VEIN OF GALEN MALFORMATION: ANESTHESIA CONCERNS

▶️Vein Of Galen Malformation (VOGM) is a amplification of the median vein of the procencephalon (which is a precursor of the Vein of Galen), caused ~ means of an arterio venous (A-V) switch from the choroidal arteries of the going before. and posterior circulation. It can origin  A-V shunting and akin systemic effects and hydrocephalus. 

▶️Incidence is not so much than 1% of cerebral vascular malformations.

▶️PROBLEMS:

✔️Most of the issues are due to the effect of A-V shunting

✔️Congestive Cardiac Failure and Pulmonary Hypertension : Due to A-V shunting . The etiology of cordial failure may begin in utero. High output cardiac failure is associated with VGAM for the cause that 60 to 80% of aortic children flow is directed through the VGAMS low resistant shunt. Blood flow travels through the VGAM during diastole creating a purloin phenomenon. The reduction of diastolic squeezing can lead to myocardial ischemia deputy to reduced coronary blood flow. 

 ✔️Ventriculomegaly : A-V shunting –> increased dural bay pressure –> resistance to CSF note to the sinus –> enlargement of ventricles

✔️Seizures

▶️INDICATIONS FOR DEFINITIVE MANAGEMENT: CCF, Hydrocephalus , Neurological symptoms

▶️TREATMENT

✔️Main goal of the usage is to control the A-V shunt

✔️Endovascular embolization is the preferred handling; other option is surgical clipping.

✔️Embolization of the feeding arteries and draining veins can result in reduction of blood run through the VOGM which is the guide to improved cardiac function and brain mischief prevention.

✔️Embolization is not so much invasive and has a higher survival assessment than open neurosurgical procedures. It provides victory hemodynamic stability with minimal pain. Heart failure is every indication for urgent embolization. 

▶️ANESTHESIA CONCERNS

✔️Improving the cardiac function is the key to escape multiple organ failure. The mortality find fault with for all neonates in heart failure undergoing transcatheter embolization be possible to be up to 50%, mortality is a great deal of higher when pulmonary hypertension is existing.

✔️Cardiac failure is hard to treat and most beta agonists at the same time with diuretics and Milrinone have been used through varying success. Although total systemic vascular hindrance is reduced through the VOGM, the nursling in cardiac failure has an increased extracranial vascular resistance. So interventions that reduces extracranial systemic opposition is likely to improve systemic perfusion. Nitric oxide has been used to enjoyment pulmonary hypertension in these patients.

✔️The goal is to bring to pass partial embolization with the endpoint of improving mind failure. So, the embolization may subsist staged. Each session is limited ~ means of the volume of contrast media delivered and the patient’s tolerance of the procedure. The ultimate goal of these sessions is to completely occlude the VOGM as long as avoiding neurological and cardiac injury

✔️Intracerebral hemorrhage what is ~ to venous hypertension is a potentially lethal complication of endovascular management. There is a speculation that this complication can be avoided by staging the embolization procedure. Perforation of the veiny sac can usually be managed by reversal of anticoagulation and continuation of spiral ring embolization. Ischemic neurological deficits, Pulmonary embolization through embolic agents ( due to the ~-pitched flow across the intracranial shunt that drains this moment into the central venous system) are other concerns. 

Reference: 

Anesthetic Implications of Neonatal Vein of Galen Aneurysmal Malformation (VGAM)  Ira S Landsman, Than Nguyen 

 

National Institute of Health’s Women’s Health Initiative study.

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