J Neurosurg 88:74–80, 1998

Endovascular treatment of mural-type vein of Galen
malformations
VAN V. HALBACH, M.D., CHRISTOPHER F. DOWD, M.D., RANDALL T. HIGASHIDA, M.D.,
PETER A. BALOUSEK, M.D., SAMUEL F. CIRICILLO, M.D., AND MICHAEL S. B. EDWARDS, M.D.
Departments of Radiology, Neurointerventional Section, and Neurosurgery, University of California at
San Francisco, San Francisco, California; and Department of Pediatric Neurological Surgery, Sutter
Medical Systems, Sacramento, California
Object. In this study the authors report on the results of endovascular treatment for mural-type vein of Galen malformations (VGMs) in a group of infants.
Methods. Eight children (six infants and two neonates) who suffered from symptoms caused by a mural-type VGM
were treated by means of endovascular therapy. Their age at the time of treatment ranged from 13 days to 19 months
(mean 7.6 months). Two neonates and three infants who presented with hydrocephalus and increased head circumference, one of whom was stabilized with a shunt, underwent elective closure of the malformations 3, 4, 6, 6, and 13
months later, respectively. Two patients presented with hemorrhage; one had an intraventricular hemorrhage (IVH) on
the 1st day of life and one, a 5-month-old infant, suffered a large parenchymal hemorrhage and an IVH; both patients
were immediately cured by means of endovascular techniques. One child presented with a seizure and cortical venous
drainage that were treated immediately. Eleven separate treatment sessions were conducted; eight via transarterial
femoral access and the remaining three via a transvenous approach. Two patients were treated by using transfemoral
transvenous embolization with fibered coils, and one patient required a transtorcular transvenous approach to permit
complete closure of the fistula with electrolytically detachable coils. The embolic devices used included silk suture
emboli (three patients), electrolytically detachable coils (three patients), and fibered platinum coils (seven patients). In
seven patients, complete closure was demonstrated on postembolization arteriographic studies. The eighth patient had
stagnant flow in a giant 6-cm varix treated with arterial and venous coils but has not yet undergone follow-up studies.
Late follow-up arteriography was performed in four patients at times ranging from 11 to 24 months postprocedure. In
one patient, thrombosis of the malformation and shrinkage of the varix were confirmed on follow-up computerized
tomography scanning. The remaining three patients have not yet undergone follow-up angiographic examination. Two
asymptomatic complications occurred, including separation of the distal catheter, which was removed with a snare
device, and a single platinum coil that embolized to the lung, producing no symptoms in 101 months of clinical follow
up. The follow-up period ranged from 3 to 105 months, with a mean of 52 months.
Conclusions. Endovascular therapy is the treatment of choice for mural-type VGMs and offers a high rate of cure
with low morbidity.

KEY WORDS • vein of Galen malformation • platinum microcoil • embolization •
mural-type malformation • arteriovenous malformation • children

V

EIN of Galen malformations (VGMs) are recog-

nized as a rare cause of morbidity and mortality in
the neonate and less commonly in infants.1,7–13,15
Neonates usually present with high-output cardiac failure,
which is most often fatal despite medical therapy.8,10
Conversely, patients with VGM who present in infancy
may have mild or no heart failure but usually present with
developmental delay, hydrocephalus, and seizures.1,2,10,11,15
Lasjaunias and colleagues2,11,12 have proposed that VGMs
be subclassified into two distinct types: choroidal and
mural. Mural-type VGMs receive arterial supply from the
collicular and posterior choroidal vessels that may be uni74

lateral or bilateral and drain into the median prosencephalic vein. Clinically, mural-type malformations present in infants with macrocephaly or failure to thrive and
who have mild cardiac symptoms.2,11,12 We report on the
results of therapy in eight children with mural-type VGMs
that were treated with a combination of newer embolic
agents: silk sutures, fibered platinum microcoils, and electrolytically detachable platinum coils.
Clinical Material and Methods
Between July 1986 and October 1997, 34 children with
J. Neurosurg. / Volume 89 / July, 1998

Endovascular treatment of VGMs
TABLE 1
Summary of clinical characteristics in eight children treated for VGMs*
Case
No.

