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

Neonates with vein of Galen aneurysmal malformations (VGAMs) presenting with cardiac failure have high morbidity and mortality, and outcomes are significantly better in those presenting in later childhood. Neurologic outcomes in survivors are perceived to be uniformly poor, which may lead to the neonate being denied treatment. We assessed outcomes of modern neonatal intensive care and endovascular embolization in a consecutive series of such neonates presenting with cardiac failure. Between 1996 and 1998, five infants (three male, two female) were diagnosed with symptomatic VGAMs in the first week of life, four of whom had intractable, high-output cardiac failure and underwent initial endovascular treatment. There were 15 endovascular procedures and one neurosurgical clipping in these five patients. Transarterial and transvenous routes were required, using multiple embolic agents. We emphasized the use of sonographically guided, percutaneous transtorcular-venous-access, moveable-core guidewire as an embolic agent; routine MR imaging; and MR angiography. Immediate outcomes included control of cardiac failure with normal neurologic function in four (80%) patients and one (20%) death from intractable cardiac failure. On follow-up examination, three (60%) infants showed no evidence of neurologic abnormality or cardiac failure; one (20%) infant showed moderate developmental delay. Two have had no further shunting on angiography, one has minimal flow, and one is awaiting follow-up imaging. Endovascular therapy with modern neuroanesthetic and neurointensive care can provide good outcomes even in the highest-risk neonates with VGAMs and cardiac failure. If medical management of cardiac failure fails, and there is no evidence of gross cerebral parenchymal damage on imaging, urgent endovascular treatment is feasible and can reduce the almost-100% mortality otherwise expected, without invariably severe morbidity. Use of multiple embolization strategies in multiple stages usually is necessary in these patients, and novel approaches and embolic agents may be necessary.