Endovascular Management of Vein of Galen Aneurysmal Malformations: A Retrospective Analysis over a 15-Year Period

Abstract

Objectives: This retrospective study was aimed at assessing our results of endovascular management in vein of Galen aneurysmal malformation (VGAM).

Materials and methods: This is a retrospective study of 26 patients of VGAM who underwent endovascular treatment between 1998 and 2012. All patients underwent trans-arterial embolization. Of 26 patients, 23 were treated using n-butyl cyano acrylate (Glue), while 3 out of 26 patients were treated using the ethylene vinyl alcohol (EVOH) copolymer.

Results: Ages of the treated patients ranged from 1 day to 18 years of age. Of the patients treated, 17 were males and 9 were females. Around 15 of the VGAMs were of the mural variety and 11 were choroidal in nature. A good outcome was seen in 22/26 (85%) of the patients. Complications were seen in total in 7/26 patients (26.92%) of which 3/26 (12%) has a fatal outcome.

Conclusion: Endovascular embolization for VGAMs is highly efficacious and has helped create a population of VGAM survivors in this condition, which until only a few decades ago caused high mortality and morbidity.

Keywords: EVOH; Onyx; Vein of Galen aneurysmal malformations (VGAMs); glue; vein of Galen (VOG).

Figure 1. CECT of the brain shows a dilated median vein and hydrocephalus. There is no atrophy or parenchymal calcification present.

Figure 2. (A) Left Vertebral artery angiogram in lateral projection shows a mural type of VGAM with supply to the dilated median vein from a hypertrophied right lateral posterior choroidal artery. (B) Selective microcatheter angiogram confirms the good distal position of the microcatheter closely approximating the fistula. (C) Glue cast from the injection of concentrated glue. (D) Immediate postprocedure angiogram shows marked slowing of flow within the dilated median vein.

Figure 3. A 7-month control angiogram: (A–C) arterial, parenchymal and venous phases of the left vertebral artery angiogram (D–F) arterial, parenchymal, and venous phases of the right ICA angiogram show nonvisualization of the VGAM.

Figure 4. Postcontrast axial T1WI shows the lateral extension of the glue cast on the right side along the superior surface of the tentorium associated with intense homogeneous enhancement. There is perifocal vasogenic edema associated. Findings indicate a foreign body type of reaction/granuloma incited by the embolic material.

Figure 5. MRI (A) Axial T2WI and (B) MR venography show an aneurysmally dilated median vein which drains into a falcine sinus (arrow).

Figure 6. Left vertebral angiogram lateral projection (A) arterial phase, (B) venous phase, and (C) left ICA angiogram arterial phase lateral projection show mural type of VGAM supplied by medial and lateral posterior choroidal, thalamo-perforators, anterior choroidal, posterior pericallosal, and subependymal arteries. It drains into a dilated falcine sinus. Persistent occipital and marginal sinuses are present. (D) A fluoroscopic image demonstrating glue casts after the second session of embolization using the posterior communicating artery (asterisk) and the anterior cerebral artery (dashed arrow).