Symptoms at Presentation

Age at
Presentation

Age at Initial
Treatment

Treatment

1
2
3
4
5
6
7
8

increasing HC, Parinaud’s syndrome
increasing HC
hemorrhage
increasing HC, seizure
mild CHF at birth, increasing HC
hemorrhage
increasing HC, Parinaud’s syndrome, seizure
increasing HC

2 mos
prenatal
5 mos
19 mos
birth
birth
prenatal
4 mos

5 mos
14 mos
5 mos
19 mos
5 mos
13 days
6 mos
6 mos

TA coils, silk
TA coils, silk
TA silk
TA & TT coils
TA & TV coils
TV coils
TA coils
TA coils

No. of Clinical Follow
Sessions
Up (mos)

2
1
1
2
2
1
1
1

101
90
90
51
42
35
4
3

* CHF = congestive heart failure; HC = head circumference; TA = transarterial; TT = transtorcular; TV = transvenous.

VGMs were treated using endovascular techniques by our
group at the University of California at San Francisco
Medical Center. Twenty-six of these lesions were classified as choroidal-type VGMs by using the scheme proposed by Lasjaunias and colleagues,2,11,12 and eight (24%)
were characterized as mural-type VGMs and are the subject of this publication.
Eight children (six infants and two neonates) who had
mural VGMs were treated using a variety of interventional techniques including transarterial embolization (seven
patients), transfemoral transvenous embolization (two patients), and transtorcular embolization (one patient), and
combinations of embolic materials including silk suture
emboli and fibered and nonfibered platinum microcoils.
Table 1 summarizes these data as well as the age at presentation, age at treatment, number of treatment sessions
and route, and duration of the clinical follow-up period.
Presenting Symptoms

Five of the children initially presented with increasing
head circumference and hydrocephalus. One of the cases
of hydrocephalus was detected in utero, and the child

underwent placement of a ventriculoperitoneal (VP) shunt
at birth, which permitted a delay in endovascular therapy
until the 14th month. A second child (Case 1) developed
increasing head circumference and intermittent Parinaud’s
syndrome (Fig. 1) at 8 weeks of age. Because the child
was developing normally otherwise with no seizures or
cardiac symptoms, endovascular therapy was delayed until 5 months of age. A third child was noted to have ischemic changes on serial magnetic resonance (MR) images
and received treatment at 6 months of age after suffering
a seizure. The fourth child was noted to have congestive
heart failure at birth and was successfully treated with
medical therapy. He was noted to have increasing head
circumference and was treated initially at 5 months of age.
The fifth child was noted to have hydrocephalus at 4
months of age.
Two children presented with hemorrhage. The first was
a neonate who presented at birth with a seizure and in
whom computerized tomography (CT) scanning revealed
a large intraventricular hemorrhage (IVH) with partial
thrombosis of the prosencephalic vein. A second infant
presented at 5 months of age with seizures and hemiparesis from a deep parenchymal hemorrhage and IVH (Fig.

FIG. 1. Case 1. A and B: Left vertebral arteriogram, anteroposterior (A) and lateral (B) projections, demonstrating
two separate connections (curved arrows) between the lateral posterior choroidal branches of the PCA and the midline
prosencephalic vein. C: Arteriogram showing selective microcatheter injection after placement into the distal fistula
(see corresponding arteriogram [B]). D: Postembolization selective arteriogram obtained after placement of platinum
coils and silk suture into the fistula site, demonstrating complete fistula closure. Note reflux into the distal anterior cerebral artery (straight black arrow) through the limbic arcade and continued patency of the medial posterior choroidal artery
(long thin arrow). E: Left vertebral injection arteriogram, lateral projection, obtained 14 months postprocedure demonstrating persistent and complete closure of the VGM.

