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  • Use of Adenosine Cardiac Arrest to Facilitate NBCA Treatment of High Flow Vein of Galen Malformation in Two Infant Cases

    Final Number:

    Jeremy C Peterson MD; Koji C. Ebersole MD

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    Meeting: Congress of Neurological Surgeons 2016 Annual Meeting

    Introduction: Vein of Galen Aneurysmal Malformations (VGAM) are congenital high flow shunt systems that most commonly present in the neonatal and infancy stages of life and account for <1% of cerebrovascular lesions. The treatment paradigm has had many changes from open vascular to endovascular to combined treatment. The primary goal is reduction of clinical symptoms and not full obliteration of the lesion especially early in life. We present two infant (2 month and 3 month) patients with VGAM that developed evidence of worsening hydrocephalus related to venous congestion associated with a high flow mural type A-V shunt. To improve the distal treatment of each pedical with NBCA glue; the high flow system was diminished by achieving temporary cardiac arrest using adenosine.

    Methods: In the first case, a 4F catheter was advanced to the left internal carotid artery. Next, a microcatheter and microwire were used to access the right pericallosal artery. Once the level of the fistula was reached maximal Esmolol drip was used to decrease flow to the lesion without success. The decision was made to induce cardiac pause with adenosine to allow controlled embolization. NBCA glue was prepared and once half of the catheter dead space was reached adenosine provided five seconds of asystole and 5 seconds of bradycardia allowing complete occlusion of the pedicle. This process was repeated in two other pedicles resulting in significant flow reduction of the shunt. This technique was replicated at the onset of treatment of our second patient with similar success.

    Results: Following embolization follow-up imaging showed continued resolution of the hydrocephalus in each patient. Both patients are well at 2.5 years and 6 months follow-up, respectively.

    Conclusions: Adenosine induced cardiac arrest is a safe option to facilitate treatment of VGAM with NBCA glue in infants.

    Patient Care: Discussion and evaluation of this technique will help to improve controlled embolization of high-flow pedicles when treating patients with Vein of Galen Aneurysmal Malformations. With further refinement in dosing characteristics among pediatric patients this technique will help reduce amount of NBCA glue that travels through the shunt and is deposited within the lungs during treatment.

    Learning Objectives: By the conclusion of this session, participants should be able to 1) Describe the characteristics of high flow VGAM that may make them difficult to treat even with fast setting NBCA glue, 2) Identify which patient would benefit from adenosine cardiac arrest during endovascular treatment, 3) Discuss, in small groups how to prepare the anesthesia and endovascular teams for the complex steps required when using this technique.


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