Vascular Abnormalities

Endovascular treatment of vascular malformations is becoming safer and more effective in obliterating lesions that were traditionally treated with large craniotomies and brain surgeries. Combining endovascular therapy with radiation has permitted "bloodless" surgery for many of the smaller vascular lesions located in eloquent areas of the brain. Much of this is covered in other chapters and is not reviewed here; however, one disease process deserves special attention.

Vein of Galen malformation is a disease process specific to pediatric neurosurgery. These lesions, which comprise a fistulous connection of the arterial circulation to the vein of Galen or nearby venous structures with resultant dilation of the vein of Galen, can have significant effects on newborns. In some less fortunate cases, the circulatory steal is so severe that children are born with severe hypoxic-ischemic encephalopathy and often do not survive. However, others are born with more benign symptoms such as high-output cardiac failure or hydrocephalus. Although some lesions can thrombose without treatment

(22), the majority require obliteration. Endovascular obliteration of the fistula, either from the arterial or venous side, has become the treatment of choice, and open surgery is now really just of historical interest for the treatment of vein of Galen malformations. The results are often remarkable, with instantaneous resolution of the heart failure and the children often going on to live normal lives (23).

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