J. Neurosurg. / Volume 89 / July, 1998

75

V. V. Halbach, et al.

FIG. 2. Case 3. A: Unenhanced CT scan demonstrating acute hemorrhage in the right thalamus and internal capsule
with IVH. B and C: Left vertebral injection arteriograms, lateral (B) and anteroposterior (C) projections, demonstrating a mural-type VGM supplied by a single enlarged lateral posterior choroidal artery. A high-grade stenosis is present
in the draining falcine sinus (straight arrow). D: Left vertebral arteriogram, Towne’s projection, obtained after
embolization with silk suture, demonstrating complete obliteration of the fistula site. Complete and persistent closure of
the VGM was confirmed on a 12-month follow-up arteriogram.

2A) from a previously unsuspected VGM. Emergency endovascular treatment resulted in a complete cure in both
children.
One child presented with a grand mal seizure and was
noted to have bulging scalp veins, a loud intracranial bruit,
and increasing head circumference. Angiographic studies
demonstrated thrombosis of both transverse sinuses and
diversion of flow into collateral scalp veins from the
VGM.
All eight patients were evaluated by a pediatric cardiologist and all were believed to have mild cardiomegaly and
mild or no overt cardiac failure.

creasing head circumference were otherwise developmentally normal, and their initial radiographic evaluation
failed to reveal any ominous findings. Therefore, the initial therapy was delayed 3, 4, 6, 6, and 13 months, respectively. One of these patients, Case 7, had new ischemic
changes noted on serial MR images, suffered a seizure,
and was treated at 6 months of age. The two patients who
presented with hemorrhage were treated within 2 weeks of
presentation. The last child presented with seizures, was
noted to have thrombosis of both transverse sinuses and
cortical reflux, and was treated immediately to eliminate
the risk of hemorrhage.

Radiographic Features

Endovascular Treatment

Arterial Supply. The number of arterial connections

ranged from one (Fig. 2B) to four. Two children harbored
a solitary connection. In all eight patients the blood supply
came from posterior choroidal vessels arising from the
posterior cerebral artery (PCA) and in two patients additional supply arose from the superior cerebellar artery.
Venous Anatomy. The prosencephalic vein involved
ranged in size from 12 to 60 mm, with a mean of 33 mm.
A straight sinus was present in four patients and the veins
drained through a falcine sinus in two. One patient had
both a straight and falcine sinus. Six of the eight patients
exhibited a downstream stenosis in the straight sinus (five
cases) or both transverse sinuses (one case). Both patients
who presented with hemorrhage had a severe stenosis
involving the straight sinus (Fig. 2B), and one of these
patients exhibited partial thrombosis of the prosencephalic vein.
Timing of Treatment

All eight patients underwent radiographic evaluation of
the malformation before receiving definitive therapy. This
included CT or MR examination, intraarterial digital subtraction angiography, and transfontanelle cerebral and cardiac ultrasound. The five patients who presented with in76

All endovascular procedures were performed via a
transarterial femoral access by using a No. 4 French diagnostic or guiding catheter that was placed through a No. 4
French femoral sheath and introduced by means of a
micropuncture system. Systemic anticoagulation was
achieved with the administration of a 70 U/kg bolus of
porcine heparin sulfate with 35 U/kg given every hour
thereafter. The response to the heparin boluses was monitored, and an activated clotting time was obtained before,
during, and after administration of the heparin doses with
the aid of a Hemochron machine.
Transarterial Embolization Technique

The guiding catheter was placed in the distal vertebral
artery (VA), and a variable-stiffness microcatheter and
microguidewire were navigated through the guiding catheter into the large-caliber feeding vessel just proximal to
the vessel’s entry into the dilated prosencephalic venous
pouch. Radiopaque markers of a known diameter were
placed on both sides of the skull before arteriographic
studies were obtained to permit calculation of the magnification factor on each individual run and to allow precise
measurement of the feeding vessel and varix. Once a
desirable position in the distal feeding vessel was
achieved and confirmed with selective arteriographic imJ. Neurosurg. / Volume 89 / July, 1998

