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Deep venous communication in vein of Galen malformations: incidence, Imaging, and Implications for treatment
  1. Hans Kortman1,
  2. Ershad Navaei2,
  3. Charles A Raybaud2,
  4. Kartik Dev Bhatia3,
  5. Manohar Shroff2,
  6. Karel terBrugge4,
  7. Derek Armstrong5,
  8. Vitor M Pereira6,
  9. Peter B Dirks5,
  10. Timo Krings4,
  11. Prakash Muthusami2
  1. 1 Department of Radiology, Elisabeth-TweeSteden Ziekenhuis, Tilburg, The Netherlands
  2. 2 Department of Image Guided Therapy, Hospital for Sick Children, Toronto, Ontario, Canada
  3. 3 Department of Neuroradiology, Toronto Western Hospital, Toronto, Ontario, Canada
  4. 4 Division of Neuroradiology, Department of Medical Imaging and Division of Neurosurgery, Department of Surgery, Toronto Western Hospital, University Health Network, Toronto, Ontario, Canada
  5. 5 Department of Neuroradiology, Hospital for Sick Children, Toronto, Ontario, Canada
  6. 6 Department of Medical Imaging, Toronto Western Hospital, Toronto, Ontario, Canada
  1. Correspondence to Dr Hans Kortman, Department of Radiology, Elisabeth-TweeSteden Ziekenhuis, Tilburg 5000 LC, The Netherlands; hgjkortman{at}


Background Failure to appreciate deep venous drainage pathways is a major cause of severe complications in the endovascular treatment of vein of Galen aneurysmal malformations (VOGMs).

Objective To report deep venous drainage patterns in patients with VOGM, emphasizing the internal cerebral veins, and to describe the challenges in evaluating these.

Methods Patients with VOGM presenting to our institute between 2000 and 2018 were retrospectively analyzed. Patients with complete and good quality imaging datasets were included in the study. Three neuroradiologists with expertise in the subject independently analyzed the deep venous drainage patterns on multi-sequence MRI and digital subtraction angiography. Follow-up imaging studies were analyzed for alterations in deep venous drainage patterns that occurred following endovascular treatment. Descriptive statistics were used to report findings.

Results Twenty-three patients had optimal quality MRI imaging and 25 had optimal quality DSA imaging available. In 14/23 (61%) patients, internal cerebral vein (ICV) communication could be reliably identified on MRI and in 8/25 (32%) patients on DSA. Deep venous communication with the VOGM was demonstrated in 8/26 (30.8%) patients. One (3.8%) patient demonstrated ICV communication with the VOGM only on postoperative imaging, while in 2 (8%) patients the ICV drainage route changed from VOGM to alternative pathways after the procedure. Other variant pathways included lateral mesencephalic vein, superior or inferior sagittal sinus, anterior mesencephalic vein, tentorial sinus, deep Sylvian vein, and superior vermian vein.

Conclusion ICV communication with the VOGM is not uncommon and requires dedicated preprocedural imaging to identify it. However, there are significant challenges in assessing this communication in the presence of high-flow fistulae, vessel tortuosity and size, and contrast limitations in this population.

  • angiography
  • MRI
  • vascular malformation
  • arteriovenous malformation
  • intervention

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  • Contributors HK and PM (principal investigator) had full access to all the data in the study and take responsibility for the integrity of the data and the accuracy of the data analysis. Concept and design: HK, CAR, TK, PBD, DA, KDB, PM. Acquisition, analysis, or interpretation of data: HK, KDB, EN, VMP, TK, KtB, MS, PM. Drafting of the manuscript: HK, EN, KDB, VMP, HK, DA, PM. Critical revision of the manuscript for important intellectual content: HK, KDB, CAR, VMP, TK, KtB, PBD, MS, EN, PM. Statistical analysis: HK. Administrative, technical, or material support: KDB, EN, MS, PM. Supervision: CAR, TK, KtB, PBD, MS, PM.

  • Funding The authors have not declared a specific grant for this research from any funding agency in the public, commercial or not-for-profit sectors.

  • Competing interests None declared.

  • Patient consent for publication Not required.

  • Ethics approval Ethics approval, including a waiver for obtaining informed consent from participants given the retrospective nature of the study and the long time period being assessed, was granted by the research ethics board of the Hospital for Sick Children, Toronto, Ontario, Canada.

  • Provenance and peer review Not commissioned; externally peer reviewed.

  • Data availability statement Data are available upon reasonable request. All data relevant to the study are included in the article or uploaded as supplementary information. The authors agree to share deidentified data on request.