Neurointervention.  2018 Mar;13(1):41-47. 10.5469/neuroint.2018.13.1.41.

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

• Kim DJ
• Suh DC
• Kim BM
• Kim DI

• KMID: 2424048
• DOI: http://doi.org/10.5469/neuroint.2018.13.1.41

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.

Keyword

Coil; Embolization; Glue; Vein of Galen aneurysmal malformation

MeSH Terms

Adhesives*
Aneurysm*
Arteries
Cerebral Veins*
Choroid
Fistula
Follow-Up Studies
Humans
Hydrocephalus
Methods
Veins*
Adhesives

Figure

• 

  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.

Reference

1. Lasjaunias PL, Chng SM, Sachet M, Alvarez H, Rodesch G, Garcia-Monaco R. The management of vein of galen aneurysmal malformations. Neurosurgery. 2006; 59:S184–S194. discussion S3-13. PMID: 17053602.

2. Lasjaunias P, Ter Brugge K, Berenstein A. Surgical neuroangiography: Clinical and interventional aspects in children. 2nd ed. Berlin Heidelberg: Springer-Verlag;2006.

3. Khullar D, Andeejani AM, Bulsara KR. Evolution of treatment options for vein of galen malformations. J Neurosurg Pediatr. 2010; 6:444–451. PMID: 21039167.

4. Berenstein A, Fifi JT, Niimi Y, Presti S, Ortiz R, Ghatan S, et al. Vein of Galen malformations in neonates: new management paradigms for improving outcomes. Neurosurgery. 2012; 70:1207–1213. discussion 1213-1204. PMID: 22089754.

5. Moon JH, Cho WS, Kang HS, Kim JE, Lee SJ, Han MH. Vein of galen aneurysmal malformation: endovascular management of 6 cases in a single institute. J Korean Neurosurg Soc. 2011; 50:191–194. PMID: 22102947.

6. Thiex R, Williams A, Smith E, Scott RM, Orbach DB. The use of onyx for embolization of central nervous system arteriovenous lesions in pediatric patients. AJNR Am J Neuroradiol. 2010; 31:112–120. PMID: 19749215.

7. Germanwala AV, Vora NA, Thomas AJ, Jovin T, Gologorsky Y, Horowitz MB. Ethylenevinylalcohol copolymer (onyx-18) used in endovascular treatment of vein of galen malformation. Childs Nerv Syst. 2008; 24:135–138. PMID: 17701187.

8. Pearl M, Gomez J, Gregg L, Gailloud P. Endovascular management of vein of galen aneurysmal malformations. Influence of the normal venous drainage on the choice of a treatment strategy. Childs Nerv Syst. 2010; 26:1367–1379. PMID: 20725731.

9. Mitchell PJ, Rosenfeld JV, Dargaville P, Loughnan P, Ditchfield MR, Frawley G, et al. Endovascular management of vein of galen aneurysmal malformations presenting in the neonatal period. AJNR Am J Neuroradiol. 2001; 22:1403–1409. PMID: 11498438.

10. Kong JC, Cheng KM, Cheung YL, Chan CM. Transarterial embolisation with guglielmi detachable coils in an infant with a vein of galen aneurysmal malformation. Hong Kong Med J. 2012; 18:435–438. PMID: 23018073.

11. Heuer GG, Gabel B, Beslow LA, Stiefel MF, Schwartz ES, Storm PB, et al. Diagnosis and treatment of vein of galen aneurysmal malformations. Childs Nerv Syst. 2010; 26:879–887. PMID: 20049460.

12. Meila D, Hannak R, Feldkamp A, Schlunz-Hendann M, Mangold A, Jacobs C, et al. Vein of galen aneurysmal malformation: Combined transvenous and transarterial method using a “kissing microcatheter technique”. Neuroradiology. 2012; 54:51–59. PMID: 21455720.

13. Kim DJ, Kim DI, Suh SH, Byun JS, Jung JY, Kim J, et al. Vein of galen aneurysmal malformation: Treatment by transarterial venous sac and fistula embolization using coils and glue. Neurointervention. 2006; 1:31–34.

14. Recinos PF, Rahmathulla G, Pearl M, Recinos VR, Jallo GI, Gailloud P, et al. Vein of galen malformations: Epidemiology, clinical presentations, management. Neurosurg Clin N Am. 2012; 23:165–177. PMID: 22107867.

15. Lasjaunias P, Rodesch G, Terbrugge K, Pruvost P, Devictor D, Comoy J, et al. Vein of galen aneurysmal malformations. Report of 36 cases managed between 1982 and 1988. Acta Neurochir (Wien). 1989; 99:26–37. PMID: 2756850.

16. Hamasaki T, Kai Y, Hamada J, Miura M, Kondo Y, Ushio Y. Successful treatment of a neonate with vein of galen aneurysmal malformation. Pediatr Neurosurg. 2000; 32:200–204. PMID: 10940771.

17. Watban JA, Rodesch G, Alvarez H, Lasjaunias P. Transarterial embolization of vein of galen aneurysmal malformation after unsuccessful stereotactic radiosurgery. Report of three cases. Childs Nerv Syst. 1995; 11:406–408. PMID: 7585669.

18. Payne BR, Prasad D, Steiner M, Bunge H, Steiner L. Gamma surgery for vein of galen malformations. J Neurosurg. 2000; 93:229–236. PMID: 10930008.

19. Triffo WJ, Bourland JD, Couture DE, McMullen KP, Tatter SB, Morris PP. Definitive treatment of vein of galen aneurysmal malformation with stereotactic radiosurgery. J Neurosurg. 2014; 120:120–125. PMID: 23870021.

20. Alvarez H, Garcia Monaco R, Rodesch G, Sachet M, Krings T, Lasjaunias P. Vein of galen aneurysmal malformations. Neuroimaging Clin N Am. 2007; 17:189–206. PMID: 17645970.

21. Levrier O, Gailloud PH, Souei M, Manera L, Brunel H, Raybaud C. Normal galenic drainage of the deep cerebral venous system in two cases of vein of galen aneurysmal malformation. Childs Nerv Syst. 2004; 20:91–97. discussion 98-99. PMID: 14691640.

22. Iizuka Y, Kakihara T, Suzuki M, Komura S, Azusawa H. Endovascular remodeling technique for vein of Galen aneurysmal malformations--angiographic confirmation of a connection between the median prosencephalic vein and the deep venous system. J Neurosurg Pediatr. 2008; 1:75–78. PMID: 18352807.