Endovascular treatment of VGMs

FIG. 3. Case 7. Left and Center: Left VA injection arteriograms, lateral projection (left) and Towne’s projection (center), demonstrating a large vessel arising from the PCA communicating with the prosencephalic vein. A second smaller
connection was demonstrated from the right PCA. The point of the fistula is localized by a short straight arrow. Right:
Left VA injection arteriogram, Towne’s projection, postembolization demonstrating complete closure of the fistula by
means of multiple electrolytically detachable fibered and pushable platinum coils (short straight arrows) placed in the
prosencephalic vein and left fistula.

ages, then embolization was performed using the following technique. Platinum fibered microcoils with a diameter slightly larger than the caliber of the distal feeding
vessel were chosen. In the first two cases, additional
embolization was performed with silk suture emboli to
enhance the thrombogenicity of the platinum coils. In one
case silk suture alone was used as an embolic agent. In the
last four cases, advances in coil design permitted complete
occlusion of the feeding vessels with no need for silk
suture as an adjunct treatment. In the most recent case, a
series of prototype fibered electrolytically detachable coils
and standard electrolytically detachable coils were used
for occlusion of the feeding vessels. In this last case coils
were delivered via transarterial access into the prosencephalic vein and one of two feeding arterial vessels (Fig.
3 right).
When cessation of flow was observed in the pedicle of
the feeding vessel, the embolization was terminated. The
microcatheter and guiding catheters were withdrawn and
the systemic anticoagulation was reversed by means of
protamine sulfate administered slowly during a 10-minute
period.
Transfemoral Transvenous Embolization Technique

In two patients the transarterial embolization attempt
was unsuccessful, leading to incomplete obliteration of
the malformation. In one patient a large arterial connection was obliterated by means of transarterial embolization techniques; however, the malformation was still supplied by a smaller connection that could not be accessed
through an arterial route because of excessive tortuosity.
In the second case the tortuosity precluded arterial access
close to the malformation. Both patients were treated via
a transfemoral venous access in the following fashion: a
No. 4 French guide catheter was positioned in the dominant internal jugular vein, and through this a variable-stiffness microcatheter was navigated in a retrograde fashion
through the torcula into the draining falcine or straight
J. Neurosurg. / Volume 89 / July, 1998

sinus and into the prosencephalic vein draining the malformation. Customized fibered platinum coils matching
the diameter of the prosencephalic vein were delivered
with the aid of a coil-pushing wire. Sequentially smaller
fibered coils were delivered into the prosencephalic vein
until thrombosis of the varix was achieved.
Transtorcular Embolization Technique

In a single case, transarterial embolization resulted in
occlusion of the dominant supply to the malformation, but
a smaller second feeding vessel could not be accessed via
this route. This infant suffered occlusion of both transverse sinuses that could not be accessed via a transfemoral
venous approach. Therefore, assisted by a team of pediatric neurosurgeons, we placed a catheter via a transtorcular approach and delivered electrolytically detachable
nonfibered platinum coils into the venous pouch, producing complete thrombosis of the malformation.
Sources of Supplies and Equipment

The No. 4 French guiding catheters were purchased
from Cordis Corp., Miami Lakes, FL, and Medtronic
MIS, Sunnyvale, CA, and the femoral sheaths were
obtained from Cordis Corp. The No. 4 French diagnostic
catheters and micropuncture system were acquired from
Cook, Inc., Bloomington, IN. The heparin sulfate was purchased from Elkins-Sinn, Inc., Cherry Hill, NJ. The clotting time was measured with a Hemochron machine
obtained from International Techidyne, Edison, NJ. The
microcatheters (Tracker model) were purchased from
Target Therapeutics, Fremont, CA. The microguidewires
(Rapid Transit model) were obtained from Cordis Corp.
Fibered microcoils were acquired from Cook, Inc., and
Target Therapeutics. Prototype fibered and standard electrolytically detachable coils were purchased from Target
Therapeutics. The coil-pushing wire was obtained from
Terumo Inc., Boston Scientific, Watertown, MA.
77

