA run, injecting into the vertebral artery, shows good correlation with the MR angiography. Note the perforating vessels from the tip of the basilar artery and adjacent P1 segments of the posterior cerebral arteries, as well as the posterior choroidal supply.

C, Lateral projection shows transfemoral transvenous catheterization of the VGAM, guide catheter (arrowhead) passing to “torcular,” with microcatheter passed through this into the VGAM itself (arrow). Note the faint opacification of the VGAM.

D, Lateral projection shows direct percutaneous puncture of the torcular with the catheter (arrow) placed along falcine sinus into the central portion of the VGAM. The coil mass shown (*) comprises previous platinum coils from the transfemoral transvenous approach and the guidewire sections soaked in thrombin deployed as an embolic agent.

E, Lateral projection shows transarterial route through vertebral, basilar, posterior cerebral and posterior choroidal arteries. Note the extreme tortuosity of vessels (*) resulting from long-standing arteriovenous shunting and high flow. The tip of the catheter has been placed through the fistula into the malformation; contrast (arrow) confirms the position. NBCA can then be deployed, occluding the fistula and adjacent terminal portions of the artery and coil mass.

F, Delayed follow-up imaging, lateral projection, shows late arterial-phase carotid injection with no evidence of shunting. Coil mass shown subtracted (*).