Experimental stage of intrauterine correction of the aneurysm of the vein of Galen

Introduction. Arteriovenous malformation of the vein of Galen (AVM VG) is a rare vascular malformation of the central nervous system, mainly diagnosed in the neonatal or postnatal period. Despite significant advances in the field of neonatal endovascular embolization, the mortality rate and the incidence of severe neurological complications remain high. In this regard, the development of intrauterine surgical technologies opens up prospects for interventions aimed at preventing cardiovascular complications and hypoxic damage to the central nervous system. Objective: Development of a method for intrauterine partial occlusion of arteriovenous malformation of the vein of Galen under ultrasound control in an experiment.
Materials and methods. The method of minimally invasive intrauterine embolization of arteriovenous malformation of the vein of Galen refers to the methods of fetal surgery, leads to a decrease in blood shunting and relief of cardiovascular insufficiency. The model of malformation was the left atrium of a sheep fetus. The use of this technique was approved at a meeting of the Ethics Committee of the Ural Research Institute of Occupational Medicine of the Ministry of Health of the Russian Federation on September 12, 2021.
Study results. During two experimental interventions on the model of arteriovenous malformation of the vein of Galen, modeled on sheep fetuses, partial intrauterine embolization was successfully performed using microspirals and adhesive compositions. It was found that this technique provides a significant decrease in the blood flow velocity in the chambers of the heart (by 3-4 times), without intraoperative disturbances in the cardiac activity of the fetuses. The use of an adhesive composition prevented the migration of spirals. All fetuses remained alive at the end of the experiments.
Conclusion. The proposed technique of partial intrauterine embolization of arteriovenous malformation of the vein of Galen in the experiment showed potential effectiveness in reducing blood flow through the aneurysmally altered vessel. The obtained data confirm the possibility of safe administration of embolic material under ultrasound control, which allows us to consider this approach as a promising stage of preparation for intrauterine treatment of this pathology in high-risk fetuses. Further studies are needed to clarify the criteria for selecting patients and assess the clinical effectiveness of the proposed method.

1. Bursac D. et al. Literature review and case report: Rare case of successful prenatal detection of Vein of Galen Malformation (VGAM). European Journal of Obstetrics & Gynecology and Reproductive Biology: X. 2024; 22:100306. https://doi.org/10.1016/j.eurox.2024.100306

2. Raybaud C. A., Strother C. M., Hald J. K. Aneurysms of the vein of Galen: embryonic considerations and anatomical features relating to the pathogenesis of the malformation. Neuroradiology. 1989; 31: 109-128. https://doi.org/10.1007/BF00698838

3. Cai C., Zhang Q., Shen C. Vein of Galen malformations—report of 2 cases and literature review. Frontiers of Medicine in China. 2008; 2: 317-322. https://doi.org/10.4236/oalib.1101478

4. Breysem L. et al. The value of fast MR imaging as an adjunct to ultrasound in prenatal diagnosis. European radiology. 2003; 13: 1538-1548. https://doi.org/10.1007/s00330-002-1811-6

5. Dagklis T. et al. Aneurysm of the Vein of Galen Diagnosed with MRI. Case Reports in Obstetrics and Gynecology. 2013; 2013(1): 716762. https://doi.org/10.1155/2013/716762

6. Lasjaunias P. L. et al. The management of vein of Galen aneurysmal malformations. Neurosurgery. 2006; 59 (5): 184-194. https://doi.org/10.1227/01.NEU.0000237445.39514.16

7. Herghelegiu D. et al. Antenatal diagnosis and prognostic factors of aneurysmal malformation of the vein of Galen: A case report and literature review. Medicine. 2017; 96 (30): 7483. https://doi.org/10.1097/MD.0000000000007483

8. Deloison B. et al. Hidden mortality of prenatally diagnosed vein of Galen aneurysmal malformation: retrospective study and review of the literature. Ultrasound in obstetrics & gynecology. 2012; 40 (6): 652-658. https://doi.org/10.1002/uog.11188

9. D’Amico A. et al. Outcome of fetal vein Galen aneurysmal malformations: a systematic review and meta-analysis. The Journal of Maternal-Fetal & Neonatal Medicine. 2022; 35 (25): 5312-5317. https://doi.org/10.1080/14767058.2021.1878494

10. Garcia-Monaco R. et al. Congestive cardiac manifestations from cerebrocranial arteriovenous shunts: endovascular management in 30 children. Child’s Nervous System. 1991; 7: 48-52. https://doi.org/10.1007/BF00263834

11. Hoffman H. J. et al. Aneurysms of the vein of Galen: experience at the Hospital for Sick Children, Toronto. Journal of neurosurgery. 1982; 57 (3): 316-322. https://doi.org/10.3171/jns.1982.57.3.0316

12. Gillet de Thorey A. et al. State of the art of antenatal diagnosis and management of vein of Galen aneurysmal malformations. Prenatal Diagnosis. 2022; 42 (9): 1073-1080. https://doi.org/10.1002/pd.6203

13. Orbach D. B. et al. Transuterine ultrasound-guided fetal embolization of vein of Galen malformation, eliminating postnatal pathophysiology. Stroke. 2023; 54 (6): 231-232. https://doi.org/10.1161/STROKEAHA.123.043421

14. Brinjikji W. et al. Endovascular treatment of vein of Galen malformations: a systematic review and meta-analysis. American Journal of Neuroradiology. 2017; 38 (12): 2308-2314. https://doi.org/10.3174/ajnr.A5403

15. Adaev A.R, Yakovlev S.B, Khukhlaeva E.A. Arteriovenous malformations of vein of Galen: results of treatment. Burdenko’s Journal of Neurosurgery. 2012; 76 (3): 54-60. (In Russ.)

16. Lagunavichene M.L. et al. Spontaneous obliteration of congenital arteriovenous malformation of the brain in childhood. Russian Bulletin of Perinatology and Pediatrics. 2020; 65(3): 126-130. (In Russ.) https://doi.org/10.21508/1027-4065-2020-65-3-126-130

17. Johnston I. H. et al. Vein of Galen malformation: diagnosis and management. Neurosurgery. 1987; 20 (5): 747-758. https://doi.org/10.1227/00006123-198705000-00013

18. Bhatia K. et al. Factors contributing to major neurological complications from vein of Galen malformation embolization. JAMA neurology. 2020; 77(8): 992-999. https://doi.org/10.1001/jamaneurol.2020.0825

19. Arko L. et al. Fetal and neonatal MRI predictors of aggressive early clinical course in vein of Galen malformation. American Journal of Neuroradiology. 2020; 41(6): 1105-1111. https://doi.org/10.3174/ajnr.A6585

20. Berestov V. et al. Huge cerebral pial arteriovenous fistula in a newborn: illustrative case. Journal of Neurosurgery: Case Lessons. 2022; 4 (16). https://doi.org/10.3171/CASE22294

21. Orlov K. et al. Superselective transvenous embolization with Onyx and n-BCA for vein of Galen aneurysmal malformations with restricted transarterial access: safety, efficacy, and technical aspects. Child’s Nervous System. 2017; 33: 2003-2010. https://doi.org/10.1007/s00381-017-3499-6