V. V. Halbach, et al.
Illustrative Cases

Results
Eleven endovascular procedures were performed in
eight patients in whom mural-type VGMs were diagnosed. Complete angiographically confirmed closure was
documented in seven patients on postembolization angiograms, and subsequent CT and MR examinations
revealed thrombosis and shrinkage of the varix in six
cases. In a single case of a 60-mm prosencephalic vein
treated by using both transarterial and transvenous techniques, stagnant flow was noted on the postembolization
arteriogram. A follow-up arteriogram has not yet been
obtained, but 37 months later the child remains neurologically intact on clinical examination.
Four children underwent follow-up arteriographic evaluation (range 11–24 months postprocedure) in which
complete closure of their malformation was confirmed.
Three children have not yet undergone follow-up arteriographic examination. The parents of one child refused
the late follow-up arteriographic study; however, serial
delayed CT scans have shown thrombosis and shrinkage
of the varix. The child remains free of symptoms.
The patients in Cases 2 and 3, both of whom required
numerous silk suture emboli to achieve closure of the malformation, developed postprocedure fevers as high as
39˚C that lasted several days and abated spontaneously.
Complete workups including blood and urine cultures,
chest radiographs, and cerebrospinal fluid culture in one
patient proved negative for infection. Our experience with
silk suture embolization in other patients has shown us
that transient postprocedure fevers related to the use of
this agent are quite common. After the development of
more thrombogenic platinum coils, we did not have to use
silk suture as an embolic material in the last five patients.
Two children underwent VP shunt placement at 1 and
14 months before endovascular treatment. Thirteen
months after successful endovascular treatment, one child
developed a malfunction in a shunt placed at birth that was
revised, resulting in resolution of his symptoms. All eight
patients showed stabilization of their head circumference,
and none required delayed VP shunt placement.
The child who presented at birth with seizures and a
large IVH is developmentally delayed at 2 years of age.
Another child, who had a parenchymal hemorrhage, initially presented with a dense hemiparesis and has only a
mild residual leg weakness and mild restriction of upward
gaze 84 months posttreatment. The remaining six children
are intellectually and developmentally normal. The clinical follow-up period ranged from 3 to 105 months (mean
52 months).
Operative Complications

There were two asymptomatic complications. In one
patient, the distal catheter became detached in the distal
VA during delivery of a long prototype coil. An endovascular snare wire (Cook Inc.) was used to remove the coil
and distal catheter with no difficulty. In the second patient,
a single 3-mm coil passed through the prosencephalic vein
and lodged in a peripheral pulmonary vein, producing no
symptoms. He remains free of symptoms at 101 months of
follow up.
78

Case 1

This infant was noted to have an enlarging head circumference and progressive intermittent Parinaud’s syndrome at 8 weeks of age. At 1 month of age an MR examination revealed a VGM. On subsequent arteriographic
studies (Fig. 1A and B) two large-caliber connections between the posterior choroidal vessels and the midline
dilated prosencephalic vein were confirmed. Because the
child was developing normally and showed no signs of
congestive heart failure we elected to delay therapy until
the age of 5 months. At that time, a microcatheter was
navigated to the largest fistula site via a transarterial
access (Fig. 1C) and several fibered platinum coils followed by pieces of silk suture were delivered to the fistula site, producing complete closure of this connection
(Fig. 1D). A single coil migrated through the fistula at
the time of embolization and lodged in a lower lobe
pulmonary arterial branch, producing no symptoms. The
infant did well clinically with stabilization of his head circumference and resolution of the Parinaud’s syndrome. A
second embolization was performed at 11 months of age
in which small fibered coils were used to occlude the
remaining smaller fistulous connections. We confirmed
complete closure of the malformation on a postembolization arteriogram and a follow-up arteriogram obtained at
14 months (Fig. 1E). The child has developed normally
and at the age of 8 years remains neurologically intact
with no symptoms.
Case 3

