Vein of Galen aneurysmal malformation treatment with direct open surgical access of the transverse sinus and transvenous selective endovascular embolization: a hybrid approach

Vein of Galen aneurysmal malformations (VOGMs) are rare congenital cerebrovascular malformations associated with an almost 100% morbidity and mortality rate if untreated. Open surgical case reports had reported intraoperative neonatal mortality rates close to 100%, rendering the disease untreatable. The development of endovascular techniques subsequently provided a viable treatment option for these complex cases, with a staged transarterial approach currently being the preferred mainstay treatment.We report on a technique that involves direct exposure of the transverse sinus under image-guided mini-craniotomy in a vascular hybrid intraoperative theater, followed by direct puncture of the transverse sinus with venous access to embolize the VOGM via a transvenous route. This was performed in a 3-year-old patient in whom further transarterial embolization was not feasible and who had bilateral occlusion of the internal jugular veins. The procedure was successful, with elimination of the high-flow arteriovenous shunt and no procedure-related complications.