Adjuvant Coil Assisted Glue Embolization of Vein of Galen Aneurysmal Malformation in Pediatric Patients

Abstract

Purpose: Adjuvant coils may offer advantages in flow control during glue embolization of high flow vein of Galen aneurysmal malformation (VGAM) patients but involves specific issues such as feasibility, durability and coil mass effect. The purpose of this study is to assess the outcome of adjuvant coils in addition to transarterial glue embolization for treatment of these patients.

Materials and methods: Five pediatric VGAM patients (age range; 11 weeks to 2 yrs 2 mos) with high flow fistulous angioarchitecture were treated with adjuvant coils 1) in the distal feeding artery and/or 2) in the vein of Galen followed by glue embolization of the shunt. The angiographic / clinical outcomes were assessed.

Results: Adjuvant coils were deployed in the distal feeding artery (n=3), vein of Galen pouch plus distal feeding artery (n=2). Additional transarterial glue embolization of the fistulae was successfully performed (n=4). Complete occlusion was achieved with coils in one case. Complete occlusion was achieved for all mural type cases (n=4). Residual feeders remained in a case of choroidal type of VGAM. No complications were noted related to the treatment. All patients showed normal development on follow up (range: 7.6 to 88.8 mo, mean 49.3 mo). Initial hydrocephalus improved on follow up despite coil mass effect in dilated vein of Galen.

Conclusion: Adjuvant coils for flow control with glue embolization may be a safe and effective treatment method for VGAM patients with high flow fistulous feeders.

Keywords: Coil; Embolization; Glue; Vein of Galen aneurysmal malformation.

Fig. 1. Pre (A, C) and post (B, D) adjuvant coil assisted glue embolization of 2 cases of mural type VGAMs (AP views). Case 2 (A, B); 4month year old male was referred for VGAM. The angiography showed a VGAM with 2 high flow fistulae. Due to the high flow, coils were deployed in the enlarged vein of Galen followed by coils in the distal feeding arteries. Additional glue embolization resulted in complete occlusion of the shunt. Case 3 (C, D); A 10-month old girl was referred for incidental findings of craniomegaly and slight delayed development. MR (not shown) and DSA showed a VGAM with three high flow fistulae. Detachable coils were successfully deployed at the distal aspect of the feeding arteries. Additional glue embolization occluding the fistulous point resulted in complete occlusion.

Fig. 2. Case 1: Reversible changes of hydrocephalus in accordance with reopening and occlusion of the VGAM shunt. MR T2 weighted image taken two days after the initial coil embolization of the dilated vein of Galen and the proximal venous pouch show mild hydrocephalus. Glue was not used due to complete occlusion of the shunt with the coils (A). Three months follow up showed aggravation of hydrocephalus which prompted a repeat DSA revealing reopening of the previously coil embolized feeding artery (B). Second stage embolization was performed with additional adjuvant coils in the distal feeder and glue embolization. Complete occlusion was achieved. Six months follow up after the second stage embolization show marked improvement of the hydrocephalus despite the persistent mass effect in the dilated vein of Galen (C). Five years follow up show no signs of hydrocephalus (D). The patient is clinically normal on seven years follow up.