This healthy infant developed seizures and an acute
hemiparesis at 5 months of age. A CT scan revealed a
parenchymal hemorrhage (Fig. 2A) into the left thalamus
and internal capsule secondary to a VGM. A mural-type
VGM with a severe stenosis in the draining straight sinus
(Fig. 2B and C) was demonstrated on arteriographic studies. During advancement of a prototype coil, the distal
catheter became detached when the coil was in the distal
VA and, therefore, a snare was used to remove it, which
was accomplished without difficulty. A second microcatheter was advanced to the fistula site and silk suture
was used for embolization until complete thrombosis was
observed (Fig. 2D). Complete thrombosis of the prosencephalic vein and resolution of the hydrocephalus were
revealed on subsequent MR images. A follow-up arteriogram obtained 15 months later confirmed complete closure of the fistula site. The child has shown gradual neurological improvement since the hemorrhage and has a
mild hemiparesis and slight restriction of upward gaze 84
months posttreatment.
Case 7

This 6-month-old boy was diagnosed in utero as having
a VGM. He was born prematurely and was hospitalized
with failure to thrive but had no cardiac symptoms. He
was noted to have increasing head circumference and
mild, intermittent Parinaud’s syndrome. Serial MR images
revealed new ischemic changes at 6 months of age. The
infant underwent arteriographic studies, in which two separate fistula connections with the prosencephalic vein
J. Neurosurg. / Volume 89 / July, 1998

Endovascular treatment of VGMs
were identified (Fig. 3 left). The smaller connection arose
from a fetal PCA that was extremely tortuous. Via a transarterial approach, a microcatheter was navigated through
the left-sided connection into a dilated 36-mm prosencephalic vein. Electrolytically detachable coils were delivered into the varix initially followed by fibered platinum
coils for a total of 50 coils. Electrolytically detachable
fibered and nonfibered coils were deposited into the arterial connection just proximal to the fistula and just distal
to normal PCA branches (Fig. 3 center). A control postembolization arteriogram revealed closure of the fistula
(Fig. 3 right). The child continues to progress normally.
Discussion
Vein of Galen malformation is a rare condition that
almost exclusively affects children. The nomenclature is
somewhat imprecise because the abnormal arterial connections are made with the median vein of the prosencephalon, an embryological precursor of the vein of
Galen.2 The clinical presentation can range from severe
high-output congestive heart failure to seizures, macrocephaly, and mental retardation.1,2,10,11,15 Lasjaunias and
colleagues2,11,12 have proposed that VGMs be subdivided
into two distinct categories: choroidal and mural types,
based primarily on their angioarchitecture. Choroidal
VGMs classically demonstrate an abundance of bilateral
arterial supply from choroidal arteries, pericallosal arteries, and/or subependymal branches of the thalamoperforating vessels. The connection is extracerebral and subarachnoid, communicating with the anterior aspect of the
median vein of the prosencephalon. The choroidal type is
more common and typically presents with heart failure in
the neonate.2,11,12
Mural-type VGMs harbor a lesser number of connections arising from the collicular or posterior choroidal
artery branches, which may be unilateral or bilateral. Patients with mural-type VGMs typically present with macrocephaly or failure to thrive, and cardiac failure is typically mild or absent.2,11,12
Although it was suggested in the earliest reports that
VGM had a propensity to produce intracranial hemorrhage, this has recently been challenged. Berenstein and
Lasjaunias2 (widely regarded to have the most experience
in endovascular treatment of VGMs) have not observed
hemorrhage in their respective series. They suggest that
many of the patients who have been reported to have suffered a hemorrhage from a VGM actually harbor a parenchymal arteriovenous malformation that drains to the vein
of Galen, producing dilation of this structure. It is important to note that two patients (25%) in this series presented with bleeding and that both of them had severe downstream stenosis of the draining straight sinus (Fig. 2B).
Lasjaunias, et al.,11 reported on the treatment of 43 children with VGMs, of whom 16 (37%) had the mural type.
Two of these mural-type malformations spontaneously
thrombosed, and the remaining 14 children were treated in
18 treatment sessions. Nine (64%) were completely cured.
Of two reported deaths, one resulted from multiorgan failure and one patient was completely cured by embolization
but died as a result of improper therapeutic timing and
management.11 Lasjaunias stressed the importance of
bucrylate embolization via a transarterial route.
J. Neurosurg. / Volume 89 / July, 1998

Our results in seven mural-type VGMs show a complete cure in all seven after treatment via both a transarterial and transvenous approach. We agree that the transarterial route is preferable and only use a transvenous
approach when treatment via the first route is unsuccessful. This series is unique in that we use fibered and unfibered platinum coils (in conjunction with silk suture
early in the series) rather than liquid adhesives. The improvements in coil design including denser packing ability, more thrombogenicity, and the ability to reposition
detachable fibered platinum microcoils have obviated the
need for silk suture as an adjunct. We believe that the
greater accuracy of fibered coils, as well as the ability to
position them via both transarterial and transvenous
routes, makes them a superior choice as an embolic agent
in the treatment of VGMs. Others have reported success
with the transarterial4,15 and transvenous3–5,15,17 deposition
of coils in this condition; nonetheless, in experienced
hands, liquid adhesives such as bucrylate have also shown
considerable success in treating this disease.2,7,11–14
It is important to note that high morbidity and mortality rates are associated with VGMs and that the morbidity
rate is strongly dependent on the age at presentation.
Johnston and colleagues10 reviewed the records of the 232
patients reported on who had this condition. These pooled
data showed an overall mortality rate of 56% for both
treated and untreated patients. The highest mortality rate
(91.4%) was found in neonates and was equally high in
those treated surgically or medically. Vein of Galen malformations present less commonly during infancy. However, patients treated surgically still had a 32% mortality
rate, and significant levels of morbidity were seen in half
of the survivors. Significant advances in surgical techniques have improved these results in the past 10 years.16,18
However, the greatest reduction in morbidity and mortality rates associated with this disease has been in patients
treated using endovascular techniques.2,3–7,11–15,17
The timing of the first embolization procedure depends
on the presenting symptoms. The two children who presented with intracranial hemorrhage were treated on an
emergency basis with complete closure of the VGM. The
remaining children presented with less catastrophic signs
and symptoms, usually consisting of increasing head circumference and hydrocephalus, which allowed definitive
treatment to be delayed several months until the risks of
angiography, contrast load, and embolization were reduced. However, if the initial angiographic examination
disclosed cortical venous reflux or a high-grade stenosis in
the draining straight or falcine sinus, this indicated a higher risk for subsequent hemorrhage.
Conclusions
Mural-type VGMs classically present in infancy with
macrocephaly, seizures, and, less commonly, hemorrhage.
These recalcitrant lesions can be cured by using a variety
of embolization techniques. In this series, we achieved
complete angiographically confirmed cure with no morbidity or mortality in all eight patients treated by means of
platinum coils and/or silk suture emboli placed via both
arterial and venous approaches.
79

V. V. Halbach, et al.
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Manuscript received July 9, 1997.
Accepted in final form February 23, 1998.
Address reprint requests to: Van V. Halbach, M.D., Department
of Radiology, Neurointerventional Section, University of California
at San Francisco, 505 Parnassus Avenue, Room L352, San Francisco, California 94143–0628.

J. Neurosurg. / Volume 89 / July, 1998